Articles

Below are featured articles on the following topics by AIM providers:

• Osteoarthritis
• Update On Cervical Cancer Screening
• Deep Vein Thrombosis
• Chronic Obstructive Pulmonary Disease (COPD)
• Boost your Fiber and improve your Health
• What is "Flesh Eating" Bacteria?
• High Blood Pressure...What Is It and What To Do About It?
• Update on Hair Loss
• Making Better Food Choices
• Is my shoulder pain something serious?
• New Guidelines for PAP Testing for Women
• Prevention of Stroke/TIA
• How Useful are Fish Oils?
• Shingles
• Your lack of sleep may be killing you
• Lose Weight “Non Diet” Way!
• Carotid Stenosis: A general approach to diagnosis and treatment
• High Cholesterol and Diet
• Does Eating Out Make You Fat?
• MRSA – Methicillin Resistant Staphylococcus Aureus
• Understanding Hair Loss / Alopecia
• Frequently Overlooked Vitamin Deficiency
• Guidelines for Treating High Cholesterol
• Negative Effects of Diabetes on Overall Health
• Pneumonia Vaccine
• Melanoma
• The 100 Day-Old Cough...Pertussis
• Bioidentical Hormone Replacement Therapy
• Parkinson’s Disease
• America is Overweight!
• Yoga Benefits
• Amazing Benefits of Massage

To print any one of these articles, simply highlight the text with your cursor, then under FILE, choose PRINT and choose SELECTION or SELECTION ONLY (depending upon your browser) and your printer should only print the text that you highlighted.

Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) is a progressive and mostly preventable condition characterized by airflow limitation that is not fully reversible. This limitation is usually progressive and associated with abnormal inflammatory responses in the lungs to noxious particles or gases. There are two current types of COPD; emphysema and chronic bronchitis. There can however be substantial overlap among the different types of COPD. 

Emphysema is defined by abnormal and permanent enlargement of the airspaces that are distal to the terminal bronchioles and accompanied by destruction of the airspace walls without obvious fibrosis. Emphysema can exist in individuals who do not have airflow obstruction, however, it is more common among patients who have moderate to severe airflow obstruction. 

Chronic bronchitis is defined by a chronic productive cough for three months in each of two successive years in which other causes of chronic cough have been excluded. This inflammation is associated with CD8 T-lymphocytes, neutrophils, and CD68+ monocytes/macrophages whereas the inflammation in asthma is associated with CD4+ T-lymphocytes, eosinophils, and increased interleukin (IL)-4 and IL-5.

Most patients have a history of smoking or alternative inhalational exposure. However, approximately 20% of patients with COPD are lifelong non smokers. Certain historical features should increase the suspicion for COPD including hemoptysis, lung cancer, coronary artery disease, osteoporosis, depression, skeletal muscle weakness, and weight loss. Weight loss is often associated with a worse prognosis; however, the majority of patients are overweight or obese.

Patients generally have a sedentary lifestyle and sometimes unknowingly avoid exertional dyspnea by adjusting their expectations and avoiding activities. They may be unaware of the extent of their limitations and may only complain of fatigue. Patients will often present with respiratory symptoms and complain of dyspnea and a chronic cough. This may be initially only during exertion but eventually become noticeable with even less exertion and even at rest. The chronic cough will often have an insidious onset of an early morning cough with sputum production and may progress to occur throughout the day. The sputum will often be mucoid and becomes purulent during exacerbations.

There are a myriad of testing available to your providers to aid in the diagnosis of COPD. Pulmonary function tests are the cornerstone of the diagnostic evaluation, while chest radiography (x-ray), computed tomography (CT scan), and arterial blood gases are also available.

COPD can be treated through a variety of lifestyle modifications and pharmacotherapy. Various inhaled bronchodilators and corticosteroids can be used based on the severity and progression of the disease. In severe cases intermittent or continuous oxygen may be required. Lung strengthening exercises are also an important component in an attempt to maintain lung volume and function.

COPD can become a debilitating condition but with early detection and lifestyle modifications in addition to pharmacotherapy, it can be managed.

- Jared R Shafer, PA-C 

Boost your Fiber and improve your Health!

You have probably heard a lot about the importance of increasing the amount of fiber in your diet.  If you are like most people you are not really sure how to do that.  Let’s clear up some of the confusion and get you on the road to a higher fiber diet!

Most nutrition facts labels only tell us how much fiber is in a product.  They do not usually differentiate between the two types of fiber, soluble and insoluble. So what is the difference and why should we care? 

Insoluble fiber is considered gut friendly.  It has a laxative effect and adds bulk to the diet.  It does not dissolve in water. This is the type of fiber that is helpful for prevention of constipation.  Sources of insoluble fiber include whole grains, bran, brown rice and many fruits and vegetables.

Soluble fiber does dissolve in water.  It forms a gel and slows down digestion.  It can help with a feeling of fullness and may aid in weight control.  There is also some evidence that soluble fiber can help with lowering bad cholesterol.  Good sources of soluble fiber include oatmeal, oat cereals, beans and legumes and fruits and vegetables.  Especially good sources include Psyllium seeds (5 gm), Brussels Sprouts (3 gm) and Quaker High Fiber Oatmeal (8 gm).  Be careful of products advertising that they will help lower your cholesterol!  Often the soluble fiber number does not really support the claim.

The recommendation for fiber intake is 25-35 gm per day.  Most Americans are lucky to get half of that!  To get more fiber make half of your plate vegetables and fruit, choose whole grains.  Consider using beans or legumes as your protein source instead of meat. Make sure your cereal has at least 5 gm fiber per serving.  Do not rely on information from the front of the box, always check the Nutrition Facts label for accurate information that you can trust.  Finally, if you are looking to increase your fiber intake, make sure to do so gradually to prevent discomfort!

  - Lisa Stillman, MPH, RD, LD

What is "Flesh Eating" Bacteria?

There has been increased awareness of a bacterial infection that “eats” human flesh recently.  However, conditions that fit this description are not new in the medical arena.   Several types of bacteria including certain strains of streptococcus as well as methcillin-resistant staphylococcus aureus (mrsa) are known to cause serious skin and deeper tissue infections.   The more superficial infections of the skin would usually be called cellulitis.  If the infection goes deeper, the term is fasciitis.  In the case of fasciitis, the best course of treatment is going to be surgical removal of the affected tissue as well as antibiotics, usually given by intravenous route.  Symptoms of a severe skin infection may include pain, redness, and inflammation on the skin surface.  In more advanced stages, pain may not be present.  Also, fever, vomiting and other signs of toxicity may be present.  On examination, the skin may evolve from red to bluish to gray tones.  Often, air can be felt upon pressing on adjacent tissue.  This is an important clue that a deeper infection (ie fasciitis) is present.

The  presence of the infecting bacteria (usually more than 1 bacterial species) is generally one-half of the criteria  necessary for  necrotizing cellulitis/fasciitis to occur.  The person who is exposed typically has a background medical condition that puts them at risk for developing tissue infection once exposure has occurred.   Such conditions include diabetes, recent surgery, traumatic wounds, intravenous drug use, obesity, and a compromised immune system.  However, it is possible that a person may develop this serious skin condition in the absence of chronic medical conditions.

General measures to decrease the likelihood of necrotizing cellulitis/fasciitis include general good hygiene measures, optimizing your health through proper diet and lifestyle choices and seeking medical help if you develop a skin sore/lesion that appears to be worsening over several days instead of getting better. It is likely that early recognition  and treatment of an early skin wound/sore will lead to a quicker healing time and decreased risk for developing necrotizing cellulitis/fasciitis.  

- Betsy Horton-Pawlowski, MD

High Blood Pressure…What Is It and What To Do About It?

High blood pressure affects 1 in 3 individuals.  High blood pressure or hypertension is defined as top number (systolic) blood pressure over 140 or bottom number (diastolic) blood pressure over 90.  People can have hypertension in the absence of any other contributing disease (primary hypertension) or hypertension as a result of another condition/disease (secondary hypertension).   Primary hypertension is more common. 

Risk factors for hypertension include obesity, excessive alcohol intake, decongestant or stimulant use, dark skinned individuals, mother or father with hypertension, anxiety/agitation, vitamin d deficiency and physical inactivity.  Secondary hypertension may be caused by oral contraceptives, pregnancy, hormone-producing tumors, kidney disease and sleep apnea.  It is important to treat a chronically elevated blood pressure.  Home or fire- department measurements are helpful in making the diagnosis. Treatment of hypertension is important as it will lead to reducing risk for stroke, kidney disease and heart disease.  It is important to understand that hypertension is not a curable condition.  Treatment requires taking medications and other therapies for the long term.  As a person ages, it may be that they will not require medication for hypertension.  However, the decision to reduce medications must be made with the input of your health care provider.

  - Betsy Horton-Pawlowski, MD 

Update On Hair Loss

Hair loss (alopecia) is often a reversible condition of the scalp.  Scarring refers to scalp conditions that permanently damage the hair follicle whereas non-scarring refers to scalp conditions that do not lead to permanent damage of the follicle.  Scarring scalp conditions include lupus, severe infections and chemical exposures.  Non-scarring conditions include male pattern hair loss, mild scalp infection, trauma and other inflammatory conditions of the skin.  Periods of significant mental or physical stress can lead to a temporary, reversible alopecia as well.

The hair growth cycle consists of anagen(2-3 years), catagen (2-3 weeks) and telogen (3-4 months.  80-80 percent of hair follicles are in anagen at any given time.  Normally, no more than 75 hairs are shed.  Shed hairs are normally in the telogen phase in the absence of any disease/disorder.

Male pattern hair loss (androgenetic) is the most common cause of hair loss.  This form of hair loss affect men and women equally.  Those affected have an inherited shortening of ANAGEN.  This leads to a miniaturized hair follicle.  The genes responsible for this are influenced by testosterone and it’s byproducts. 

Other causes of hair loss include thyroid imbalance, iron deficiency, excessive testosterone production and medications.

Treatments for androgenetic hair loss are available in over the counter and prescription preparations. 

                                                              - Betsy Horton-Pawlowski, MD 

Making Better Food Choices

If you are like most Americans chances are that you eat out several times each week.  In fact, Americans eat out an average of 4-5 times each week.  This has steadily increased over the past several decades.  In my practice as a dietitian I have worked with clients who eat every meal out! This can be a recipe for disaster when it comes to our health.  Not surprisingly, restaurant eating is one of the reasons for the explosion of overweight and obesity in the United States.  Currently two thirds of American adults are either overweight or obese.  If the rate of our weight gain continues to increase at the current alarming rate, the entire nation will be overweight in 40 years!  Obesity threatens to rival cigarette smoking in health care costs.  One method in combating obesity is to make better restaurant choices.

As a nutrition professional, I realize that dining out is here to stay.  People are busy and enjoy their meals away from home.  Eating out used to be viewed as a treat.  Unfortunately, we have continued that mindset while increasing the amount of times we treat ourselves. The first line of defense is to educate ourselves about the nutritional content of the foods you are choosing.  How do you do that?  Currently, you have to do a little digging.  Most restaurants do not provide nutrition information on the menu.  Some of them will post nutrition info on their websites.  If you want a good comprehensive site try www.dwlz.com or www.calorieking.com among others. 

This information can even be accessed right at the restaurant with a smart phone! The good news is later this year restaurants with 20+ chains will be required to provide nutrition information on the menu.  The bad news?  In places where this is currently being done it does not seem to help people make better choices. What else can we do?  Do not drink your calories.  Sweet  tea or coke with a refill or two is 500 extra calories that don’t fill us up.  Secondly, stick with regular size items.  Super sizes may seem like a deal, but the price will ultimately be paid in increased weight and decreased health.  Try a different side.  Many restaurants are offering healthier options.  Ask for light salad dressing and mayo and get it on the side.  A tablespoon of regular mayonnaise has 90 calories.  I cringe every time I see a sub shop glop on the mayo.  Don’t assume a salad is a good choice.  One popular restaurant offers a grilled chicken salad that weighs in at a whopping  1100 calories!  Why?  Portion size, dressing and bread.  Speaking of portion sizes, don’t feel like you have to eat all of the meal.  It is too big!  It is ok to bring it home.  In fact, you may want to pack half of it up at the beginning of the meal. 

These are just a few of the tips to keep restaurant calories at bay.  As always, successful weight loss only comes to those who are ready to make some changes.  The guiding principles are paying attention and portion control.  Applying these guidelines can lead to lower weight and better health.

- Lisa Stillman RD

Is my shoulder pain something serious?

Most Americans suffer from chronic aches and pains, especially as we age. But knowing when something should be evaluated by a doctor or can be treated at home can be difficult to determine. 

Your shoulder is an amazing joint made up of 3 major bones; the humerus, scapula, and clavicle. The head of your arm bone, the humerus, fits into a groove on the scapula called the glenoid. This groove is covered in a layer of cartilage and uses the surrounding muscles and ligaments to maintain the stability of the humerus in this groove. Four of these muscles make up the rotator cuff; the supraspinatus, infraspinatus, subscapularis, and teres minor. These muscles attach to the head of the humerus to the shoulder bone, the scapula. A disruption in these muscles can cause chronic uncomfortable pain or severe debilitating loss of function. 

There can be numerous causes of shoulder pain or weakness including but not limited to: arthritis, tendon inflammation, instability from a lack of muscle strength/tone, or a broken bone/trauma. Other less common causes of shoulder pain include: nerve problems, tumors, and infections. 

Often times a long weekend of painting, cleaning, lifting can cause some inflammation in the shoulder muscles or tendons and lead to pain. Overhead activities like pitching, swimming, weight lifting, throwing a football/softball can also lead to repetitive stress on the shoulder and to shoulder soreness or pain. This can often be cured by reducing your workload on the joint, using ice repeatedly, and taking over the counter NSAIDs (non-steroidal anti-inflammatories) like Advil, Aleve, or Motrin. Pain that does not begin to improve in 1-2 weeks or progresses in pain and weakness may signify something more serious and further work-up with imaging that may include x-rays or an MRI. These can be ordered by your PCP or may need to be done by a specialist based on your insurance coverage.

- Jared R Shafer, PA-C

New Guidelines for PAP Testing for Women

Cervical cancer has been proven in large part to be caused by the human papilloma virus (HPV).  The human papilloma virus is contracted typically through sexual intercourse.  This virus infects the cells of the cervix and has the potential to genetically alter the normal cell growth cycle.  As a result, uncontrolled cell growth can lead to cervical cancer.  Out of the 40 types of HPV known to infect cervical cells, 18 are prone to damaging the cells thus causing cancer. 
The advent of the Papanicolaou smear (PAP) has aided physicians in screening for abnormal cells.  This test has traditionally been performed yearly in sexually active women.  Advances have occurred in the technique of this test in the last 15 years. Overall, the incidence of cervical cancer in the United States has decreased by 50 percent over last 30 years. 
With the latest knowledge that most cases of cervical cancer are caused by HPV, screening with a PAP test as well as for HPV increases accurate detection of cervical cancer. Results of a routine PAP test are as follows:

Previously, a result of ASCUS required repeat testing in 2-3 months.  However, combining HPV testing with PAP gives more concise information regarding the need for biopsy without waiting for repeat testing. The American College of Obstetricians and Gynecologists, in 2009, issued new guidelines for screening for cervical cancer: 
1) PAP test for all women starting at age 21 (younger is not necessary).  If normal, repeat PAP every 2-3 years
2) PAP plus HPV for women over 30 years of age.  If negative, repeat PAP/HPV every 3 years.
3) At age 65, after 3 normal PAP/HPV over a ten year period, no more PAP testing is needed.  
However, your physician may elect to continue every 3 year screening for women who are still sexually active or have multiple partners.4) No PAP testing in women who have had a full hysterectomy with complete excision of cervix, granted no history of abnormal cervical testing (i.e. precancerous or cancerous lesions). 

One final note, the Advisory Committee on Immunization Practices recommends the HPV vaccine to all females ages 9-26. This is a particularly exciting advancement in cancer prevention as this is an actual vaccine against cancer.  However, it only covers 4 of the 18 cancers causing HPV. Therefore, vaccinated women are still recommended to have screening as outlined above.

- Betsy Horton-Pawlowski, MD

Prevention of Stroke/TIA

Stroke is the third leading cause of death and the leading cause of disability in the United States. Current research indicates that there is more than 4.4 million American stroke survivors. Approximately 780,000 individuals experience a stroke each year: 180,000 of these are recurrent strokes.
Strokes can be categorized as ischemic or hemorrhagic. Ischemic strokes, caused by lack of blood flow due to arterial obstruction, account for 87% of all strokes. Hemorrhagic strokes, caused by arterial rupture, account for 13% of all strokes. A transient ischemic attack (TIA), defined as a focal neurological
deficit lasting less than 24 hours, is a stroke warning that is critical to recognize. Following a TIA, the 90-day stroke risk is between 3 and 17.3%, with the greatest risk occurring within the first 30 days.
Risk factors for ischemic stroke that cannot be modified include age older than 55 years, male gender, black race, family history of diabetes or previous stroke; and prior stroke or TIA. Risk factors that are modifiable include smoking cessation, limited alcohol consumption, and aggressive management of
atrial fibrillation, diabetes, dyslipidemia, hypertension, and obesity.
Atrial fibrillation is an independent risk for primary and secondary stroke and is associated with a five-fold increase in stroke risk. The risk of Atrial fibrillation-associated stroke increases with age over 65 years. Fifteen to 20% of all strokes are attributed to Atrial fibrillation. Recommended treatment of Atrial Fibrillation is Warfarin (anticoagulant) for patients at high risk for stroke (target INR 2.5, range 2.0 to 3.0); Aspirin 81- 325mg for patients with low risk of stroke or those unable to take oral anticoagulants.
Diabetes increases the risk of stroke between 1.8 and 6-fold. The 2006 American Heart Association guidelines for secondary stroke prevention recommend that patients with diabetes should maintain glucose to near normal levels (80 to 120). The Hemoglobin A1c goal is less than 7%. Target blood pressure for diabetics is less than 130/80 with Ace Inhibitors and ARBs being
first choice medications.
Low high-density lipoprotein cholesterol (HDL-C or “good” cholesterol) levels are a known risk factor for carotid artery disease and stroke. Goal for “good” cholesterol (HDL-C) is over 50mg/dL. A Low-density lipoprotein cholesterol (LDL-C or“bad” cholesterol) level of less than 100mg/dL for those with coronary heart disease (CHD); a goal of 70mg/dL is recommended for patients at very high risk with multiple risk factors. Administration of a statin drug is recommended for patients with prior ischemic stroke or TIA without known
coronary heart disease to reduce the risk of future stroke or cardiovascular event.

Approximately 50% of all strokes can be attributed to hypertension . Recommended blood pressure range is less than 140/80 or less than 130/80 for those with diabetes or chronic kidney disease. Smoking doubles ischemic stroke risk . Quit smoking period. Patients at risk for stroke should be encouraged to eliminate or reduce consumption of alcohol: no more than 2
drinks/day for men; no more than 1 drink/day for non-pregnant women. In addition to the above recommendations, patients should be encouraged to lose weight (recommended BMI 18.5 to 24.9) exercise regularly (30-60 minutes a day of continuous or accumulated exercise most days of the week), and eat a low-fat diet rich in fruits and vegetables.

Coral Benge, PA-C

How Useful Are Fish Oils?

Fish oils contain omega 3 fatty acids. Eicosapentaenoic acid (epa) and docosahexaenoic acid (dha) are the most studied of the omega 3 fatty acids.  Epa and dha are found primarily in fatty fish.  Mackerel and Atlantic salmon are fish varieties with high levels of these substances. Alternatively, fish oil supplements provide known doses of epa and dha without the exposure to mercury commonly found in fish. Lovaza is the only prescription form of epa and dha. 
Studies have shown that supplementation with omega 3 fatty acids can lower triglyceride levels. High triglyceride levels are associated with atherosclerosis, or hardening of the arteries. Even more promising is the use of omega 3 fatty acids in combination with a low density lipoprotein (ldl) – lowering agent such as a statin. There has been proven benefit against progression of atherosclerosis in people treated with both agents. This could lead to a decrease risk of heart attack, stroke, and peripheral arterial disease. Omega 3s also have been shown to decrease likelihood of arrhythmias such as atrial fibrillation and ventricular fibrillation in certain people at risk.
Most over the counter fish oil supplements should be sufficient to offer cardiovascular protection. However, the consumer should read the label to find out exactly how much dha and epa is contained within each dose. Doses totaling 1000 milligrams of epa PLUS dha are recommended in order to be beneficial.  
Side effects of fish oil supplements are limited to stomach upset and fishy odor.

- Betsy Horton-Pawlowski, MD

Shingles

Herpes Zoster or Shingles is a painful rash that is caused by the same virus that causes chickenpox. The term shingle comes from the Latin word, “cingulum”, which means belt or girdle which is appropriate because the rash usually appears in a band or belt-like pattern on the body. The rash is cause by varicella-zoster virus the same rash that causes chickenpox. After a chickenpox infection the virus travels to the nervous system to reside in an inactive state. The virus can stay in inactivated state in the nervous system for years. When activated the virus returns to skin to produce a band-like rash following the line of nerve patterns on one side of the body called “dermatomes”.

The rash usually begins as itching, burning or tingling. Within days, a rash of blisters appears on the body. After 2-3 days the blisters open and crust over. Most times, the rash is accompanied by redness and pain. The pain can be mild or severe and sharp or burning.

The risk of developing the rash occurs with advanced age (although it can occur with any age) and with weakened immune system. Your immune system is weakened by certain cancers, immune-suppressing medications, chemotherapy, and HIV.

Some of the complications are skin infections, eye complications and post herpetic neuralgia. Post herpetic neuralgia which is pain or unpleasant sensations that continue four or more months after the rash is the most common complication. It occurs in 10-15 percent of those with shingles and usually occurs in individuals over the age of 60.

Treatment of the acute rash usually is a combination of antiviral, steroids and pain medications. Anticonvulsants and antidepressants can also be used for the pain and post herpetic neuralgia.

Prevention of Shingles includes boosting natural immunity and vaccination. Vaccination for herpes zoster has been found to reduce the incidence of infection by 50 percent and the incidence of postherpetic neuralgia by 60 percent. The vaccine is now recommended for most adults over 60 and can be given even if a person has previously had shingles in order to help prevent recurrence.

Follow up with your primary care physician if you are experiencing any signs or  symptoms of shingles and if you do not have a physician please visit us at Alpha Internal Medicine, we will be more than willing to help you.

- Erinn Harris-Wilson, MD

Your lack of sleep may be killing you

Insomnia is the number one sleep disorder. Over the past 40 years sleep duration in the United States has decreased by two hours a night. Interestingly, studies have shown over the years that people who sleep less than seven hours have a higher mortality than the people who get seven to eight hours of sleep. Insomnia is defined as difficulty in initiating and/or maintaining sleep despite adequate opportunities to sleep with the presence of daytime impairment. A person is considered an acute insomniac if their lack of sleep has persisted for up to three months. While 40% of people fall into the acute insomnia category 10% are chronic insomniacs who have had insomnia more than six months.

The prevalence of no n-restorative sleep increases with age and is more common in women. Fifty percent of women experience sleep disturbances during menstruation, seventy nine percent during pregnancy, and thirty six percent during menopause. Some symptoms of insomnia may seem obvious: fatigue, mood disturbances and irritability; while others we may not associate with our quality of sleep: decreased motivation and energy, social or functional problems, proneness to errors at work or while driving, muscle tension, headaches, elevated blood pressure, and even gastrointestinal problems.

There are four main patterns of insomnia:

1. Difficulty initiating sleep;

2. Difficulty maintaining sleep;

3. Awakening early and unable to sleep again;

4. Consistently nonrestorative or poor sleep.

Patterns of insomnia frequently change; however, many patients with depression may have sleep onset and maintenance insomnia, whereas both caffeine and alcohol cause insomnia in the second half of the night. Several different types of medications can cause insomnia with just a few being: antidepressants, bronchodilators, beta blockers, corticosteroids, decongestants, and stimulants. Circadian disorders (abnormalities in the body’s internal “clock”) are caused by jet lag, shift work, and an irregular sleep schedule.

If you suspect you have insomnia see your doctor for a thorough physical examination and diagnostic evaluation to confirm that insomnia exists and to identify medical conditions, psychiatric illnesses, other sleep disorders, medications, or substances that may be contributing to your insomnia.

Treatment for insomnia varies; however, first line treatment is always good sleep hygiene.

Ten basic steps you or your loved ones can take to good sleep are:

1. Don’t stay in bed too long;

2. Make sure you maintain the circadian cycle (avoid jet lag, shift work, irregular sleep schedule);

3. Avoid day time naps;

4. Avoid stimulants after lunch;

5. Don’t take a toddy (alcohol) before bedtime;

6. Don’t smoke;

7. Exercise regularly and earlier in the day;

8. Don’t go to bed hungry;

9. Don’t watch TV or read in bed;

10. Keep the noise down and keep the bedroom at a comfortable temperature.

- Coral Benge, PA-C

Lose Weight “Non Diet” Way!

It’s that time of year again. The holidays are traditionally a time when people overindulge. It is not uncommon to gain 5-10 pounds on top of a weight that was not that healthy to begin with. After all, two thirds of Americans are overweight. In January, after having made our New Year’s resolutions, we will be bombarded with new diet books all promising a quick fix. Let me be the first to burst your bubble...there is no such thing as a quick fix! You did not put those extra fifty pounds on in three weeks! But, there is hope. This time try something different. A new program called Intuitive Eating helps you to identify and address the reasons for your bad eating behaviors. It is based on a book by the same name and has been used successfully with many patients in our practice. It does not require calorie counting or special foods and it really works! The class includes eight one hour sessions and a copy of the book. New day and evening sessions will be offered in January.

- Lisa Stillman, RD

Carotid Stenosis: A general approach to diagnosis and treatment

Carotid stenosis is narrowing of the carotid arteries, the neck arteries that supply the brain. The narrowing is most often the result of plaque buildup or atherosclerosis. As the arteries become more narrow, blood flow to the brain can become diminished which could lead to a stroke or transient ischemic attack (TIA).

Risk factors for atherosclerosis such as high blood pressure and high cholesterol should be aggressively treated. However, sometimes, surgical intervention is appropriate. Carotid artery stenosis can be reversed using surgery or angioplasty/stent. Angioplasty/stent is a less invasive option as the stenosis is approached going through the artery, or endovascularly, without the need for significant incision. Also, there are less inherent risks with angioplasty/stent as the need for anesthesia is diminished.

Though it has been felt that patients fare better with surgical correction of stenosis, newer studies show that angioplasty/stent may be as effective. In conclusion, people with blockage at or above 70 percent may benefit from surgical or endovascular correction, particularly in those individuals who are otherwise healthy but who have had recent stroke or TIA.

- Betsy Horton-Pawlowski, MD 

High Cholesterol and Diet

The number one question that people ask me after they have been told they have high cholesterol is “What can I eat?” Many of us would like to avoid taking cholesterol lowering medications and manage our cholesterol by diet; however knowing a little about cholesterol is helpful in knowing how to manage it.

Cholesterol is an essential fat-like substance in the body that is a building block for some vitamins and hormones. It helps process body fats and keeps the body’s cells strong and flexible. However, it is important to keep cholesterol at the recommended level in order to prevent fatty deposits on the arteries called plaques. The recommended level for your total cholesterol is less than 200. There are also two other cholesterol types - HDL and LDL. HDL (the “good” cholesterol) should ideally be greater than 60. LDL (the “bad”

cholesterol) should be 120 or less depending on other medical problems you may have.

A good way to lower your cholesterol is maintaining a healthy diet. One way to do this is to decrease your saturated and trans fat intake. Most saturated fat is found in animal fat such as highly marbled meats, poultry skins, high fat dairy, butter, eggs, and palm oils like coconut oil. Trans fats are manmade and are found in margarine, cookies, dessert mixes, chips etc. Eating foods low in cholesterol also are a good way to lower cholesterol; however, high fat foods such as the ones noted above are processed in your body to turn into cholesterol.

Therefore, a good way to maintain a healthy lifestyle and lower your cholesterol is to eat a diet rich in whole grains, fruits, vegetables, lean meats, and low fat dairy products. In addition, nutritional supplements like omega 3 fatty acids and red yeast rice will help increase your HDL and lower LDL respectively. Additional information about foods to help your lower cholesterol can be obtained from a registered dietician. Happy Eating!

- Erinn Harris-Wilson, MD

Does Eating Out Make You Fat?

As you have probably heard, America is experiencing an epidemic of overweight and obesity . Two thirds of American adults are considered overweight with a body mass index (BMI) of over 25 and one third are obese with a BMI above 30! Many factors have contributed to this, including the frequency with which we eat out. Currently, 41% of our food dollar is spent outside the home, compared with 19% in 1955. Obviously, eating out has become a fixture in our culture.

Is there anything we can do to combat its impact on our waistline? Yes! One of the best ways is to educate yourself on what you are eating. Some restaurants will provide nutrition information on their websites. A good comprehensive website with information on over 500 restaurants is www.dwlz.com . You will be surprised to learn the calorie content of the meals you are choosing, even if you are trying to be good! Other tips include avoiding buffet restaurants. The tendency to “get your money’s worth” can easily override good intentions.

Another tactic is to put 1/2 of your entrée in a to-go box at the beginning of the meal. You will still get plenty of food with only half the calories!

- Lisa Stillman, RD

MRSA Methicillin Resistant Staphylococcus Aureus

Staphylococcus aureus (Staph) is a bacteria that is carried on the skin of about 30 percent of healthy individuals. In this setting, the bacteria usually cause no symptoms. However, when the skin is damaged, even with a minor injury such as a scratch, Staph can cause a wide range of problems, from a mild skin infection to a severe, life-threatening illness, especially in young children, older adults, and people with a weakened immune system.

Staph infections were treated with antibiotics derived from penicillin, such as methicillin. Staph that can be treated with these drugs is called methicillin-susceptible  staphylococcus aureus, or MSSA. Unfortunately some strains of staph have become resistant to methicillin and other similar antibiotics. These strains are known as MRSA (Methicillin Resistant Staph), which cannot be cured with traditional penicillin-related drugs.

A person can be “colonized” with MRSA, meaning that he or she carries the bacteria on the skin or in the nose but has no signs or symptoms of the illness.

Colonization can develop in a variety of ways:

• By touching the skin of another individual who is colonized with MRSA,

• Via the tiny droplets that are exhaled during breathing, coughing, or sneezing,

• By touching a contaminated surface (such as a counter top, door handle).

Active infection with MRSA can develop when a person is colonized and the bacteria enter an opening (eg, a cut or wound) in the skin. Most cases of MRSA develop in hospitalized patients. In hospitals and other long-term healthcare facilities, MRSA can be spread from one patient to another on the hands of health care workers. Washing the hands before and after touching the patient and changing gloves between patients decreases the risk of spreading MRSA .

Community-associated MRSA infections may occur more commonly in certain populations, such as daycare centers, prisons, in the military, or in athletes who play on a team. However, many people who live in the community and develop MRSA infections have no risk factors.

Patients infected with community-associated MRSA (CA-MRSA) usually have signs of a skin infection. Such skin infections often appear spontaneously and may be mistaken for a spider bite. The skin may have a single raised red lump that is tender, a cluster of “pimples”, or a large tender lump that drains pus.

It is also possible to develop infection in other areas of the body if the bacteria enter the bloodstream through an opening in the skin. Infection can then develop on a heart valve, in a bone, joint, or the lungs, or on devices (such as pacemakers or replacement joints).

Patients with skin infections can be tested for MRSA with a culture. Results of the test are usually available in 48 to 72 hours. If MRSA is suspected, an antibiotic that can eliminate MRSA is started immediately. It is very important to carefully follow the instructions for taking the antibiotic, including taking it on time and finishing the entire

course of treatment, even if the infection improves after a few days.

Stopping the treatment early or skipping a dose could allow the bacteria to become more resistant, which could allow the infection to spread and require longer treatment. If the oral antibiotic is not effective or if the infection is causing serious illness, it may be necessary to treat the person in the hospital. The best way to prevent and control MRSA in the community is not clear.

The Center for Disease Control and Prevention has made the following recommendations:

• Keep hands clean by washing thoroughly with soap and water,

• Alcohol-based hand sanitizers are a good alternative for disinfecting,

• Keep cuts and scrapes clean, dry, and covered with a bandage until healed,

• Avoid sharing personal items such as towels, washcloths, razors, clothing, or uniforms,

• People who use exercise machines at sports clubs or schools should be sure to wipe down the equipment,

• Use of disinfectant (antimicrobial cleaning agent) on surfaces (eg, counters, door knobs, phones, computer keyboards) can help to reduce or eliminate bacteria.

- Erinn Harris-Wilson, MD

Understanding Hair Loss / Alopecia

More than half of men and women in the United States experience hair loss. About 30% of people have hair loss by age 30 years, and about 50% have hair loss by age 50 years. Hair loss is so common that most of the time it is considered a normal variation and not a disease. In general, most hair loss is not associated with systemic or internal disease. Under normal conditions, scalp hairs live for about three years; then they enter the resting phase. It is therefore normal to lose about 100 hairs every day. Common causes of hair loss are male pattern baldness, thyroid disease, iron deficiency, high fever, medications, stress, sudden weight loss, surgery, chemotherapy, childbirth. Some conditions produce small areas of hair loss, while others affect large areas of the scalp. 
Alopecia areata: A common condition, alopecia areata usually starts as a single, quarter-sized circle of perfectly smooth baldness. Alopecia patches usually regrow in three to six months without treatment. Sometimes, hair grows back in white. Alopecia areata is considered an autoimmune condition, in which the body attacks itself (in this case its own hair follicles). Most alopecia patients, however, do not have systemic problems and need no medical tests. Treatments for alopecia areata include injecting steroids into affected patches to stimulate hair growth.
Traction alopecia: Tight braids and ponytails can pull hard enough on hairs to make them fall out. If this happens, it's best to choose hairstyles that put less pressure on hair roots.
Trichotillomania: This is a habit of pulling at hairs or twisting them, sometimes without realizing it. 
Tinea capitis (fungal infection): Fungal infection of the scalp for the most part affects school-age children. Bald spots usually show broken-off hairs.
Androgenetic alopecia (male-pattern baldness): Doctors refer to common baldness as "androegentic alopecia," which implies that a combination of hormones and heredity (genetics) is needed to develop the condition.
What treatments are there for hair loss in men?
Many conditioners, shampoos, vitamins, and other products claim to help hair grow in some unspecified way. These are harmless but useless. To slow down hair loss, there are two basic options: 

Minoxidil (brand name: Rogaine): This topical application is over-the-counter, no prescription is required. It works best on the crown, less on the frontal region. Available as a 2% solution, Rogaine may grow a little hair, but is better at holding onto what's still there. There are few side effects with Rogaine. The main problem with this treatment is the need to keep applying it twice a day, and most men get tired of it after a while. In addition, Minoxidil works less well on the front of the head, which is where baldness bothers most men. This drug also comes in a higher strength, 5%, which may be a bit more effective.

Finasteride (brand name: Propecia): This is a lower-dose version of a drug that shrinks prostates in middle-aged men. Propecia is by prescription and is taken once a day. Propecia does grow and thicken hair to some extent, but its main use is to keep hair that's still there. It's therefore best for men who still have enough hair to retain. One side effect is impotence, but this is no more common than it is in the general population, and is reversible when the drug is stopped. There's also the cost, about $60/month, not reimbursed by most health insurers.
What treatments are there for hair loss in women?
Ask your doctor about minoxidil (the generic name for Rogaine). This is over-the-counter and available in 2% and 5% concentrations. It's something of a nuisance to apply, but it helps conserve hair and may even grow some. Propecia is a drug that helps men retain their hair. It is unsafe for women of childbearing age to take this drug, or even handle tablets. Propecia is safe for older women but not very effective; newer studies suggest that it might be somewhat helpful and may be worth considering. Surgical procedures like hair transplants can be useful for some women.
What are other options for hair loss?
Hairpieces, etc.:Among the time-honored ways to add hair temporarily are hairpieces or hair weaving, in which a mesh is attached to your remaining hair and artificial or human hair of similar color and texture is woven with existing hair. 
Surgery: Surgical approaches include various versions of hair transplantation (taking hair from the back and putting it near the front) or scalp reduction (cutting away bald areas and stitching the rest together). Transplant procedures have improved greatly in recent years. They can produce much more attractive and natural-looking results. When considering a hair transplant, check the surgeon's credentials and experience carefully.

- Diliana Panova, MD

Frequently Overlooked Vitamin Deficiency

The elegant 76 year old had spent the last 10 years totally disabled in a wheelchair. Yet, at every encounter, she made you feel like a dear friend and the joy of our Lord was always on her lips, in spite of, or perhaps because of..., the challenges she faced. We always ended our visits in prayer. Though I suspect she is now dancing on both legs with Jesus... I will miss her!

One triumph we shared was when Ella’s (not her real name) easy bruising cleared up after I increased her Vitamin C to 1000 mg twice a day. Unexpectedly she also became more alert and chipper. We had decided to check Vitamin C levels when it was learned that some of her routine medications blocked the absorption of Vitamin C. It thrilled me when she called me with the praise report to tell me she could not believe the difference she felt with the Vitamin C.  

Vitamin deficiency is frequently overlooked and discounted by many professionals; perhaps they are overwhelmed with the work loads practitioners endure since HMOs rule our world. Vitamin deficiency can wreak havoc on the way you feel, not only because of muscle aches, depression, and bruising, but also because of energy levels and endurance.  

Since Ella’s case, there have been nearly 30 other people who actually have had scurvy here in Fayette County. Seventy percent of our patients also have been found to be Vitamin D deficient. Vitamin D deficiency can cause leg pain, osteoporosis and hearing loss. We also know now that with Vitamin D levels greater than 50 ng/ml, there is decreased risk of breast cancer and diabetes. 

What makes matters worse: several of the medicines that are considered routine (for an internist) such as high blood pressure medications, cholesterol medications, diabetic medications, female hormones, antibiotics, and antacids can block the absorption of a variety of nutrients. For example, many cholesterol medications block co-enzyme Q10 which can cause leg pain, a weakened immune system and decreased energy. Decreased calcium can cause not only osteoporosis, but also seizures. Decreased zinc can cause loss of hair, dermatitis (dry itchy skin), as well as increased risk of infection.

Be sure you are exercising regularly and getting the correct amount of vitamins and minerals. If you are taking a medication that can cause decreased absorption of certain vitamins be aware of the symptoms you can develop. For instance, Vitamin K and Coumadin taken together without supervision can be life-threatening. Therefore it would be wise to consult your doctor before adding any vitamins to your daily health regimen.

Ella's quality of life was enhanced when we adjusted her Vitamin intake and I truly enjoyed my time with her! As you consider what vitamin and mineral supplements you might need, keep in mind that eating five or six fruits and vegetables a day is still the best way to get the proper amount of vitamins.

- Coral Benge, PA-C