Erie County Medical Society

The Erie County Medical Society, founded November 5, 1828, serves Erie County, PA with this timely and authoritative health information.

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Shingles - What You Need to Know

What Is Shingles?

Shingles is the return of an infection long forgotten from childhood.  Current medical thinking is that when a childhood case of chickenpox resolves, the virus causing it does not vanish.  Instead, it migrates from the skin, along the path of nerves, to a collection of nerve cells called a ganglion, which resides close to the spinal cord or brain.  Then, when the immunity containing the virus in the ganglia diminishes, the virus reemerges along the distribution of the nerve causing an outbreak.

What Are the Symptoms?

Symptoms usually begin with an unusual feeling in a broad localized area called a dermatome. The feeling can be a sensation of tingling, itching, or, more usually, pain.  Thereafter the area may become reddened and very slightly swollen.  Small blisters then form in the area and the sensation may change to burning, throbbing, or stabbing.  The blisters may enlarge and coalesce and the contained fluid changes from clear to cloudy.  The blisters then rupture, scab over, and gradually resolve.

Often, this ends the episode entirely; but, sometimes there are sequelae.  The most frequent of these are scars in the area and pain long after the resolution of the blisters.

Who Gets Shingles?

Shingles can afflict anyone who has previously been infected with chickenpox.  However, certain risk factors substantially increase the possibility of being afflicted.  Common risk factors include immunosuppressive therapy either for autoimmune diseases or for transplant rejection prevention, and TNF (Tumor Necrosis Factor) inhibitors such as are used in the treatment of rheumatoid disease.  

Diseases that pose risk factors for shingles are inflammatory bowel disease, rheumatoid arthritis, chronic obstructive pulmonary disease, asthma, chronic kidney disease, lymphoma, multiple myeloma, HIV, acute lymphocytic leukemia, and depression.  

However, the most common risk factor is age.  The probability of shingles increases with age and reaches 50% in those over 85 years old. Only 10% of shingles patients are younger than 20 years old.

Incidence of shingles is also reported to be higher in whites by 75% and in females.  

Since the introduction of widespread chickenpox vaccination in 1995, the incidence of shingles may decrease as the vaccinated population ages.

Can You Get Shingles Without Ever Having Been Infected with Chickenpox?

Technically, no.  But, practically, one may forget ever having had chickenpox, especially if the case was mild.  The US Centers for Disease Control (CDC) estimates that 99.5% of those born in the US and over 40 years of age have been infected with chicken pox.

Additionally, shingles is possible in persons who have been exposed to the attenuated virus by chicken pox vaccination.  However, the likelihood of shingles here is much less than in those exposed to the wild virus in community- acquired chickenpox.

Finally, children have gotten shingles because their mother contracted chickenpox when she was pregnant with them.

Can Shingles Recur?

Yes, shingles recurs in about 4% of shingles sufferers.

What Are the Consequences of Shingles?

The most common complication of shingles is post-herpetic neuralgia (PHN).  It is a continuation, or sometimes reappearance after a brief respite, of the pain that accompanies the shingles episode.  Occasionally the quality of the pain or discomfort changes somewhat.  PHN may last for months or years.  Like shingles itself, PHN also increases in likelihood with age.  50% of shingles victims over the age of 60 develop PHN.

A less serious complication from a shingles episode is localized bacterial infection from scratching the skin lesions.  More serious but rare complications are meningo-encephalitis, ischemic stroke, spread of shingles far beyond the original restricted distribution, paralysis, and blindness, deafness, or facial weakness from shingles of the face.

Is There a Test for Shingles?

Although laboratory tests for shingles virus exist, they are generally used only in unusual circumstances as in cases in which the typical symptoms do not appear or cases in which an early recognition of the attack is needed because of a patient’s low immunity.

The physician typically diagnoses shingles from the appearance of the involved skin and the history provided by the patient.

What Is the Treatment for Shingles?

The most specific treatment for shingles is one of the antiviral drugs.  These are most effective when begun within 72 hours of appearance of the rash, but they have some effect even when given later.  These drugs can both shorten and soften the attack and reduce the risk of subsequent PHN.

Nonspecifically, there are numerous options for the treatment of the pain associated with shingles and PHN.  These involve analgesics such as ibuprofen or sometimes stronger, anti-seizure medications, antidepressants, and sometimes corticosteroids.  Nerve injection is also used.  Sometimes a capsaicin cream or lidocaine path is helpful.

Of course, the best way to approach a problem is not to have it, so let us go on to discuss prevention.

Shingles Prevention - Chicken Pox Vaccination

Since shingles is reactivation of a childhood chickenpox infection, an effective approach is the two-dose vaccination against chickenpox.  It will prevent chickenpox in about 90% of those vaccinated and will shorten and reduce the severity of the chickenpox infection in the rest.  By herd immunity, it also reduces the community frequency of chickenpox, thus protecting those who cannot be vaccinated.

Shingles Prevention - Shingles Vaccination

Those who have already had chickenpox can also be vaccinated but with the single-dose shingles vaccine.  Because the incidence of shingles, and, in those afflicted by shingles, the incidence of PHN increases substantially with age, the CDC recommends shingles vaccination for all those 60 years of age and older.  The Infectious Disease Society of America is more aggressive and recommends shingles vaccination for those 50 years of age and older.

The shingles vaccine is not perfect, but it reduces the incidence of shingles by 70% in those aged 50-59, by 64% in those aged 60-69, and by a somewhat lesser amount in those 70 years of age and older.

Testing for a previous chicken pox infection is not required for shingles vaccination.  Even those with a past attack of shingles can be vaccinated, since a subsequent attack of shingles is still possible.  Of course, the shingles vaccination is not a treatment for a current attack of shingles or PHN.

Since the virus in the shingles vaccine is severely weakened, but still live, it is contraindicated in pregnancy and in those with immunodeficiency states, leukemia, lymphoma, HIV, tuberculosis, or those on immunosuppressive therapy, chemotherapy, or radiation therapy.

Conclusion

Shingles is a disease that it eventuates in a great deal of pain, suffering, and disability. Further, treatments are only partially effective in many and ineffective in some.  We are fortunate to live at a time when there are vaccines to substantially reduce the frequency and severity of chickenpox, shingles, and post-herpetic neuralgia.  All who are candidates for these vaccinations are well advised to take advantage of them to keep our lives and senior years free of disability and pain.    

Thomas Falasca, DO

SOURCES

Centers for Disease Control and Prevention – www.cdc.gov

National Institute of Health Senior Health – www.nihseniorhealth.gov

Mayo Clinic – www.mayoclinic.org

American Academy of Dermatology – www.aad.org

Massachusetts General Hospital – www.massgeneral.org

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Osteoporosis

What Is Osteoporosis?

Osteoporosis is what it sounds like, porous bone.  

Microscopically, bone appears as a network of structural supports running in all directions enclosing a vast number of spaces.  The multidirectional structures provide strength in all directions.  The spaces provide lightness as well as compartments for blood-producing bone marrow.  

This structural network is the subject of continuous activity, in which bone is being resorbed and new bone is being laid down.  But when bone resorption outpaces bone construction, the spaces enlarge and coalesce while the network structures thin or disappear.  The density gradually decreases and the bone becomes fragile and subject to fracture.  Moderate decreased density and increased fragility is known as osteopenia.  Severe decreased density and increased fragility is known as osteoporosis.  The bones most frequently fractured are the spinal vertebrae, the hip, and the wrist.

Who Gets Osteoporosis?

An estimated 10 million Americans have osteoporosis and an additional 43 million have osteopenia.  

Women are four times more likely than men to develop osteoporosis.  A great deal of this increased propensity occurs after menopause.

Frequency and site of osteoporotic fracture is related to age.

The frequency of osteoporotic fracture begins substantially increasing after the age of 50. 

Wrist fractures predominate in the age range 50-59 years.

Spinal vertebral fractures predominate in the age range 60-69 years.

Hip fractures predominate in the age range 70-79 years.

Asians and white people, especially those of northern European descent, are more likely to develop osteopenia and osteoporosis.

Other risk factors increasing the probability of osteoporosis are

Family history of osteoporosis.

Thin build or small stature.

Amenorrhea.

Late menarche.

Early menopause.

Inactivity or immobilization.

Some medications, including anticonvulsants, systemic steroids, thyroid supplements, heparin, chemotherapeutic agents, anti-psychotic drugs, and insulin.

Tobacco or alcohol use.

Androgen or estrogen deficiency.

Calcium deficiency.

Dowager hump.

Diseases such as hyperthyroidism, hyperparathyroidism, celiac disease, malabsorption, inflammatory bowel disease, rheumatoid disease, leukemia, heart failure, multiple sclerosis, and sarcoidosis.

What Are the Consequences of Osteoporosis?

The major consequence of osteoporosis is osteoporotic fracture.  These fractures can be painful, unsightly, debilitating, and lead to difficulties of digestion, breathing, and mobility as well as more fractures. Further, they impact life expectancy.

While some spinal vertebral compression fractures may be painless, other fractures of the spinal vertebrae and other bones can be quite painful, both acutely and long-term.

Spinal vertebral compression fractures lead to the infamous and unsightly dowager’s hump.  

The forward bending produced by the spinal vertebral compression fractures impedes lung expansion and compresses the abdominal contents, thus restricting gastric capacity and impacting nutrition.

The forward-bending posture effected by the spinal compressions impedes balance and gait. This leads to falls and additional fractures.

Following hip fracture, only one third of patients return to their previous level of functioning and one fifth require long-term nursing home care.

Persons having experienced a hip fracture have twice the likelihood of another fracture as persons without fracture.

Vertebral fracture increases the five-year mortality risk by 15%.

Hip fracture is associated with a one-year mortality increase of 20%.

What Are the Signs of Osteoporosis?

Some signs of osteoporosis are shortening and curvature of the spine frequently manifested as a forward bending posture.  But osteoporosis is often a silent disease that doesn’t manifest itself until an osteoporotic fracture occurs.

What Are the Available Tests?

Because osteoporosis is largely a silent disease, testing is important to determine if osteoporosis is present or if bones are losing density to a serious degree.  Several testing modalities are available.

DEXA scanning is the current standard for evaluating bone mineral density and consequent fracture risk. It is used to calculate bone mineral density at the lumbar spine, hip, and upper thigh.  

Peripheral DEXA scanning is used to evaluate bone mineral density at the wrist.  It is used to evaluate patients at very low fracture risk. Its ability to predict spinal vertebral fracture is lower than DEXA done at the lumbar spine.

QCT scanning is used to measure bone mineral density in the lumbar spine.  It is somewhat more sensitive than DEXA but requires a higher radiation dose.  Currently, only about 5% of all bone mineral density evaluations are done by QCT.

QUS differs from DEXA, peripheral DEXA, and QCT in that the DEXAs and QCT are x-ray modalities, while QUS is an ultrasound modality, done at the heel, and achieving measurements by means of sound waves.  Although low-cost and portable, QUS does not have the accuracy of the two DEXA scans or QCT. Additionally, QUS is not used for tracking skeletal changes over time or monitoring response to treatment.

Who Should Be Tested, and When?

The National Osteoporosis Foundation (NOF) recommends bone mineral density testing for all women 65 years of age or older and all men 70 years of age or older.  It further recommends testing for all post-menopausal women with risk factors and all men over 50 years of age with risk factors, such as those indicated above.

For patients diagnosed with osteoporosis, the NOF recommends re-testing 1-2 years after beginning treatment and at 2-year intervals thereafter.

For those without major risk factors and who test in the normal range, the NOF states only that longer re-test intervals are acceptable.

The best advice is to consult your physician about the need for bone mineral testing, the type of testing appropriate for you, and the appropriate testing interval.  Your physician is in the best position to tailor the guidelines to your specific health situation.

Treatment Choices

Your physician now has more treatment choices than ever to offer those affected by osteoporosis. Bisphosphonates can inhibit bone resorption.  Additionally, there are estrogens, calcitonin, parathyroid hormone type drugs, selective estrogen receptor modulators, monoclonal antibodies, calcium salts, and vitamin D. Finally, there are braces to redistribute spinal forces, and even interventional techniques such as kyphoplasty.

Prevention

The best way to deal with a problem is not to have it!  Accordingly, prevention is paramount in any approach to osteoporosis.  Of course, preventive measures cannot guarantee that osteoporosis will not occur, but these measures greatly reduce the chances. Imperfect prevention is certainly better than no prevention!  

In osteoporosis prevention, here are some key elements:

Stop smoking.

Moderate alcohol consumption.

Engage in weight-bearing exercise. 

Insure adequate calcium and vitamin D intake.

Consult with your doctor about periodically evaluating bone mineral density.                                                                                                                          

Conclusion

Your best defense against osteoporosis is awareness.  This includes preventive measures, risk factors, consequences, and the availability of bone mineral density testing and treatment options.  Such awareness can enable you to avoid disfigurement, disability, and even life shortening consequences.

Thomas Falasca, DO

SOURCES

National Osteoporosis Foundation         nof.org NIH Senior Health                                   nihseniorhealth.gov       American College of Rheumatology       rheumatology.org

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Food Safety

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FOOD POISONING AVOIDANCE

DEFINITION

Food poisoning is any illness caused by the consumption of food or water contaminated with bacteria or their toxins, or by parasites, viruses, or chemicals.

INCIDENCE

The US Centers for Disease Control and Prevention (CDC) estimates 1 in 6 Americans (48 million people) are affected by foodborne illness annually and that 128,000 people are hospitalized and 3,000 die.

SYMPTOMS

Most cases of food poisoning are mild and self-limiting.  They produce symptoms of abdominal pain, headache, vomiting, diarrhea, and bloating.  Occasionally, the stool may be mucous or bloody, especially if bacteria are not confined to the lumen of the intestine but manage to penetrate the intestinal wall. Some food-borne microbes can produce a transient arthritis.  

The more serious types of food poisoning can produce life-threatening symptoms that affect the kidneys, liver, and nervous system.

HOW DOES FOOD AND WATER GET CONTAMINATED?  

Food poisoning is caused by the consumption of contaminated food or water. Contamination occurs during production, processing, distribution, or preparation.

Production Contamination

A sick hen can produce eggs that are contaminated even before they are laid. 

Contaminated water used for irrigation can contaminate the fruits and vegetables before they are harvested.   

Fish may become contaminated from the smaller sea creatures that they ingest.

Processing Contamination

Contaminated water used to wash fruits and vegetables can contaminate those foods.

Peanut butter can become contaminated if roasted peanuts are stored in unclean conditions or contact contaminated unroasted peanuts.

During the animal slaughter process, bacteria from the animal’s intestines can contaminate the meat.

Distribution Contamination

Refrigeration interruptions during storage or transportation can allow temperatures to rise sufficiently to allow bacterial growth. 

Fresh produce can be contaminated if transported in a truck that was not cleaned after transporting animals or animal products.     

Container or packaging damage during transportation can permit bacterial growth.

Preparation Contamination

Food preparation workers who do not adequately wash hands can spread pathogens from their hands to food.

Utensils such as knives or cutting boards used on raw poultry can, if not thoroughly washed, contaminate fruits or vegetables upon which they are subsequently used.

AN INCREASING PROBLEM

Although information is difficult to evaluate because of underreporting, the CDC is concerned that cases of food poisoning have been on the rise in recent years.  Some of the factors contributing to the increase are

Increases in imported foods, with over 50% of outbreaks being related to imported foods.

Changes in the environment.

Emerging bacteria and antibiotic resistance.

ANTIBIOTIC RESISTANCE

Injudicious use of antibiotics on the farm kills or arrests sensitive bacteria and allows resistant bacteria to proliferate. If these are transmitted from food-producing animals to humans through the food supply, they can produce severe, antibiotic-resistant infections in humans.

The Centers for Disease Control and Prevention (CDC) supports the US Food and Drug Administration (FDA) recommendation that antibiotics important in treating humans be used in food-producing animals only under veterinary oversight and only to address animal health needs, not to promote growth.

PREVENTION

Due to a variety of factors, including warmer temperatures, foodborne illness increases in summer. Stay healthy and safe during warmer months by following these food safety recommendations:

At a picnic or cookout:

Use an insulated cooler filled with ice or frozen gel packs.  Frozen food is also a cold source.

Foods that need to be kept cold include raw meat, poultry, and seafood; deli and luncheon meats or sandwiches; summer salads (tuna, chicken, egg, pasta, or seafood); cut up fruit and vegetables; and perishable dairy products.

A full cooler will maintain its cold temperature longer than a partially filled one.  Keep the cooler out of the direct sun by placing it in the shade.

Avoid opening the cooler repeatedly to keep your food colder longer.

When cooking on the grill:

Use separate cutting boards and utensils for raw meat and ready-to-eat items like vegetables or bread.

Keep perishable food cold until it is ready to cook.

Use a food thermometer to make sure meat and poultry are cooked thoroughly to their safe minimum internal temperatures.  

Beef, Pork, Lamb, & Veal (steaks, roasts, and chops): 145 °F with a 3 minute rest time

Ground meats: 160 °F

Whole poultry, poultry breasts, & ground poultry: 165 °

Always use a fresh, clean plate and tongs for serving cooked food.  Never reuse items that touched raw meat or poultry to serve the food once it is cooked.

When serving food outdoors:

Perishable food should not sit out for more than two hours.  In hot weather (above 90 °F), food should NEVER sit out for more than one hour.

Serve cold food in small portions, and keep the rest in the cooler.  

After cooking meat and poultry on the grill, keep it hot until served – at 140 °F or warmer by setting it to the side of the grill rack.

When food shopping:

Check “sell-by” and “use-by” dates.  Do not buy products that are out of date.

Do not buy or use damaged, swollen, rusted, or dented cans.

Choose unbruised fruits and vegetables.

Do not eat “self-serve” foods or free food samples.

Do not buy or use cracked eggs.

As a rule, do not buy or use unrefrigerated eggs.  Eggs that have been treated to destroy Salmonella–by in-shell pasteurization, for example–are not required to carry safe handling instructions, but the labeling will usually say that they have been treated.

Pick up frozen and refrigerated items just before you check out at the grocery store.

Refrigerate groceries right away, and never leave perishable foods out for more than 2 hours.

Separate raw meat, poultry, and seafood from other items in your shopping cart and in your grocery bags.

When dining out:

Avoid high-risk food sources, such as salad bars, delicatessens, buffets, potlucks, and street food vendors.

Do not eat raw fruits or vegetables (i.e. salads) when eating out since you cannot be sure that these foods were properly washed.

Avoid “fresh-squeezed” juices; always ask if juices are pasteurized.

When taking food to-go, always put the food in the to-go container yourself instead of having the server do it for you.

Leftovers

Before eating leftovers, be sure to reheat them to 165 °F, and use a food thermometer to measure the temperature.

CONCLUSION

        Food poisoning is an item no one wants on his or her menu.  It is unpleasant at best and fatal at worst.  The Erie County Medical Society offers these recommendations to keep food poisoning off your menu and out of your diet for the summer and all year round.  Bon appetite!

MORE INFORMATION

        Further information on food poisoning and food safety is available from these sources:

·      Centers for Disease Control and Prevention www.cdc.gov

·      FoodSafety.gov www.FoodSafety.gov

·      US Food and Drug Administration www.fda.gov

 Thomas Falasca, DO

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What You Need to Know about Zika Virus

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Zika Virus - What You Need To Know

What Is Zika?

The Zika virus is a mosquito-transmitted infection, like yellow fever and West Nile. It was first identified in the Zika Forest near Entebbe, Uganda, in eastern Africa, in 1947.  The forest is protected for scientific research and is home to about 40 varieties of mosquito.  

Initially, the virus was found only in Africa and Asia, but it made its first appearance in the Western Hemisphere in Brazil in May 2015.  Since then, Zika has arrived in the United States by way of travelers returning from Central and South America. The fact is that it is here now and can spread here now.

Transmission

The virus is primarily transmitted by the “bite” of the female mosquito of the species Aedes. The “bite” is actually the penetration of the skin by the fine microtubular proboscis of the mosquito and the acquisition of the victim’s blood through the proboscis.  The female mosquito needs the blood in order for its eggs to develop, but the virus from the blood distributes through the mosquito’s body and eventuates in the mosquito’s saliva.  When the mosquito “bites” its next victim, it injects saliva before withdrawing blood.  The saliva contains anticoagulants that prevent the blood from clogging the microtubule of the mosquito’s proboscis.  But, upon injecting the saliva, the mosquito transmits the virus to its next victim.  The victims consist of both human and non-human primates.

Other Transmission

In addition to mosquito transmission, Zika infection can also be transmitted sexually, as well as during pregnancy and delivery.

There have been a few reported cases of men sexually transmitting the virus to women. This mode of transmission may be more prevalent than initially thought.  It is not known if women can sexually transmit the disease to men.

Additionally, pregnant women can transmit Zika virus to their developing fetus as well as to the infant at delivery.  Additional studies are needed to determine the frequency with which maternal infection becomes fetal infection and the frequency with which fetal infection results in birth defects.

Further, there have been reported cases of Zika virus being transmitted by blood transfusion and laboratory exposure.  

Finally, the Zika virus has been found in the breast milk of infected mothers.  It is unknown at this point whether the virus can be passed to breastfed offspring by breastfeeding.

Clinical Course

Once infected, the victim may begin to exhibit symptoms in 2 to 12 days.  Once begun the symptoms last for 2 to 7 days.  It is thought that the virus remains in the blood of infected persons for about a week; however, it can remain longer, but not indefinitely. Once patients recover, they are immune.

Symptoms are usually quite mild and include fever, rash, joint pain, eye inflammation, muscle pain, and headache.  All of these symptoms may not appear.  Notably, only 1 in 5 infected people develops symptoms.

Complications

Superficially, Zika doesn’t seem so bad.  But, the devil is in the complications.  One of these affects the offspring of a woman infected with Zika during pregnancy. Another affects the victim his or her self after they seem to have recovered from the infection.

Microcephaly is a birth defect in which babies are born with small heads and damaged brains.  Some cases have no identified cause, but others have been related to infections by rubella, toxoplasmosis, and cytomegalovirus during pregnancy. Importantly, doctors in Brazil identified a sharp increase in this condition 5 months after Zika virus infections first appeared there.  While Brazil documented 147 cases of microcephaly in 2014, it had 4180 reports from October 2015 through January 2016, inclusive.  While many of these cases may not prove to be Zika related, the indications are worrisome and are being evaluated by Brazilian authorities and the World Health Organization.

Guillain-Barré Syndrome is a paralysis lasting weeks to months and occasionally having permanent consequences.  It most frequently affects a patient after apparent recovery from a viral or bacterial infection.  Brazil has reported increased numbers of GBS among patients previously infected with Zika. Also, in 2013 in French Polynesia, associated with a Zika outbreak there were 42 cases of GBS; this was 8 times the expected number.  Both situations are being investigated.

Testing

Two types of laboratory testing are available for Zika.  

The first detects the presence of virus.  It can reveal the disease early when the levels of virus in the blood are high. But, after the virus clears the blood, it can still be present in seminal fluid, possibly rendering male patients contagious.

The second detects antibodies to the virus and becomes effective after the first week or so of infection.  Thereafter, it remains positive so may not distinguish between a present active infection and a past infection.  Additionally, it can be cross-reactive with related virus infections and may even react falsely positive to past yellow fever vaccination.

The moral is that tests must be interpreted and related to other diagnostic information. They don’t provide automatic answers in and of themselves.

Finally, at the time of this writing, the tests are not commercially available. They are performed only at the CDC and at some state and local health departments.  They are not sufficiently available to be used unsparingly and must be reserved for specific cases.

Treatment

The treatment for Zika infection is symptomatic and supportive.  It consists of rest, fluids to avoid dehydration, and acetaminophen for fever and pain.  

Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) are discouraged.  These drugs can have adverse effects on blood clotting.  But a disease known as dengue can also have adverse effects on blood clotting; and, dengue and Zika are transmitted by the same mosquito and can be confused.  If dengue is mistaken for Zika they and aspirin or NSAIDs are administered, the bleeding can be worsened.  So, until dengue is ruled out, aspirin and NSAIDs are contraindicated.  

Further, Zika patients should, as a public health measure, protect themselves from mosquitoes.  This will prevent previously uninfected mosquitoes from obtaining the virus from patients and transferring it to healthy persons.

There is no specific antiviral drug treatment for Zika.

Efforts are underway to develop a Zika-preventing vaccine but this may not be available for some time.

Prevention

While in certain circumstances pregnancy avoidance and condom use are important in Zika prevention, the mainstay of prevention is mosquito protection.

Mosquitoes are the most active agent in the spread of this disease and the mosquitoes that spread it are of the species Aedes. These are aggressive indoor and daytime “biters” and are found in most parts of the United States.  63% of the US population lives in areas where the disease can easily spread by this method.  Many others visit these areas.

Here are some tips for mosquito protection.

Eliminate sources of standing water. The mosquitoes involved can multiply in sources as small as flower vases and even bottle caps.  

Stay in air-conditioned or screened rooms as much as possible.

Use an EPA-approved mosquito repellent.  These repellents are evaluated by the Environmental Protection Agency for safety and effectiveness.  Reapply the repellent as directed.  Always apply the repellent over sunscreen when using both.

Wear long-sleeved shirts and long pants

Cover baby carriers with mosquito netting.

Sleep under a mosquito net if outside or overseas.

Choose travel destinations judiciously. 

Consult the Centers for Disease Control and Prevention (CDC) website, CDC.gov, for areas where Zika is prevalent.   

Consult directions about not using insect repellent under clothing, around face or eyes, and on children.   

When needed use permethrin-treated insect repellent clothing as mosquitoes can “bite” through clothing that is not sufficiently durable.

Avoid mosquitoes even if you are already infected, at least for the first week of illness.  This prevents mosquitoes from transmitting your virus to a healthy person.

The following measures can reduce the risk of sexual transmission.

British health authorities have urged men returning from areas in which the virus is circulating to remain abstinent or use condoms for 28 days.

The CDC has said that pregnant women whose male partners have spent time in these areas should abstain from sex or have their partners use condoms during intercourse for the duration of the pregnancy. Guidelines may change once more is known.

Other measures can reduce the risk of fetal transmission.

The CDC advises pregnant women not to travel to countries and territories in Latin America and the Caribbean where the Zika virus causing infections.  The list of these areas is constantly updated and the current list is available at www.cdc.gov.

The CDC recommends that all pregnant women who have traveled to a place with a Zika outbreak get tested 2 to 12 weeks after returning especially if they develop a fever, rash, joint pain, or red eyes during their trip or within 2 weeks after.

Pregnant women without symptoms of Zika who continue to reside in Zika- prevalent areas should have blood testing for Zika at the beginning of pregnancy care and mid-term.

Finally, to reduce the risk of Zika transmission via transfusion, the US Food and Drug Administration suggests that blood donors defer donation if they have been the sexual partners of men who had visited a Zika-endemic area in the 3 months prior to sexual contact.

The Future

An interesting development on the horizon is OX513A.  This is a genetically modified male Aedes mosquito designed by the British company Oxitec.  It is designed to stop the spread of Aedes-vectored infections by passing on a gene that causes death to its offspring.  Since the female Aedes only mates once, this effectively eliminates her from the reproductive pool.  The OX513A also carries a fluorescent marker so that he can be easily tracked during field trials.  One of these was conducted in Brazil in 2011 and was reported as eliminating 99% of the target population.

Conclusion

So we can understand the concern of the physicians and scientists at the World Health Organization (WHO) and the United States Center for Disease Control and Prevention.  Zika is spread by a vector that we don’t seek or accidentally encounter; it is spread by a vector that actively seeks us.  It avoids the radar because most of those infected never become ostensibly ill. Although almost invisible in the current generation, it can cause substantial morbidity in the following generation.  The habitat of the vector is growing because of climate change.  The chances of encountering the vector in its native habitat are growing because of greater world travel.  Therefore, scientists believe that the disease will become locally transmitted in every country in the Western Hemisphere except Canada and Chile.

Hopefully, with the innovation of measures such as OX513A, vaccine development, and expanded knowledge and practice of mosquito protection, the threat of local spread of Zika in our area will be contained.

Thomas Falasca, DO

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Cold Hands

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Cold Hands - Innocent or Not?

Who Gets Cold Hands?

Cold hands or feet in wintertime are commonplace.  Sometimes, however,cold hands can be a sign of something more serious.  Here are things you need to know about what is innocent, serious, or emergent.

When It’s Innocent

Cold hands can be a normal response to stress.  Under stress, the body tends to divert blood away from skin and peripheral areas of the body in order to better supply muscles and vital organs.

Intense cold hands also occur in response to decreased temperature.  First, cold is a stress.  Second, heat dissipates more rapidly from peripheral and well perfused areas of the body as hands, feet, and head.  Third, the body responds to this heat loss by decreasing circulation to the hands and feet in order to reduce the heat loss.

But about 10% of people have an exaggerated response to stress and especially to cold.  This is called “primary Raynaud phenomenon.”  In addition to feeling cold, the hands or feet often exhibit a color change that begins with white, then becomes blue, and finally shifts to red when circulation returns.  Pain, tingling, or numbness may also occur in the affected area.

These changes are bilateral and symmetric, i.e., they occur to a similar extent and at the same time on both left and right.  Women are more subject to these changes than men.  The phenomenon often begins in a person’s teens or twenties and tends to persist.

This situation is innocent when the episodes are short-lived, reverse rapidly on rewarming, and involve no other changes.  The phenomenon very rarely becomes serious when the decreased blood flow to the affected area results in tissue damage.  Some evidence suggests that persons exhibiting the Raynaud phenomenon have a somewhat increased risk of cardiovascular disease.

When It’s Serious

Raynaud phenomenon is serious when it is associated with tissue damage and when there is an identifiable underlying cause.

The underlying cause can be an occupational disease, blood disease, autoimmune disease, infectious disease, metabolic disease, malignant disease, or even a medication.

Some of the occupational causes are past frostbite, or other injury, use of vibrating tools, lead or arsenic exposure, and exposure to organic solvents such as polyvinyl chloride, xylene, toluene, or acetone.

Some blood diseases associated with the phenomenon are polycythemia, cryofibrinogenemia, and paroxysmal nocturnal hemoglobinuria.

Autoimmune diseases implicated in the phenomenon are scleroderma, lupus erythematosis, rheumatoid disease, vasculitis, and Sjøgren Syndrome.

Infectious diseases associated with Raynaud phenomenon are hepatitis infections associated with cryoglobulinemia and Mycoplasma infections with cold agglutinins.

Metabolic diseases with links to Raynaud phenomenon are diabetes mellitus, pheochromocytoma, myxedema, and acromegaly.

Malignant diseases related to Raynaud phenomenon are leukemia, lymphoma, myeloma, and adenocarcinoma of the lung.

Finally, even medications can be associated with Raynaud phenomenon.  Some of these are oral contraceptives, ergot alkaloids, beta-blockers, cyclosporin, methylphenidate, and some cancer chemotherapeutics.

When It’s an Emergency

Of course, a white or blue color change that doesn’t rapidly reverse, or that reverses and then becomes painful or numb, is an emergency.  This is especially true  if the affected area had become white and hard or if it had been subjected to prolonged immersion in cold water.  The problem here may be frostbite, thromboangitis oblterans, or arterial embolus.  These circumstances warrant a trip to the hospital emergency room.

What To Do

The treatment for Raynaud phenomenon depends on whether it is innocent, serious, or an emergency.

The treatment for innocent Raynaud phenomenon is straightforward.  Insofar as possible, avoid exposure to cold air, cold liquids, and cold surfaces.  Wear substantial gloves, or preferably mittens, and substantial socks.

Since circulation to hands and feet is reduced to prevent further loss of heat from the body in general, it is important to avoid overall heat loss.  Drss warmly in general and wear a substantial hat, since a great deal f heat is lost from the head and face.

Avoid smoking and caffeine as these reduce blood flow to the extremities.

Report these symptoms to your physician since some of your medications may contribute to the problem and your physician may want to reevaluate them.

The treatment for serious Raynaud phenomenon is more complex.

Of course, the common sense solutions still apply.  It is always good sense to avoid cold exposure, dress warmly, and stop smoking.

But now, you need to have your physician evaluate you.  First, you may have one of the aforementioned underlying diseases that can cause Raynaud phenomenon.  These diseases may require treatment in themselves; and, the Raynaud may not improve unless the underlying problem is addressed.  Second, your physician may be able to offer medical treatment that makes the phenomenon less troublesome.

Finally, if the problem is an emergency, you need to go to the hospital emergency room.  Conditions such as frostbite, thromboangitis obliterans, and arterial embolus require serious intervention, or even surgery, to prevent possible loss of fingers, toes, or an extremity.

So Now You Know

Now you understand some of the mechanisms behind cold hands and when this phenomenon is exaggerated.  You know that if this problem bothers you, avoid cold, dress warmly including mittens and a substantial hat, and avoid caffeine.  And, you now have one more good reason to stop smoking!  If the phenomenon is particularly troublesome, consult your physician.  If the white or blue discoloration does not rapidly reverse or is accompanied by pain or numbness, visit the hospital emergency room.  Armed with this knowledge, you should get more enjoyment from the colder months.

Thomas Falasca, DO  

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Seasonal Flu

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Seasonal Flu

What Is Flu?

Influenza, or “flu,” is a highly contagious respiratory illness that occurs in seasonal epidemics.  An episode of flu typically runs its course over several days.  Although usually just a severe nuisance, flu can sometimes result in respiratory failure and death.

Symptoms

An attack of influenza is usually accompanied by muscle aches, headache, fever, sore throat, red watery eyes, runny nose, and cough.  Only some of the symptoms may be present.

These symptoms sound like a cold, and like a cold, flu is a respiratory infection. However, influenza is caused by a different virus and is more severe.

Severity

Each year about 200,000 Americans are hospitalized because of flu complications. The number of deaths varies depending on the annual virus strain; but American deaths have recently ranged from 3,000 to 49,000 in a year.  While human lives are most important, it is noteworthy that even mild strains of the flu can impact the American economy by $10 billion annually in lost productivity.

Contagion

Influenza is typically spread by the aerosol droplets propelled in the course of a cough or sneeze.  Even people six feet from a sneeze are at increased risk of infection from these micro particles.  

Flu can also be spread from surfaces.  If a person coughs into their hand or sneezes into a handkerchief and then touches an object such as a doorknob or computer keyboard, that object becomes contaminated. A person who touches the object shortly afterward can be infected, usually when they transfer the virus from their hand to a mucous membrane such as the nose, mouth, or eye.

Because of the high level of contagion, it is important that flu patients remain home to avoid infecting coworkers.

Infectivity

Once a person becomes infected by the virus, it takes 1 to 4 days before they exhibit symptoms.  However, they may transmit the virus to others even before symptoms become evident. Thus it is not sufficient to avoid persons who appear to be sick.  It is important to make a habit of frequent hand washing as this can reduce both virus dissemination and acquisition.

Complications

Occasionally influenza does not run its normally uneventful course, but instead results in complications.  Some of the most serious of these are viral pneumonia, bacterial pneumonia, respiratory failure, an inflammation of the heart (myocarditis), an inflammation of the membrane surrounding the heart (pericarditis), and multiorgan failure.

Vulnerability

Fatalities are most common in infants and the elderly. Thus it is important that senior citizens receive vaccination, the “flu shot.”  Vaccination is also important for pregnant women.  Pregnant females are not at risk from the flu shot and they need vaccination because they are at increased risk of complications from flu and they need to pass on their immunity to the newborn.

Others who are at increased vulnerability are those who are immunocompromised from disease or chemotherapy.

Pandemics

A pandemic is an epidemic that occurs over a broad area.  Four flu pandemics have occurred in the last century.  These epidemics occurred when a highly contagious and aggressive strain of the virus emerged.  

The infamous “Spanish flu” of 1918 killed nearly 675,000 people in the US and a possible 50 million people worldwide.  

The “Asian flu” of 1957 killed about 69,800 people in the US.  

The “Hong Kong flu” of 1968 took the lives of 33,800 people in the US.  The relatively modest number may have been largely due to the availability of antibiotics to treat secondary bacterial infections.  

The “swine flu” of 2009 caused between 9,000 and 18,000 deaths.  The reduced number of deaths in this epidemic may have been due to the fact that 80 million people were vaccinated.

Flu Vaccination Does Not Cause Flu

Vaccination against flu can be by injection or nasal spray.  The injection contains virus that is inactivated (“killed”). The nasal spray contains virus that is attenuated (“weakened”) and so altered that it can be active only at the cooler temperatures of the nose and not in the warmer temperatures of the lungs. The result is that flu vaccination does not cause the flu!

Vaccination Side Effects

Serious vaccination side effects are quite rare.  They are circumvented by avoiding certain flu vaccinations in specific groups of people.

Traditionally, flu vaccine was produced using chicken eggs and was contraindicated in persons with egg allergy.  Since 2012 a vaccine prepared in a different manner has been available for persons 18 years of age and older who are allergic to eggs.

An inactivated virus vaccination rather than an attenuated virus vaccination is generally appropriate for persons with weakened immune systems congenitally, from illness, or from chemotherapy.

In short, some type of flu vaccination should be appropriate for most individuals 6 months of age and older.

So If I Get Vaccinated, I Can’t Get the Flu, Right?

Not quite!  In the recent past flu vaccination has had 70% effectiveness against influenza B and 60% effectiveness against influenza A.  This is so because

The US Center for Disease Control (CDC) must project in advance the virus strains of the upcoming flu season.

Different individuals have different capabilities of manufacturing antibodies in response to the stimulus of the vaccine.

It takes 1-4 days after infection for flu symptoms to emerge.  Persons can be infected before they receive the vaccination.

It requires 7-14 days for the body to build antibodies from the stimulus of the vaccination. Vaccinated people can be infected with flu during this time period.

Symptoms of flu can be simulated by other virus infections.  Flu vaccinated persons who seem to get the flu may have these other infections.

How Can I Prevent the Flu?

The best method of dealing with the flu is not to have it!  In order to greatly reduce chances of getting the flu, it is most important to take these precautions:

Practice frequent hand washing, especially after contact with objects touched by infected persons or the general public.

Avoid proximity to infected persons.

If infected, stay home and avoid contact with others. Bear in mind that you are infectious for 4-9 days after onset of symptoms.

Finally, present yourself for vaccination.  This is your surest way of protecting yourself from flu.  As an added benefit, remember that by getting vaccinated, you are also protecting newborns, elderly, chemotherapy patients, and others unable to fully benefit from their own vaccination.

Conclusion

So please stay well this season and protect yourself from flu.

Thomas Falasca, DO

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Tinnitus

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Ringing in the Ears

What It Is

Ringing in the ears is technically known as tinnitus, which is the perception of sound in the ears or the head in the absence of any outside sounds.  Although the word comes from the Latin tinnire, “to ring,” it can also be a buzzing, roaring, or static sound.

Population

A proportion of 10-15% of the US population is estimated to experience tinnitus according to a US Government Survey of 2012.  Incidence increases with age, male sex, exposure to loud noise, and hearing loss.

Causes

Tinnitus is sometimes associated with medical conditions such as high blood pressure or with states of increased blood flow such as anemia, overactive thyroid, or pregnancy. 

Occasionally, the cause is an anatomic process within the head or neck. This could be as simple as impacted ear wax. But it could be as serious as a carotid artery problem or tumor.  Indicators of this type of seriousness are tinnitus that changes with heartbeat or tinnitus that is one-sided.  These should be immediately evaluated by a physician.

Medications have been known to cause tinnitus.  Some of these are nonsteroidal anti-inflammatory drugs, especially high dose aspirin; diuretics such as ethacrynic acid, furosemide, and bumetanide; chemotherapeutic agents, especially the platinum agents; quinine based medications and herbals; some blood pressure medications; and, some antibiotics.  Medication induced tinnitus may be permanent or reversible.

Frequently, the cause of the tinnitus is never identified.  In this case the more reasonable expectation is that the condition be managed rather than eliminated.

Treatment

If the tinnitus results from a medical condition, then that underlying medical condition can be treated and the resulting tinnitus may resolve.

If the tinnitus results from a medication, then the medication can be switched and, again, the resulting tinnitus may resolve.

Anatomic tinnitus can be treated with simple procedures or with various surgeries.  Again, this can produce resolution or improvement.

The remaining cases are more difficult to treat.  

Niacin is an old remedy for tinnitus.  If patients can tolerate the flush it produces, they frequently report some relief.

Melatonin 3 mg at bedtime may not directly affect the tinnitus, but it can help with the insomnia that tinnitus can help cause.

Nortriptyline 50 mg at bedtime can be helpful if it is taken for at least three weeks and patients can tolerate any resulting dry mouth. 

Paroxetine 10 mg at night or sertraline 50 mg daily has also been reported helpful. 

Otherwise, masking the tinnitus with low-level white noise is a method that has been used for over half a century.  The devices resemble hearing aids and are worn during the day.  Of those referred for such devices, about one sixth eventually wear the device and report some benefit.  For patients troubled mostly at night, a bedside radio may suffice.  Masking tinnitus during the night often has some residual effect the following day.

Relaxation training doesn’t directly reduce the tinnitus but may reduce the distress cause by it.

Repetitive transcranial magnetic stimulation stimulates the brain through the intact scalp and seems to induce changes in the brain’s excitability that persist beyond the period of stimulation.  There are reports of its effectiveness in treating tinnitus.

Hearing aids have also been used in the treatment of tinnitus.  The best way to determine if a hearing aid will help is through a trial.  Hearing aids seem helpful in about half of cases.

Conclusion

Tinnitus can be a complex problem.  Frequently there is no simple solution that works perfectly or for everyone. Nevertheless, tinnitus can be treated. Dedicated patients and understanding physicians together can often find a way to manage the problem.

Thomas Falasca, DO

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High Blood Pressure

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High Blood Pressure

Incidence

Definition

Consequences

Causes

Treatment

Lifestyle Modification

Medication

Conclusion

Thomas Falasca, DO

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Migraine

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Master Your Migraine

Definition

Migraine is not an ordinary headache.  It is a moderate to severe headache with a throbbing sensation at one area of the head.  It is frequently accompanied by nausea and vomiting and often with profound sensitivity to light and sound.

Incidence

In the US, 30 million people suffer from migraine.  75% of these are women.  70% of migraine sufferers have a first-degree relative with a history of migraine, but the inheritance depends on many factors

Prodrome

About 60% of migraine patients experience “warning” sensations hours or days before the headache.  The “warning” sensations may include lethargy, depression, or loss of appetite

Aura

Sometimes, reportedly 20% of the time, the migraine is accompanied by disturbances that are visual, sensory, motor, or verbal.  These migraines are referred to as “classic migraine” or “migraine with aura.”  The aura may consist in flashes of light, visual loss, prickling or “pins and needles” sensations, or speech problems.  The aura usually resolves in a few minutes.

The 80% of migraines without these disturbances are called “common migraine” or “migraine without aura.”  The headache itself feels the same and responds to the same treatments.

Postdrome

After resolution, the headache may be followed by a day of postdrome.  This may include feelings of fatigue, euphoria, weakness, or loss of appetite.

Migraine Triggers

Some factors have been identified which seem to trigger migraine attacks.  These include stress, head trauma, changes of sleep pattern, and certain medications.  Hormonal changes related to menstruation, ovulation, oral contraceptives, and hormone replacement can also be migraine triggers.

Testing

Although your doctor can usually diagnose migraine on the basis of medical history, symptoms, and physical examination, tests are sometimes needed to rule out other causes if the headache problem is unusual or suddenly intensifies.  Such studies can involve blood tests, CT scan, MRI, and occasionally lumbar puncture.

Treatment

Although migraine is not, strictly speaking, curable, a number of treatments are available to alleviate an attack and to reduce the number of attacks.  If headaches occur only occasionally, a medication taken at the onset of an attack may suffice.  For more frequent headaches, medication may be needed on a continuing basis.  Lifestyle changes may also reduce headache frequency and intensity.  A consultation with your doctor will reveal the headache treatment option best for you. 

Getting the most from your doctor appointment

Since there is much to discuss at your doctor appointment, you can get the most from it by being well prepared.  Here are some tips:

Make a list of your other health conditions.

Make a list of all medications and vitamins or supplements that you are taking.  Better yet, take the labeled bottles with you.

Explain your headaches precisely, including

When the headaches first began

How often you get the headaches

How severe are the headaches

Conditions that improve or worsen the headaches

Whether anyone in your family experiences these headaches

Write down the questions you want to ask your doctor.

Take someone to the appointment with you.  A companion may remember some of the information or instructions that you forget.

Emergency Room

Some headaches signify something more severe than a common headache or even a migraine attack.  These headaches, which should prompt an immediate trip to the emergency room, are

Abrupt, severe headache

Headache with stiff neck, fever, confusion, seizures, double vision, or trouble speaking

Headache after a head injury

Headache that is worse after coughing, exertion, straining, or sudden movement

New headache occurring after the age of 50

You don’t need to suffer

Most migraine is effectively treatable.  Medication and lifestyle changes can greatly reduce your headache suffering.  By all means, see your doctor for the treatment option that is best for you!

Thomas Falasca, DO