How to decrease your chance of getting a blood clot while traveling?

How to decrease your chance of getting a blood clot while traveling?

Burning Man 2020

Asymptomatic blood clots, otherwise called deep venous thrombosis (DVT), is most common form, occurs in 2-4% of high-risk travelers.

What is a “high-risk” traveler?  Currently have cancer, recently given birth, obesity (BMI more than 30), long travel, recent surgery, hormone therapy, and previous history of a blood clot.

Do compression stockings help?  Yes! There was a recent study that looked at how well do compression stockings work in flights >5 hours to help patients NOT get a blood clot. The bottom line is that compression stockings ARE effective in asymptomatic DVTs in both high and low risk populations. The number needed to treat (NNT) is 37 in high-risk individuals.  This means that 37 people will wear compression stockings for ONE person to avoid getting a blood clot. But, that person to NOT get a blood clot could be you!  Overall, there is little harm in wearing compression stockings and they may help you. 

You can buy compression stockings online and are now available in lively patterns.

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Pertussis. Whooping cough. What you should know…

Pertussis.  Whooping cough.  What you should know…

Pertussis is also called whooping cough.  It continues to be a public health concern (with nearly 20 million infections worldwide yearly) despite there being an effective vaccine.  My husband got whooping cough years ago, we remember it well.

What are the symptoms of pertussis?  First, the patient has a runny nose, then coughs with a classic “whoop.”  A whoop is when you cough sooooo much that there is no more air in your lungs and you make a “whooping” sound while filling your lungs back up with air.  Then, the last stage of pertussis is a persistent cough. Overall, the uncontrolled coughing can last for MONTHS, even if you are treated with antibiotics. Antibiotics make you not contagious, it does not cure the cough. Additionally, studies have not shown any medications that decrease the pertussis-cough.

How to test for pertussis?  The diagnosis is made by a polymerase chain reaction test (PCR) using a nasopharyngeal swab with results coming back in 1-2 days. In the past we did cultures that took a week to result, but these are no longer done. 

How to avoid pertussis?  Get a Tdap vaccine, avoid sick people, and consider wearing a mask!  The Tdap vaccine is a combination tetanus AND pertussis vaccine. 

Who gets a Tdap vaccine?  Everyone should.  We give the vaccine to children (and it is required by most school districts to attend in-person school). The last scheduled dose is given to teens at age 11-12.  After age 12 a tetanus vaccine should be given every 10 years and ONE of the tetanus vaccines can be a TdaP (with pertussis) as an adult.  All pregnant women, regardless of the timing of their last Tdap, should receive a Tdap vaccine in their third trimester as this gives some immunity to the newborn.  More than 85% of pertussis deaths occur in infants too young to receive the pertussis vaccine.  Newborns get the pertussis vaccine at ages 2,4, and 6 months of age and are not thought to be immune to the infection until after their 6 month dose.  This is why it is important for those who have exposure to newborns (like grandparents) to get the Tdap vaccine if they have not had one as an adult.

How to treat pertussis?  We give antibiotics.  But, the antibiotics does not shorten the disease course or improve symptoms in the person infected.  Antibiotics DO prevent transmission of pertussis to others. Antibiotics should also be considered for those within 21 days of a known exposure to pertussis.  Azithromycin is the preferred antibiotic. 

I hope this helps…

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Emergency contraception, an interesting topic….

Are you wondering what form of emergency contraception is the safest and most effective for preventing pregnancy?

If a woman has a single episode of unprotected intercourse, she can conceive a child.  Nearly 50% of US pregnancies are unintended.  The likelihood of pregnancy after a single episode of unprotected intercourse is highly variable depending on where the woman is in her cycle.  Emergency contraception is the use of a device or medication to prevent pregnancy and this can be MORE THAN 95% effective at preventing pregnancy when used within 5 days of intercourse.

Research involved nearly 60,500 women who had engaged in a single act of unprotected intercourse.  The result showed the most effective method to prevent pregnancy is mifepristone. A one-time dose of mifepristone was more effective than any dose of oral levonorgestrel (Plan B One-Step).  A moderate-dose mifepristone (25 to 50 mg) was more effective than mifepristone 25 mg.  Ulipristal (Ella) is more effective than oral levonorgestrel. 

Copper IUD can be inserted up to 5 days after unprotected intercourse for use as emergency contraception.  Then it can be used for emergency contraception and can stay in place for 10 years.  The copper IUD is as effective as mifepristone for emergency contraception. 

One other method of emergency contraception is the combination (estrogen and progesterone) oral contraceptive pills often used for long-term birth control.  This is used (with a different dosing regimen) for emergency contraception and is not as effective as the rest of the methods. 

Of course, I suggest abstinence OR use of routine contraception (condoms, birth control pills, IUDs, etc) before I suggest emergency contraception. 

Ask your physician for emergency contraceptive pills. You can have them at-the-ready at home.

Be ready….

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Treatment of the common cold

The common cold is exactly that…. Very common.

There are only a few safe and effective treatments available. 

Common cold symptoms: thin nasal drainage, nasal congestion, cough, sore throat, fatigue, low-grade fever.

Treatment: Antibiotics should NOT be used for an apparent viral respiratory illnesses.  This is because antibiotics work on bacteria, not on viruses.

Over the counter analgesics (acetaminophen or ibuprofen), zinc (80-92 mg a day), nasal decongestants (like Afrin for 3 days or less)with or without antihistamines and ipratropium for cough. Nasal saline (like a Neti Pot) irrigation helps.  Menthol rub may help “open up the chest.”  Honey is suggested for sore throat for patients OLDER than 12 months.  (Honey under 12 months could cause botulism.)

Maybe lactobacillus casei may help in older adults.

What should not be used: 1. No OTC cold medicines in children less than 4 years. 2. Codeine and other cough-suppressants have not been proven effective.

When should you expect to feel better?  Most colds last for one week.  It is common for a cough to last longer, especially in smokers.

When should the patient get follow up care?  If you have a fever higher than 101 degrees, productive cough, difficulty breathing, or very bad headaches.

To help decrease spread: Wash hands!

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Do you have a TRUE penicillin allergy?

Do you have a TRUE penicillin allergy?

I often hear from patients that they have a penicillin allergy.  Penicillin allergy is the most commonly documented drug allergy in medical records.  Approximately 10% of patients report a penicillin allergy.  HOWEVER, up to 90% of patients with a reported penicillin allergy tolerate penicillin on allergy testing. 

What is the downside of having penicillin allergy reported when indeed you are not?! When penicillins cannot be used for an infection, patients are often started on an alternative broader-spectrum antibiotic with potentially poorer effectiveness and less favorable safety profile.  When patients are on broader-spectrum antibiotics this can lead to increased multidrug-resistant organism, treatment failures and increasing healthcare costs and longer hospitalizations.

There is a validated clinical prediction rule for penicillin allergy.  The PEN-FAST (penicillin allergy, five or fewer years ago, anaphylaxis/angioedema, severe, treatment) rule was made from a study of 600+ patients in Australia.  There were five independent predictors identified that are important.  The risk factors to include in the clinical prediction rule are:

Allergy event occurred five or less years ago (2 points)

Anaphylaxis/angioedema or severe adverse skin reaction (2 points)

Treatment required of penicillin allergy (1 point)

Total scoring ranged from 0 to 5 points.

If patient has 0 points, there is a 0.6% risk of really having a significant penicillin allergy.

If the patient has 1 or 2 points, there is 5% risk

If the patient has 3 points, there is a 19% risk

If the patient has 4 or 5 points, there is a 53% risk of penicillin allergy.

Consider seeing a physician who specializes in allergy testing. 

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Rural Outreach Medical Clinic (with vaccines!) this Saturday!

Silver Springs Rural Outreach Clinic UNR Med will provide medical services to the Silver Springs community during a Rural Outreach Clinic from 9 a.m.–1 p.m. on March 5 at 3595 Hwy 50 Suite 1.

What services are offered? Patients can get general physicals, sports physicals, lab work, and breast exams. The Rural Outreach Clinics offer blood pressure and blood work, diabetes screening and counseling, clinical and physical evaluations, adult and children’s influenza vaccinations, and women’s health services.

Which vaccines will be given? Immunize Nevada will also be providing COVID-19 vaccinations at this clinic.

Spanish-only speakers accommodated. All clinics have Spanish translators

Is this covid-safe? Yes, as much as possible. Patients will be screened for COVID-19 symptoms when scheduling appointments and again when arriving for appointments. Facial coverings are required. Patients are asked to come to their visit alone. All guests will be asked to wait in the car unless needed to assist the patient

Walk-ins are welcome at the Rural Outreach Clinics.

To make an appointment, call 775-391-0632 or 775-770-8679 for Spanish speakers. For questions, email ruraloutreachclinic@gmail.com. Every effort will be made to see all individuals who arrive before noon.

When: 9 a.m.–1 p.m., March Where: 3595 Hwy 50 Suite 1, Silver Springs 
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Do you have trouble swallowing? Food getting stuck? What should you watch out for?

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The medical term for difficulty swallowing is dysphagia.

Dysphagia is a frequent occurrence and is often underreported.

Esophageal dysphagia feels like food cannot pass from the esophagus to the
stomach. There are a few conditions that cause this.

·        An esophageal lesion. Most commonly this occurs
before the entrance of the stomach.

·        Gastroesophageal reflux disease (GERD). If it
feels like food gets stuck after swallowing, this may be caused by GERD. Patients
may need to chase rice or meat down with water to help the food bolus pass into
the stomach.

·        Eosinophilic esophagitis. This is a common
condition when increased eosinophils are present in the GI tissues. Eosinophils
are white blood cells that are increased in response to an allergen. So, food
allergies may increase the eosinophils in the esophageal tissue and cause pain
and difficulty passing food into the stomach.

What are red-flag symptoms?

  • vomiting
  • vomiting blood
  • unintentional weight loss
  • history of tobacco or alcohol abuse
  • exquisite pain

 

 

If there are NO red-flag symptoms an exam should be performed to rule out thyroid goiter or mass. The patient may be started on a proton-pump inhibitor (PPI) like omeprazole daily for a month. If symptoms
completely resolve, then continuation of the medication is a good plan. If symptoms remain after a month of treatment, GI consult is warranted.

If there are red-flag symptoms, the patient should see a gastroenterologist, a GI doctor, for evaluation and possible endoscopy. Endoscopy is when a camera is maneuvered inside the GI tract.  An esophagogastroduodenoscopy (EGD) is the endoscopic procedure that would be done in this case in which a camera is put down the mouth, through the stomach, and into the first part of the
small intestine. The physician can see the walls of that part of the GI tract
and evaluate for inflammation or ulcers or masses. Biopsies may be taken to
show what is going on at the cellular level. The pathology physician is the one
who looks at the biopsies to comment about the cells.

A similar condition to dysphagia (difficulty swallowing) is oropharyngeal
dysphagia.  This feels like difficulty
initiating a swallow. It can also present as coughing, food going “down
the wrong tube” or choking. The patient may have a neurologic condition:
dementia, Parkinson’s or a stroke. Oropharyngeal dysphagia has the risk of
aspiration– where food goes into the lungs.
This can cause respiratory distress and lung infections.

 

I hope this helps.

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Prediabetes. Is this diagnosis important? Helpful? Harmful?

Prediabetes.  Is this diagnosis important? Helpful? Harmful?

Before 2004, hyperglycemia (elevated blood sugars) was not considered significant.  The American Diabetes Association began in 2004 labeling elevated blood sugars of prediabetes to increase awareness and prompt physicians and patients to act. 

What constitutes a diagnosis of prediabetes? Fasting blood sugars between 110 and 125 or a hemoglobin A1c between 6-6.4%.  In 2010 the ADA lowered these thresholds to fasting blood sugar of 100 to 125 and A1c between 5.7 to 6.4$.  In 2017 an estimated 352 million adults had prediabetes or 7.3% of the world’s population. 

What is the rate of progression from prediabetes to diabetes?  Rate of conversion of 5 to 10% within one year, 25% within 4 years, and 70% of those with prediabetes diagnosis convert to diabetes. 

Treatment:  The question is DO we need to treat?  One review showed that to prevent one case of prediabetes from turning into diabetes within 3 years, 7 people need to participate in intensive lifestyle modification with weight loss and exercising.  There is a great cost of prolonged weight loss coaching.  The use of metformin prescription reduces the conversion to diabetes (but studies show that 14 prediabetics need to take metformin to avoid one patient from converting to diabetes).

Is there a harm of a diagnosis of prediabetes?  Prediabetes may be considered a diagnosis of questionable clinical significance.  Due to this the diagnosis could cause psychological distress and lead to additional testing, increased physician visits, and overtreatment. 

What to do?  Eat a healthy diet rich in vegetables, fruits, and lean meats. Do moderate exercise 30 minutes most days of the week.  Don’t smoke.  Maintain a normal weight meaning BMI between 20-25.

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Do you have green toenail discoloration?

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Do you have green toenail discoloration?

Green toenail discoloration is also called green nail syndrome.  This results from a pseudomonas infection. 

Predisposing factors for green nail syndrome:

  1. Tinea infection of the nails (because it alters the nail plate making the nailbed more susceptible to pathogens)
  2. Infection of the skin around the nails.
  3. Working as a barber, dishwasher, janitor, baker, or nail salon (because of water and chemical exposures)
  4. Use of artificial nails and nail polishes

Do you need additional testing to confirm the diagnosis?  It is a clinical diagnosis.  No labs are needed to confirm the diagnosis.

What is the treatment?  Trim the nails. Keep nails dry.  Avoid trauma to the toe.  Home treatments like vinegar soaks or diluted chlorine bleach are not known to be effective.  Topical antibiotics can be applied to the nail bed. Occasionally the nail needs to be removed.  Oral antibiotics can be used for severe infections.

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Hepatitis C. What you should know?

How many have hepatitis C?  It’s estimated that there are 3.7 million in the US with hepatitis C.  The incidence of acute hepatitis C infection quadrupled (!) between 2010 and 2018.  Only 52% of those with chronic HCV know they have it and only 37% have received treatment. 

How to screen for hepatitis C?  A blood test.  Any physician can order this.  The U.S. Preventive Services Task Force recommends one-time HCV screening in all adults aged 18 to 79 years.  In adults with ongoing risk factors, period blood work screening is suggested.

What are risk factors for hepatitis C?

  • Infants born to mothers with hepatitis C
  • Men who have sex with men
  • Incarceration
  • Hemodialysis
  • Blood transfusion before 1992
  • People with HIV or hepatitis B infection
  • Unexplained chronic liver disease

What is chronic hepatitis C?  Chronic HCV is after 6 months of infection.  HCV is often insidious with few symptoms.  Patients can get liver fibrosis, cirrhosis and liver cancer from HCV.  25% of patients with chronic HCV develop cirrhosis, although it routinely takes 25-30 years to develop. 

What is HCV treatment?  Antiviral therapy. These are prescribed by GI doctors.  There are multiple FDA-approved “pangenotypic” direct-acting antiviral treatments. Only 2% of patients discontinue treatment due to adverse effects from the antivirals.

If you have hepatitis C. Avoid all herbal and dietary supplements should be stopped. Avoid alcohol.  Tylenol use should be at 2000 mg or less daily. 

For now, it is best to know if you have hepatitis C. There is effective treatment to cure this infection.

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