Do your bones deserve a density screening?

Posted on February 24, 2011 by drlesliegreenberg

New update!  Federal recommendations provide more detail on when to screen women UNDER age 65 for osteoporosis.   

Osteoporosis is when bones are less dense and therefore, are more likely to break, or fracture. White people are at higher risk of osteoporosis than other ethnic groups, but it occurs in all groups.  Almost half of all postmenopausal women and 1 out of every 5 men older than 65 years will have osteoporosis-related fracture. Fractures can lead to pain, surgery, loss of independence/mobility, and death.

To prevent osteoporosis take adequate calcium (500 mg 3x/day) and vitamin D (1000 IU a day), exercise, and avoiding tobacco and alcohol. Drugs can prevent osteoporosis, but they are not recommended for general prevention because of their side effects and expense. Instead, the U.S. Preventive Services Task Force (USPSTF)  recommends screening for osteoporosis and prescribing drugs only to people who have documented thin bones. Screening involves measuring bone density using dual-energy x-ray absorptiometry (DEXA).

For women OLDER than 65 years the USPSTF recommends osteoporosis screening. (Medicare will currently pay for a DEXA every 2 years).  Approximately 9 out of every 100 white women who are 65 years of age with no risk factors for osteoporosis will have an osteoporotic fracture within 10 years.

Women YOUNGER than 65 years who have a risk for osteoporosis similar to that of a 65-year-old white woman should also be screened. Risk factors for osteoporosis include

  • advanced age,
  • low body weight,
  • and tobacco and alcohol use,
  • as well as having a parent with an osteoporotic fracture.

femur (thigh bone) fracture

There is a great tool to show your 10-year fracture risk.  Input your personal risk factors and the FRAX (Fracture Risk Assessment) tool helps estimate your risk for osteoporosis. The FRAX tool is available at www.shef.ac.uk/FRAX.

Lastly, about men. . . the advisory panel concluded that there is not enough information to recommend either for or against osteoporosis screening in men.

Hope this helps.

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Do you need the chicken pox vaccine?

Posted on February 22, 2011 by drlesliegreenberg

Chicken pox is a hot topic.  What once was a rite of passage has become a much maligned and feared rash.  Should you be vaccinated?  Are you already immune?  Here’s more info. . .

Varicella zoster (the chicken pox virus) is one of 8 herpesviruses, yes, “those” herpes viruses.  Usually a chicken pox infection causes fever, fatigue and up to 300 pox-like lesions.  It is self-limited and resolves spontaneously without treatment.  Significant complications like pneumonia, hepatitis and encephalitis (brain inflammation) are more common in adults, pregnant women and those who are immune suppressed. 

The varicella vaccine (the chicken pox shot) was introduced in the US in 1995.  This is a live, but altered, virus vaccine.   CDC guidelines are to give, starting at 12 months of age, two vaccines.  Most common schedule is at 12 months and then at the “kindergarten physical” at age 4-6.  Adolescents by the age of 13 should have received 2 doses of the vaccine.  Adults with ongoing risk of exposure (child or health care workers), women of childbearing age, and those with immunosuppressed houseguests should also receive 2 doses of the vaccine if not already immune (see below). 

Pregnant women should not receive the live vaccine until the infant delivers.  Interestingly, the immunosuppressed houseguests have not been found to get chicken pox from the newly immunized, unless pox lesions result.

How do you know if you are immune?

  • Documentation of two doses of varicella vaccine at least four weeks apart.  Keep those pink vaccine records into adulthood!
  • History of chicken pox or shingles infection.
  • Birth in USA before 1980 (because the infection was so commonplace and contagious).
  • Lab confirmation that the immune system has responded to a varicella “sighting.”

In high-risk groups (like health care workers or pregnant women) age alone isn’t enough, blood testing may be needed to show immunity.  The risk is that we will become a vector and pass on the infection (to our patients or unborn baby)  as contagiousness occurs 48 hours BEFORE the rash develops until all lesions are crusted over.

Be wise.  Immunize!

Posted in Dermatology, General Medicine- Adults, infections, infections, Pediatrics, Uncategorized, Vaccines, Vaccines, vaccines | Tagged , , , , , , , , , , , , , | Comments Off on Do you need the chicken pox vaccine?

Vroom. Vroom. Is your engine revving at the right speed?

Posted on February 18, 2011 by drlesliegreenberg

I’m talking about the thyroid gland.  If it is revved up, you may be anxious, have insomnia, or feel heart palpitations.  Too slow and  depression, sluggishness, and weight gain can result.

HYPOthyroidism is when the thyroid gland doesn’t produce enough thyroid hormone. It’s the most common thyroid problem. The thyroid is a butterfly shaped gland in the middle of the neck, located below the larynx (voice box) and above the clavicles (collarbone).

The thyroid produces two hormones which regulate how the body uses and stores energy (also known as the body’s metabolism). Vroom.  Vroom. or Putt.  Putt.

In about 95 percent of cases, hypothyroidism is due to a problem in the thyroid gland itself.  There are certain medications and diseases can also decrease thyroid function. You are at risk for hypothyroidism if you are

  • a woman,
  • older than 35
  • white or Mexican Americans
  • or have symptoms like fatigue, weight gain, slow heart rate, coarse hair or depression.

Most patients are diagnosed by history and physical exam. It is confirmed with one easy blood test called a TSH.  All newborns are routinely screened.

If thyroid replacement medicine is needed, a daily pill is taken which is inexpensive and well-tested.  A blood test is rechecked in 6 weeks. Symptoms should get better in 2 weeks.

Hypothyroidism is an easy fix.  Hope this helps.

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Viral rash? or child abuse?

Posted on February 16, 2011 by drlesliegreenberg

I just saw a rash this morning while teaching medical residents.  Have you heard of “fifths disease?”  I saw a slap-cheeked looking kid, at little risk of being abused.  The offending virus is Parvovirus B19.  Interesting questions were brought up.  The mom of this patient  is pregnant.  So, that unleashes a “can of worms.” 

There are significant risk factors for that mother as parvovirus can cause fetal death (rare, but possible).  We will follow blood work on the mother (parvovirus IgM and IgG) to see if she has been exposed to this virus before or if this is a “new-sighting” and therefore is more dangerous to the fetus.

For the most part, no rash (or viral) treatment needed.  The slapped-cheek look resolves spontaneously.  Some have joint pain  or mild fever both symptoms can be treated with non-steroidal anti-inflammatory pills (like ibuprofen).

For patients with sickle-cell disease or autoimmune diseases, parvovirus can cause severe blood breakdown, requiring transfusions.

We are unsure of the mode of transmission (saliva?  fomite?).  We know that parvovirus passes through a household fast, but may make its way through a school over several months.  Advice: Avoid contact with sick people.  Cover your cough.  Wash your hands!

Hope this helps.

Posted in Dermatology, Dermatology, General Medicine- Adults, infections, infections, Obstetrics, Pediatrics, Uncategorized | Tagged , , , , , , , , , , , , | Comments Off on Viral rash? or child abuse?

The 411 on pesticides. . . and you!

Posted on February 13, 2011 by drlesliegreenberg

I was asked by my patient to address pesticides and their safety.  Well, not surprisingly, they are not safe to be drank or rubbed into one’s skin.  But, what and how dangerous are they?

Organophosphates are a class of insecticides used worldwide for the past 50 years. Their use has declined in the last 10 to 20 years, because another class of insecticides, carbamates, were discovered.   Both classes are toxic to the brain and nerves.

In 2008 the United States reported 8,000 toxic exposures to these agents, resulting in less than 15 deaths. Toxicity usually results from accidental or intentional ingestion of (or exposure to) agricultural pesticides.   Eating contaminated fruit, flour, or cooking oil, or wearing contaminated clothing can also result in adverse symptoms.

Advice:  Keep poisons away from children.  Follow their instructions.  Store in their original containers and maintain labels.  Consider ladybugs to help control pests in a garden.

If a toxic ingestion occurs expect

  • excessive drooling and eye watering,
  • vomiting, and
  • difficulty breathing.   Seek emergency care immediately.

Interestingly, science reveals beneficial uses of organophosphates and carbamates.  At controlled doses, they treat glaucoma, myasthenia gravis, and Alzheimer’s dementia.

Watch out!  The next few sentences will contain chemical terms (most often seen the chemistry lab or the lawn and garden department). Types of carbamate are methomyl and aldicarb.  Whereas, organophosphate are also known as parathion, fenthion, malathion, diazinon, and dursban insecticides. Chlorpyrifos, the organophosphate agent of dursban, is found in some popular household roach and ant sprays, including Raid® and Black Flag®. The United States Environmental Protection Agency (EPA) banned many household uses of chlorpyrifos in 2001. If there is skin contamination with a pesticide, clothing should be removed and the skin aggressively cleaned with soap and water.

Further information on pesticide intoxication can be obtained in the United States from National Pesticide Telecommunications Network at: 1-800-858-7378 or http://npic.orst.edu/

I hope this helps

Posted in food, food, General Medicine- Adults, Pediatrics, toxin, toxin, Uncategorized | Tagged , , , , , , , , , | Comments Off on The 411 on pesticides. . . and you!

Does taking hormones make you feel “hormonal?”

Posted on February 6, 2011 by drlesliegreenberg

Imagine that taking hormones is like a cavemen getting clubbed over the head. . . . the hormones have to take over the body’s hormone system.  Here are some side effects to expect. . .and a hint of how long to give them to resolve.

Examples of hormonal contraception are combined (estrogen and progesterone) birth control pills, progesterone-only birth control pills, Depo-Provera shot, Implanon rods, Nuvaring, Ortho Evra patch, and Mirena intrauterine device.

Good news! Side effects from hormonal contraceptives usually decrease with time. Most resolve within three to five months. I urge my patients to be patient for 3 months when starting on a hormonal type of contraception.

Anticipating side effects may make them more tolerable in the short-term. Changing from pill to pill to other hormonal contraception without waiting for symptoms to stop is counterproductive.

Anticipated symptoms are

  • breast tenderness,
  • moodiness,
  • irregular bleeding, and
  • nausea.

It takes a few months for the hormone to dove-tail with your own hormones.

Weight gain has been found in studies to occur with the injectable depot medroxyprogesterone acetate (“Depo shot”), no other hormonal forms.  Most women start  “the Pill”  after high-school and, we know, most grown women do not maintain  their 16-year-old weight.  (Sadly, enough.)

There are some reasons that women should not start on certain hormonal contraceptives. Tell your doctor if you have had breast cancer, liver cancer, a misshapen uterine cavity (like fibroids), blood clotting problems, pelvic infections. This will help your doctor pick an appropriate form of contraception.

If you are a “DIY”er you can check the Association of Reproductive Health Professionals website. It has an interactive tool to help choose an appropriate method. http://www.arhp.org/methodmatch/

Hope this helps.

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Treatment of herpes isn’t quite like a walk on the beach

Posted on February 3, 2011 by drlesliegreenberg

How can I treat herpes? (And. . .will effective therapy have me skipping down the beach with a companion like the TV ads show?)

Treatment is antiviral medications taken orally. There are three on the market.

  • Acyclovir (Zovirax®)–the oldest and least expensive antiviral which is taken more often than the newer formulations,
  • famciclovir (Famvir®),
  • and valacyclovir (Valtrex).

The dose and length of treatment depends upon whether the outbreak is the first episode or is a recurrence.

How should I take the antiviral?  With six outbreaks or less a year, you may consider taking antivirals only during an outbreak. Unfortunately, episodic treatment does not reduce the frequency of outbreaks (but it can decrease the duration by hours to days and the severity). Episodic treatment is most effective when started within 72 hours of the first symptoms. So, it is best to have an antiviral prescription in your home.

In contrast, suppressive therapy is daily low dose antiviral treatment intended to prevent outbreaks. Suppressive therapy is recommended for those with

  • six or more recurrences each year,
  • a weakened immune system (from HIV or use of immune-suppressing drugs),
  • if you are in a sexual relationship with a partner who does not have a history of genital herpes or antibodies to HSV-1 or 2 (as determined by blood testing).

Ways to reduce spreading the virus? Taking suppressive therapy (may reduce virus transmission by half), using a latex condom with EVERY sexual encounter, avoiding sex anytime genital ulcers are present. If there are ulcers or blisters around the mouth, oral sex should not be performed.

Tell your new sexual partners.  Life goes on. . . And be sure to take a walk together.

Posted in General Medicine- Adults, infections, Sexually Transmitted Infections, Uncategorized | Tagged , , , , , , , , , , , | Comments Off on Treatment of herpes isn’t quite like a walk on the beach

Are those lesions down there. . . herpes? Gulp!

Posted on February 1, 2011 by drlesliegreenberg

I saw a patient this week.  Bright, engaging, and single. . . . she admits how dirty she feels since genital herpes was diagnosed.  “Good people get this!”  I tell her.  And, indeed it is true.  In a population-based cross-sectional survey of New York City adults, nearly 28 % were infected with herpes simplex virus (HSV-2) of which 88 % of them didn’t know it.

There is the question of:  How did I get it?  From sex (oral or genital).   Door knobs, toilet seats, utensils, or bed sheets are NOT the offending vector.

When (Read this:  from whom) did I get it?  This is difficult to say, especially if a person has had more than one sexual partner.  A current sexual partner may NOT be the source of the infection. The first outbreak usually occurs within a few weeks after infection with the virus and can be severe with symptoms like

  •  painful genital ulcers,
  •  fever,
  •  tender lymph nodes in the groin,
  •  painful urination,
  •  viral symptoms (like fever and muscle aches) and
  •  headache.

In other patients, however, the infection is mild or entirely asymptomatic. The symptoms resolve within two to three weeks

Will I get rid of the virus?  No.  After the initial outbreak, the virus travels to a nerve bundle at the base of the spine where it hibernates.  There are no symptoms during this stage.

How often will I get a recurrence?  Good question.  Within the first year after contracting HSV2, most have at least one recurrence, 1 in 3 had 6 outbreaks,  and 1 in 5 had 10 outbreaks.

How do I not get it?  (Or spread it?) HSV can shed (read this: spread to you/your sexual partners or newborn) when there are no lesions.  Use of condoms and suppressive antiviral medication can decrease the risk of spreading the infection to partners who are not infected, especially during the first year after a person becomes infected. 

Diagnosis:  See your physician for a blood test  if you have no genital lesions, or a culture if there are lesions.  This will rule out other non-herpes genital ulcers.

Stay tuned for treatment options. . . .

Posted in Dermatology, General Medicine- Adults, infections, Male issues, Sexually Transmitted Infections, Uncategorized | Tagged , , , , , , , , , , , , , , , , , | Comments Off on Are those lesions down there. . . herpes? Gulp!

Hooked on hookah?

Posted on January 30, 2011 by drlesliegreenberg

Here in Wichita hookah bars are popping up (seemingly) everywhere!  Waterpipe tobacco or “hookahs” are becoming a popular way to smoke.  Studies have shown nearly 20% of college students have smoked hookah in the past 30 days.

My little foray into the history books revealed that a 17th century physician in India proclaimed tobacco sent through water renders it “harmless.”  This falsehood continues today.

The hookah allows the smoke to pass through the water before it is carried by a hose to the smoker.  The tobacco burns using wood cinders or charcoal which likely increases health risks as they produce their own toxic chemicals.  The health effects are substantial.

According to the U.S. Centers for Diseases Control and Prevention:

  • The addictive drug nicotine is delivered and is at least as toxic as cigarette smoke.
  • The cool temperature of the smoke allows for greater depth of inhalation
  • A typical 1-hour-long hookah smoking session involves inhaling 100-200 times the smoke inhaled from a single cigarette.
  • Hookah smokers are at risk for cancers (like oral, lung, stomach and esophagus), reduced lung function, and decreased fertility.
  • Sharing a waterpipe mouthpiece with companions may spread tuberculosis and hepatitis.

The tobacco is often sweet and flavored to appeal to those who would not dream of smelling like tobacco.  The fruity-flavored nicotine still emits

  • carbon monoxide
  • nicotine
  • tar
  • heavy metals like lead, copper, zinc, cadmium, and chromium
  • volatile aldehydes (like formaldehyde–the chemical to embalm dead bodies )

Just sitting in a hookah bar is equivalent to smoking 15 to 20 cigarettes and has high levels of heavy metals such as arsenic, lead and cadmium.

Just say “no!” and meet at a coffee bar instead.

Posted in General Medicine- Adults, lung conditions, lung conditions, nicotine, oral health, Pediatrics, smoking, throat conditions, Uncategorized | Tagged , , , , , , , , , , , , | Comments Off on Hooked on hookah?

Did you just smoke your last cigarette?

Posted on January 27, 2011 by drlesliegreenberg

Frequently my smoking patients ask “HOW can I stop?”

My goal is to “stack the deck” so that you are more successful.  Surveys show 70 percent of smokers want to quit.  Over 40 percent have tried to quit in the past year by intentionally not smoking for at least 24 hours.

The long-term success rate of any one unaided quit attempt is low, with only 5 to 7  still abstinent one year later. With optimal treatment, one-year abstinence rates after a single quit attempt can exceed 30 percent!  Few patients seek a physician’s help and most don’t use the most effective treatment.  Most former smokers made several quit attempts before succeeding.  I view tobacco use as a chronic relapsing disorder whose management requires an approach like that of diabetes and hypertension.

Nicotine is highly addictive. It’s a potent psychoactive drug that skillfully causes physical dependence and tolerance. In the absence of nicotine, a smoker develops cravings for cigarettes with symptoms like

• Depressed mood

• Insomnia

• Irritability, frustration, or anger

• Anxiety

• Difficulty concentrating

• Restlessness

• Decreased heart rate

• Increased appetite which  may lead to weight gain

Pharmacotherapy for smoking cessation aims to relieve the symptoms of nicotine withdrawal and/or make smoking less physically rewarding, thereby making it easier for a smoker to stop.  Experts agree that a trifecta of nicotine replacement, buproprion, and counseling may work best.

There are many nicotine replacement products:  gum, patch and lozenges.  Few trials have directly compared them.  Their most common side effects are insomnia and vivid dreams.  The patch gives a constant amount of nicotine whereas the gum can be used to respond to cravings.

Buproprion is an antidepressant which helps decrease withdrawal symptoms.  This should be started 7 days before desired quit date.  It DOUBLES the likelihood of successful cessation.

Behavioral counseling will help.  1-800-QUIT-NOW provides telephone counseling.  Computer counseling increases abstinent rates by 45%.

Before quitting, you must decide that you want to quit, pick a date, tell loved ones/coworkers your plan (so they will support and not tempt you) and call your doctor today.

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