Thursday, August 15, 2019

A Parent’s Survival Guide to the Anti-Vax Movement

By Zachary Jones, MD
Dallas Anesthesiologist
Member, Texas Medical Association

Vaccine safety is a growing topic of conversation both online and in doctors’ offices. Three years ago, when my wife and I were pregnant with our first child and picking a pediatrician, the office manager asked if we “believed in vaccines.”  As a physician (anesthesiologist) I said, “Of course!” I was surprised the pediatrician’s office needed to ask such a screening question. 

However, three years later and now with two boys (ages 1 and 2), I too have a strong desire to know if those around us believe in the safety and efficacy of vaccines. Unfortunately, according to a reputable PLOS Medicine (peer-reviewed medical journal) article from June 2018, I live in a region designated a national “hot spot” for nonmedical childhood vaccine exemptions. Texas has multiple hot spots including Plano, Fort Worth, Austin, and Houston.  Even more concerning, the elementary school that my kids will attend has one of the highest vaccine exemption rates in the entire school district (scroll to page 35 in the viewer). That increases the likelihood of children becoming infected by vaccine-preventable diseases. While my kids are on schedule for all of their shots, this still concerns me.

Living in an area on the front lines of the anti-vaccine epidemic, I asked myself, “How can I make a difference in my community?” I had an idea – take it to the streets.

This past spring, I visited all 312 houses in my neighborhood subdivision, offering legitimate medical resources with friendly face-to-face discussion about vaccines and vaccine-preventable diseases. In support, my wife took our two boys in their red wagon along for the journey. With family in tow, my neighbors would see that I am not a salesman or an outsider, but rather a person they can trust. I considered this my “anti-Facebook” approach, where civil discourse and verified information can be traded face-to-face. The TMA Be Wise – Immunize program provided the educational handouts I used.

My experience meeting my neighbors was eye-opening. On my very first walk, I met a family a few doors down who have an immunocompromised child who cannot receive vaccines. (Patients with a weakened immune system do not have as great an ability to fight infections or diseases. Some cancer or leukemia patients are commonly in this situation.) This galvanized my efforts to spread accurate information about childhood vaccines. It took my family and me 11 walks to visit every home in my neighborhood. None were more important than that first day, when we learned someone on our very street is at risk of potentially deadly disease without the “herd immunity” we as a community of vaccinated people create around them. (If enough people are vaccinated, a herd immunity safe-zone is created, thereby helping to protect the more vulnerable people in their midst.)

Zachary Jones, MD, with one of his sons. 
Everyone I met was very supportive of my family’s efforts to spread information on the safety and efficacy of vaccines. However, my personal experience created an interesting contrast compared with what we frequently see online and in social media swarming groups of vocal “anti-vaxxers,” often from different states or other countries, peddling misinterpreted studies and unverified anecdotes.

As an anesthesiologist, my role in vaccine education is unique. I do not vaccinate patients in my medical specialty. So when some vaccine opponents name-call doctors “big pharma shills” who profit by promoting vaccines, that label doesn’t apply to me because I don’t even give the shots. However, my training during four years of medical school, four years of residency, and as a practicing physician gives me the tools to decipher complex technical studies and assess their validity. On that basis of knowledge, I know vaccines are effective and safe.

But as a parent of two little boys who have yet to complete their series of childhood vaccines and a consumer of social media myself, I see how confusing it is to sift through the noise and find accurate, honest data during the current anti-vax misinformation siege.

This brings me to my Parent’s Survival Guide to the Anti-Vax Movement:
  1. Be critical – When you see “studies” posted online, know there is a massive misinformation campaign currently being fought. I have seen anti-vaxxers take credible data on vaccines and misinterpret it on social media. 
  2. Vote with your dollars – Having just enrolled our two boys in daycare, we learned that some locations require children to be vaccinated, but others don’t. Furthermore, certain private schools will have a much higher-than-average vaccine exemption rate, while others require full vaccination. These data are available to the public in the Annual Survey of Immunization Status. Choose wisely, to protect your children.
  3. Vote with your vote! – The vaccine issue is highly political. While the anti-vax political machine is very loud, it is in fact a small (but growing) minority. Politicians will cater to small groups who reliably turn out at the polls and regularly lobby for their cause. If you want to create change, you have to vote for candidates who support vaccination and speak up to let others know as well. (If you do, you will be in the majority: Recent studies found the vast majority of Texas Republican-primary voters support vaccine requirements for school enrollment.)
  4. Trust reliable sources – Your pediatrician and primary care physician are invaluable resources; talk to them if you have any questions about vaccines. They went through grueling training to take care of you and your children. Current efforts to dehumanize your doctors and present them as part of a conspiracy couldn’t be further from the truth. Every doctor I know became one to take care of people.
  5.  Beware of wolves in sheep’s clothing – Certain anti-vax groups will present themselves as “supporting vaccine choice” in an effort to capitalize on the Texan values of self-reliance and independence. Then these same groups pump out misinformation across social media daily, to increase anti-vaccine sentiment based on misinterpreted data or outright falsehoods. Make no mistake, they are “dyed in the wool” anti-vax.
  6. Be kind to each other – These are words my grandmother left for me. Often times, a sick child or family member is at the heart of someone’s mistrust of vaccines. And while statistically that illness is overwhelmingly unlikely to have been caused by vaccination, it’s a difficult emotional journey that person is going through. Today’s climate of fear, be it fear of vaccine side effects or fear of preventable diseases, puts us at odds. Ultimately we all want our children to be healthy, and kindness is a great first step.

Wednesday, August 7, 2019

Run For Your Mind: The Significance of Exercise For Teens

By Richard Thompson, DO 
Pediatric Resident at The University of Texas at Austin Dell Medical School
Member, Texas Medical Association 

Whether it’s from cardio, weight lifting, or simply having fun playing a favorite sport, doctors recommend all teenagers get at least 60 minutes of exercise every day. However, the reality is only 27% of high school students reported getting the recommended amount of physical activity every day, according to the Centers for Disease Control and Prevention (CDC).

Most of this exercise should be aerobic in nature, like long-distance running, jogging, walking, biking, or swimming. At least three days of the week should be spent on strengthening muscles and bones, achieved through resistance/weight-bearing exercises such as squats, push-ups, or sit-ups.

Why run at all?
You may be wondering why experts recommend so much aerobic exercise. Besides helping us look and feel great, cardio activities offer a number of benefits. No one denies that a quick jog can easily release the stress built up after a long day at school. But according to research, there are even deeper reasons why exercising – particularly running – can benefit our overall mental health, not just our physical well-being.

How do I start? 
Starting any exercise regimen is far from easy. Step one is to identify a barrier. Consider all the possible hurdles that keep people from exercising on a regular basis, such as:

  • Busy schedules – due to school, work, home responsibilities, or other extracurricular activities;
  • Lack of access to trails, parks, or gyms in the community; and
  • The belief that all forms of exercise are unenjoyable.

After pinpointing your reason(s) behind not exercising, make a plan. The Community Preventive Services Task Force offers several simple strategies. First, set an achievable goal. An example is to sign up for a short race – try starting with a 5K or 10K distance. Then train with that goal in mind; start shorter jogs and runs and increase your run distance/duration over time. Another strategy can be to join or build a community around physical fitness, whether it’s enrolling in a club sport or finding people around you with similar schedules to train alongside you. Lastly, and perhaps most importantly – reward yourself! After finishing that first 5K, give yourself a few days off.

My personal take as a running enthusiast is to first discover an activity you love. I’ll be the first to admit that running is not for everyone. However, cardio can be accomplished in a wide variety of settings such as yoga, cross-fit, swimming, or biking. If you’re starting at ground zero, try several options and choose whichever kind of exercise you prefer. You are much more likely to make a habit out of doing something you love. Once you find that activity, carve out a specific time of the day to do it, and stick with it. You might be surprised to find improvements not only in your physical fitness but also in your mental health.

Why is this so important for teenagers?
Doctors recommend all teenagers get at least 60 minutes
of exercise each day because it can benefit both
 physical and mental health.
Many teens may read this and think, “I’m too young to worry about exercising,” or “I have plenty of time in my life to think about keeping in shape later, when my metabolism slows down.” However, the most important reason why teens should exercise is to proactively prevent health complications in the future – to ultimately prolong their life span. When teens enter puberty, they not only begin to experience physical changes but also significant mental ones. Teens begin to develop an independent mind as they discover their own interests and plan for the future beyond high school. Because of this, teens are especially at risk for depression, anxiety, and other mental health issues.

Exercising, even if it is just an hour per day, can make all the difference in setting teens up for a healthier life today and a healthier future, while also helping to protect them from mental illness.

Monday, August 5, 2019

When to Seek Medical Attention After Hitting Your Head

By My Le, MD
Pediatric Resident at The University of Texas at Austin Dell Medical School
Member, Texas Medical Association

When you hit your head, it can be difficult to determine whether the injury is serious enough to visit the emergency room or an urgent care center – especially when there are no open wounds, and you’re awake, alert, and feeling pretty normal. If you decide to make the trip, it can be frustrating to be sent home with no action by the doctor besides instructing you to pay attention to your symptoms and come back if they worsen. On the other hand, if you don’t go, there could be serious medical repercussions. 

First and foremost, if you or the person who has suffered a closed-head injury (meaning no penetrating or open wounds) is showing any changes in alertness or wakefulness, or you can feel a skull fracture, go to the emergency room. A trained medical professional will usually assess that patient with a cranial computed tomography (CT) scan. This test, which takes detailed scans of features inside your head, allows doctors to look for potential injured blood vessels, blood clots, bruised/damaged brain tissue (contusion), bleeding in the brain (hemorrhage), and swelling. 
Below are some concerning symptoms by age group that can appear after a closed-head injury. If you or the patient do not have any of these symptoms and are otherwise feeling well, going to the emergency room or an urgency care center might not be necessary. However, the more of these symptoms you have, the higher the risk your head injury is serious.

For patients less than 2-years-old:
  1. Scalp hematoma – This is essentially a collection of blood under the scalp and can be described as a large, boggy area of swelling.
  2. Severe injury – This can be pretty subjective, but it’s always good to consider multiple factors, such as height of the fall, the material that the head struck, and the speed of injury.  For example, some literature considers a high-speed accident (more than 40 miles per hour), a fall greater than three meters, or an injury from a high-speed projectile or object as severe.
  3. Loss of consciousness for more than five seconds (i.e. blacking out).
  4. Abnormal behavior as witnessed by family or friends.

For patients ages 2 to 18-years-old:
  1. ANY loss of consciousness
  2. Vomiting
  3. Severe injury (see above for details)
  4. Severe headache
A patient’s recovery from a closed-head injury can vary depending on how severe it is. People with milder symptoms typically recover in a few weeks. But patients who suffer from more serious head wounds will likely have long-term issues with attention, memory, coordination, balance, hearing, vision, and/or behavior. Moderate to severe head injuries can even lead to a shorter lifespan.
Your head is a delicateand essentialpart of your body. Understanding what physicians and other trained medical professionals look for when caring for a patient with a potential closed-head injury, and understanding the injury’s warning signs, can guide you when deciding whether you need to visit your local emergency department or urgent care center.

PECARN Pediatric Head Trauma CT Decision Guide

Friday, August 2, 2019

A Little Known Cause of Headache: Spontaneous Intracranial Hypotension

By Christie M. Malayil Lincoln, MD
Baylor College of Medicine Radiology and Neuroradiology Specialist
2019 Graduate, Texas Medical Association Leadership College

Do you experience headaches that change with your posture and have not been diagnosed?

Many people suffer from headaches for many different reasons. Unusual, periodic headaches might be caused by a relatively rare condition few people have heard of, spontaneous intracranial hypotension (SIH). SIH happens when the fluid pressure inside the skull is lower than normal. Here’s how this occurs: Our brain floats in pressurized fluid inside our skull. In SIH, that fluid pressure drops, allowing your brain to sag inside your head. More detail: A small defect develops in the dura, a thick material that covers the spinal cord and brain. The defect allows cerebrospinal fluid (CSF) – the fluid that bathes the brain and spinal cord – to seep out into the epidural space located just outside the dura. As the fluid leaks out, its pressure decreases, causing the brain to sag downward.

Cerebrospinal fluid leakage can cause a multitude of symptoms. The most common one is a headache – one that is better while lying down but worsens while standing (known as orthostatic headache).

Other symptoms can include neck stiffness or pain, visual disturbance like double vision, tinnitus (ringing or buzzing in the ears), hearing impairment, dizziness, nausea, vomiting, walking abnormally, or memory loss. In severe and rare cases, patients may fall into a coma.

Who develops SIH, and how does the small defect in the dura develop? 

SIH occurs in approximately five per 100,000 people, mainly in those 40 to 50 years of age. It affects women more frequently than men.

Many factors can trigger SIH, including trauma from motor vehicle collision, a sports-related injury, or a prior spine-related procedure. Other spontaneous causes like connective tissue disorder and calcified disc herniations, which can cause holes in the dura, can also result in SIH.

What diagnostic tests can be performed?

If your doctor suspects you have SIH, he or she might suggest one or more imaging tests to confirm the diagnosis. Brain magnetic resonance imaging (MRI) may be done to show the imaging hallmarks of a sagging brain, if there is severe SIH.

Your doctor may suggest a whole-spine MRI to determine
where the fluid leak is occurring. 
Your doctor might suggest a whole-spine MRI to try to determine where the fluid leak is occurring. Alternatively, he or she might want to conduct a dynamic computed tomography (CT) or fluoroscopic myelography or MR myelography to try to locate the area of leak, if the whole spine MRI does not reveal the location.

A nuclear medicine study called Indium-111 cisternography, which is performed over a 24 to 48 hour period, can also be conducted in cases where diagnosis is uncertain. This can be helpful in cases of slow CSF leaks.

A SIH diagnosis can lead to a significant change in quality of life, and the debilitating effects can cause the inability to even go to work. Therefore, it is very important to discuss your symptoms with your doctor.

How is it treated?
Your doctor might first recommend simple treatments including bed rest, drinking plenty of fluids, avoiding caffeine, and taking pain medication. Physicians might also recommend that a radiologist or anesthesiologist conduct a treatment involving injecting the patient’s own blood outside the dura to seal off the leak.

If these measures aren’t effective, a radiologist or anesthesiologist might perform a treatment called a targeted blood patch or fibrin glue injection. This procedure requires injecting either blood or fibrin glue outside the dura of the suspected leak to seal the hole. Surgery is also another solution.

This web site contains additional information about the condition and how to treat it.

Discussing a potential or established SIH diagnosis and treatment options with your doctor is important in coordinating the best care.

Thursday, August 1, 2019

Keep Hib Germs Away: Vaccination Can Prevent Serious Childhood Illness

Editor's Note: This video about Haemophilus influenzae type b (Hib) is part of a monthly Texas Medical Association series highlighting infectious diseases that childhood and adult vaccinations can prevent. posts a video about a different disease each month. Some of the diseases featured include: FluMeaslesPneumococcal diseaseHuman papillomavirus (HPV)Chickenpox and shinglesPertussis (whooping cough), Hepatitis ARubella (also known as German measles), RotavirusPolioMumpsTetanusHepatitis B, and Meningococcal B, Diphtheria, and more.

TMA designed the series to inform people of the facts about these diseases and to help them understand the benefits of vaccinations to prevent illness. Visit the TMA website to see news releases and more information about these diseases, as well as physicians' efforts to raise immunization awareness.

In the video above, Austin pediatrician and Texas Medical Association member Elizabeth Knapp, MD, talks about Haemophilus influenzae type b (known as Hib), the complications it can cause, how its contracted and the recommended vaccines people can get to protect themselves from the disease.

Bacteria are everywhere, and can be harmful if they enter certain parts of the human body. Haemophilus influenza type b (Hib) bacteria, which are typically found in the nose and throat area, can pose a serious health threat if they travel to the blood stream. Hib spreads from person to person through exposure to mucus and saliva, such as sneezing and coughing. Patients who contract this bacteria can experience fever, chills, chest pain, nausea and aches, among many other symptoms. Hib germs can cause a number of illnesses, including meningitis (an infection of the brain and spinal cord), swelling in the throat, and pneumonia (a lung infection). It can also cause infections of the blood (bacteremia), joints (infectious arthritis), bones, covering of the heart (pericardium), and even death. 

According to the Centers for Disease Control and Prevention (CDC), nearly 20,000 children got Hib disease each year before the vaccine was widely used; one in 20 died from it. The introduction of a vaccine in the 1980s nearly eliminated Hib disease, cutting cases by 99%, the CDC reports.

Because infants and children younger than 5 years old are most susceptible to contracting Hib, the CDC recommends two types of vaccine, with four doses: 2, 4, and sometimes at 6 months, and again at 12 to 15 months. Older children and adults usually do not need a Hib vaccine, except for those who have certain medical conditions who are unvaccinated and people who receive a bone marrow transplant. Talk with your doctor about the options available to avoid this disease.

Wednesday, July 17, 2019

Chest Pain in Teens: Anxiety Could Be the Culprit

By Molly Ray, MD
Pediatric Resident at The University of Texas at Austin Dell Medical School
Member, Texas Medical Association

“Do you ever feel like your heart is beating so hard it wants to jump out of your chest?” If you tell your doctor you have chest pain, he or she might ask this question.

Sometimes chest pain, chest tightness, or palpitations (a feeling of pounding/racing heart beat) are an indication of a serious condition such as a myocardial infarction (a heart attack) or severe allergic reaction (anaphylaxis).

However, what might seem surprising is that more teenage patients are visiting the emergency department or their physician complaining of chest pain. The cause of this pain in this unlikely group of patients? Acute anxiety.

Anxiety is becoming a more common diagnosis in the world of adolescent medicine. The National Institutes of Health (NIH) reports that nearly 32% of adolescent patients surveyed on the National Comorbidity Survey - Adolescent Supplement (NCS-A) have an anxiety disorder, with girls affected more often than boys. Signs and symptoms of an acute presentation of anxiety (an anxiety or panic attack) include chest pain, palpitations, shortness of breath, difficulty sleeping, poor academic performance, and feelings of uncontrollability, among various others.

How will my doctor determine if there is a serious problem?

If an adolescent patient says chest pain is the main reason for their visit to the emergency department or other acute-care facility, the most important thing the doctor will do is get a thorough medical history of that patient. It is important to know if the adolescent has any underlying medical conditions that might raise suspicion of something more serioussuch as a history of heart surgery or murmur, a bleeding disorder, any medications the patient may be taking, a family history of anyone with heart problems including sudden death at a young age (less than 50),  or if the young patient has a pacemaker. It is also important to note the factors and timing of the chest pain – time of day the pain first started; where the patient was; what they were doing; and how long the pain has been occurring. The answers to these questions will determine which tests, if any, are necessary for the doctor to perform.

What are some of the most commonly used tests?

Two of the most frequently used tests to determine the cause of chest pain in adolescents include:
  •         Electrocardiogram (ECG/EKG) – This is a tracing of your heart beat to see how fast, or slow, your heart is beating and if there are any indications of an abnormal rhythm (an arrhythmia) such as skipped beats, premature beats, or abnormal communication between the upper and lower chambers of the heart. This test is performed by placing 12 or 15 stickers containing electrical leads across the chest to capture the electrical current present in the heart. This creates an interpretable picture of the electrical activity in the heart.
  •         Chest X-ray – This is an image of the chest which allows your doctor to look at the size and shape of your heart (cardiac silhouette). We also look at the surrounding structures such as the lungs, ribs, sternum, and portions of your abdomen, which may also contain clues to the source of your chest pain.

In a healthy adolescent with anxiety these tests will likely be normal.

What can you do to help prevent acute anxiety?
  •        Recognize your triggers – Keep track of what you are doing, what you are thinking about, who you are with, and where you are when you note feelings of chest pain or other symptoms of anxiety.
  •         Develop coping strategies – This is not an easy thing to do. Finding people, places, and things that will help prepare you for interactions with your triggers or distract you from them can be helpful.
  •         Find someone to talk to – All primary care physicians and providers likely use some type of screening tool to help identify patients with signs/symptoms of anxiety early so they can help patients and connect them to the right resources. Your primary care doctor is a great place to start.

In this modern age, there are many internal and external pressures and stressors that can trigger anxiety in teens; this is something to note as more of them report chest pain and anxiety disorder diagnoses continue to rise. This article only briefly addresses one possible cause of chest pain. If you or your teen are experiencing chest pain alone, or with any other symptoms, it is important to talk to your physician.

Thursday, July 11, 2019

Heat Safety Tips: Child Heat Stroke/Car Deaths

By Angela Moemeka, MD
Pediatrics, Coppell
Member, Texas Medical Association

It’s summertime in Texas again. School is out, pools and lakes are calling, ice cream and barbecues fill the lazy days, fireworks light up the sky, and teens are getting out of bed just in time for a late lunch. Yes, those are the best elements of summer when you’re a child. Unfortunately, summer also comes with risks for kids in Texas. Our extreme temperatures make heatstroke a grim reality, and Texas boasts the highest number of child car deaths from heatstroke, followed by Florida and California.  Several children in Texas died this way in recent weeks. These tragic hot car deaths are preventable.

It takes only a few minutes in a hot car for a child’s core temperature to rise to dangerous levels that can lead to heatstroke and even death. Temperatures inside a car, even with a window cracked open, can rise as much as 20 degrees Fahrenheit in the first 10 minutes. Think of that on a day when it’s already blazing at 90 or 100 degrees! Children left unattended in parked cars, even when it feels relatively cool outside, are at greatest risk of heatstroke and hot car deaths.

What is heatstroke and what can you do to help a child with heatstroke?
Heatstroke is a medical emergency caused by exposure to high temperatures. Symptoms, which can begin within minutes, include:

Temperatures inside a car, even with a window cracked open,
can rise as much as 20 degrees Fahrenheit in the first 10 minutes.
Photo by Brent Annear
·         Hot, red skin;
·         Fast, strong pulse;
·         Headache;
·         Dizziness;
·         Nausea; and
·         Losing consciousness (passing out).

If you find someone in this condition, call 911 immediately and move the child to a cooler place. Apply cool cloths to exposed skin, armpits, forehead, and neck to help lower the core temperature. If able, give a cool bath. Do not give the child anything to drink.

The best medicine is to avoid heatstroke and heat-related illness altogether. There are three important ways to do this:

1.      Keep children hydrated with cool, nonsugary drinks.
2.      Apply sunscreen to children and dress them in loose, lightweight clothing when outdoors.
3.      Do not leave children and infants in parked cars.

Hot car deaths often occur because a distracted adult forgets the child is in the car, sometimes because he or she is napping when the adult gets out of the car. Advocacy groups like offer several safety tips to remind adults to take the child out of a parked car to a cooler location, to avoid these deaths:

·         Keep a stuffed animal in the car seat, then move the stuffed animal to the front seat when your child is in the car seat to remind you of your rear passenger.
·         Place your work bag/purse in the back seat. The idea is to have unavoidable reasons to look in the back seat.

Congress also is taking steps to prevent heatstroke deaths. Just this month, the U.S. House of Representatives introduced the Hot Cars Act of 2019 (H.R. 3593), legislation that, if passed, would have vehicles equipped with technology that alerts the driver when a car is turned off with someone still in the back seat. (The U.S. Senate introduced its version of the bill (S. 1601) in May.)

As parents and caregivers, we want kids to have safe, healthy summers with fun memories to last a lifetime. This often means busy schedules filled with camps, activities, vacations, and family outings. Taking the careful steps to prevent heat-related injury and death should be woven into every summertime experience. The little things we do to keep kids hydrated and cool during these hot Texas summer days will go a long way.
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