Wednesday, April 17, 2019

A Deeper Look at an Illness Often Bemoaned: Irritable Bowel Syndrome

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

Do you have ongoing stomach issues troubling you? You might have irritable bowel syndrome (IBS).

IBS is the most commonly diagnosed gastrointestinal condition, affecting about 12% of the North American population. People with IBS experience the following symptoms:


  • Abdominal pain or discomfort partially relieved by having a bowel movement;
  • A change in bowel habits such as constipation or diarrhea (sometimes switching between the two); and/or
  • Gas, bloating, or abdominal distention (increased abdominal pressure that causes the person’s stomach area to stick out).
IBS is a chronic disease, and the severity of symptoms can come and go over time. It can significantly affect quality of life and, for some people, even the ability to work; therefore it is very important to discuss it with your doctor.

Part of the challenge of IBS is that many different things can cause it. People without any other illness can develop IBS, but it can be associated with chronic pain, reflux or indigestion, and psychiatric disorders. Doctors believe IBS can be caused by several conditions:

  • Neurologic factors, including: increased gut sensitivity, altered connection between your brain and the nerves in your intestinal tract, and altered pain perception. Learned illness behaviors, like recurrent abdominal pain starting in childhood as a response to other factors (below), can lead to changes in the brain-gut relationship and contribute to IBS;
  • Social factors such as early life stressors, current life stressors, or history of abuse; and/or
  • Environmental factors, including food intolerance, infection, other causes of inflammation, or antibiotic use.

Several different things can flare up IBS symptoms. Some foods containing lactose and sugars can trigger symptoms. (Lactose is in milk and other dairy products, and sugars are in many foods.) They can pull water into the intestines and cause diarrhea. Some over-the-counter treatments can make IBS worse. They include nonsteroidal anti-inflammatory drugs (NSAIDs, or pain relief medicines like aspirin and ibuprofen), antihistamines (a common medication for allergies), or supplements such as iron, magnesium, or wheat bran. Lots of prescription medications also can worsen IBS, including antibiotics, antidepressants, antipsychotics, diuretics, opioids, and metformin (a drug used to treat diabetes).

Extensive diagnostic testing for patients with IBS is not usually helpful. For most patients, tests do not point to a cause. However, if you have IBS with diarrhea, your doctor may want to screen you for celiac disease – in which eating gluten can damage the small intestine – because the symptoms are similar. Your doctor might be more insistent about this testing if you have any of these risk factors:

  • Onset of symptoms after 50 years old;
  • Rectal bleeding;
  • Anemia;
  • Severe or progressive symptoms;
  • Associated weight loss; or
  • Family history of cancer, inflammatory bowel disease, or celiac disease.

Treatment of IBS is based on treating the person’s symptoms. In general, the most important treatments are not medications, but rather exercise and diet, and addressing stress or emotional/mental health disorders. Exercise causes more movement of the bowels, which improves symptoms. Diet changes can have a large effect. If a patient is sensitive to gluten, a gluten-free diet or a FODMAP diet (a diet low in fermentable carbs like sweets and starched foods) might help. A FODMAP diet limits the amount of poorly absorbed carbohydrates found in certain fruits, vegetables, and dairy products. Some patients who have IBS associated with chronic pain or psychiatric disorders should consider participating in counseling, or visiting with a psychologist.

People with IBS experience symptoms like abdominal pain,
a change in bowel habits (constipation, diarrhea), and/or gas
and bloating.
Sometimes, medications can help alleviate symptoms. For diarrhea, physicians often prescribe loperamide (like Imodium) or probiotics (good bacteria that aid digestion and maintain gut health). Probiotics can sometimes help with pain, bloating, or gas as well. For constipation, laxatives or fiber supplements can help. Sometimes ondansetron (a drug used to prevent nausea and vomiting) or antispasmodics (which relax the smooth muscles of the digestive tract) can help improve general symptoms. A physician might prescribe stronger medications like antidepressants when a patient with IBS also has psychiatric or chronic pain disorders, because these medicines can help alter the perception of pain and improve overall mood. However, the risk of side effects has the potential to outweigh the benefits of using these drugs, so the doctor might recommend them only if other treatments have not been helpful.

For more information, I recommend reading this blog post about one woman’s personal IBS experience. If you are experiencing any stomach issues, and feel like they are affecting your quality of life, make an appointment with your primary care provider to discuss if any testing is needed, and what lifestyle modifications may be helpful for you.

References:
Chey WD, Kurlander J, Eswaran S. Irritable Bowel Syndrome: A Clinical Review. JAMA. 2015;313(9):949–958. doi:10.1001/jama.2015.0954

Wednesday, April 10, 2019

Road to Recovery: How “Walk With a Doc” Improved My Health


By Marcie Lowder
Walk With a Doc participant, Wichita Falls

Editor’s Note: Walk With a Doc is a public outreach program for anyone interested in taking steps for a healthier lifestyle. Physicians host Walk With a Doc events, where they give a brief talk on a health topic of their choosing and then lead participants on a walk at their own pace. The Wichita County Medical Society hosts its Walk With a Doc events the second Saturday of each month. Physicians host more than 50 Walk With a Doc outings across Texas. Find one in your area.


I have always enjoyed walking and running. However, I have several health issues to consider: degenerative spine disease, lupus, type 2 diabetes, and mitral valve prolapse (a condition when one of your heart’s valves doesn’t work properly).

While out running one day in 2016, I felt a sharp pain in my back and down my legs. I immediately stopped running and even had difficulty walking more than a block. Finally, in December 2018, when my quality of life was no longer the “quality” I wanted, I had multiple surgeries to repair my back, all within a short period. While recuperating I had more time to peruse social media, and an upcoming Walk With a Doc (WWAD) event in Wichita Falls popped up in my news feed. Interested, I reposted the link on my Facebook page asking if anyone would like to walk with me.

My friend Cindy Bergin was the only taker. Cindy is a registered nurse at Sheppard Air Force Base in the disease management clinic taking care of diabetic patients. Cindy has had back surgery, too, and felt like walking would be good for her since seeing patients requires her to sit most of the day.
Lowder (left) and Bergin (right) pose at
a "Walk With A Doc" event.
Courtesy of Marcie Lowder

The first Walk With a Doc in Wichita Falls was Jan. 12, 2019 – exactly one month after my second surgery. It was cloudy and freezing, but Cindy and I decided to walk anyway. Everyone who came out shivered in the cold (we live in Texas and aren’t comfortable in below-freezing temps), but walking warmed up everyone, and the conversations and new friendships began.

Cindy and I were already friends, but as life would have it, we rarely saw each other. After that cold Saturday in January, we had coffee and talked for two or three hours and decided to make walking together a daily event. Cindy and I have walked almost daily since – rain or shine, freezing or hot. We meet every Saturday to walk five miles then have coffee at a local coffee shop. It is always easier to stay committed to an exercise routine if you an accountability partner.

I am so thankful for WWAD in Wichita Falls. Kim Taylor, the program’s organizer, is friendly, and the doctors have all been great! They all provide excellent information in their field of practice and answer questions. I look forward to WWAD on the second Saturday of each month to catch up with the people in the group, meet new people, and hear what the “Doc of the Month” has to say about health and exercise.
 
I have always been a huge advocate for walking as a means of exercise, and it is refreshing to see Walk With a Doc promoting that in Wichita Falls.

Participants gather at the first Walk With A Doc event in Wichita Falls on January 12, 2019.
Courtesy of Kim Taylor


Thursday, April 4, 2019

VIDEO: Protect Yourself Against Tetanus: Bacterial Infection Attacks Muscles

Editor's Note: This video is part of a monthly Texas Medical Association series highlighting infectious diseases that childhood and adult vaccinations can prevent. MeAndMyDoctor.com will post a video about a different disease each month. Some of the diseases featured will include: Flu, Measles, Pneumococcal disease, Human papillomavirus (HPV), Chickenpox and shingles, Hepatitis A, Pertussis (whooping cough), Rubella (also known as German measles), Rotavirus, Polio, and Mumps.

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 this short video, Tyler family physician and Texas Medical Association (TMA) physician leader Li-Yu Mitchell, MD, explains how people can contract tetanus, the severity of its symptoms, and the recommended vaccinations for children, teenagers, and adults to fight against this disease.

Tetanus is an infectious disease caused by a bacterial spores called Clostridium tetani, found in the environment  from dirt, to dust, to feces. When these spores enter the body through broken skin whether it's a cut from sharp objects, animal bites, or a bike accident  tetanus can develop. Tetanus is often called lockjaw because infected patients experience painful muscle spasms throughout the body – especially the jaw area. Other symptoms include muscle stiffness, trouble swallowing, headache, fever, difficulty breathing, and changes in blood pressure and heart rate. Tetanus symptoms can show up in as early as three days to three weeks, according to Dr. Mitchell.

Tetanus cases in the United States have dropped since 1900, when physicians raised awareness about better wound care...and they plummeted in the 1940's after the vaccine became available. According to the Centers for Disease Control and Prevention (CDC), tetanus cases numbered about 600 on average to about 30 today.

The shot prevents it. People of all ages can protect themselves from this disease with a vaccine. There are different recommended vaccines available, depending on a person's age. Young children usually receive the diptheria-tetanus-accellular pertussis (DTaP) or diphtheria-tetanus (DT) vaccine in five rounds: at 2, 4, and 6 months; between 15 and 18 months; and between 4 and 6 years of age.  Preteens ages 11 to 12 are strongly encouraged to get the tetanus-diptheria-pertussis (Tdap) or tetanus-diptheria (Td) booster. The CDC recommends adults get a booster every 10 years. Today's tetanus cases in the U.S. occur in unvaccinated adults, or adults who did not get their booster shot, according to the CDC.

In addition to getting vaccinated, doctors recommend people wash hands with soap and water frequently, and to treat and break in the skin as quickly as possible to avoid tetanus.

Friday, March 29, 2019

Understanding Dialysis and Kidney Diseases

By Jay Reddy, MD
Nephrology and Internal Medicine, Wichita Falls
Member, Texas Medical Association 

Editor’s Note:  March is National Kidney Month. The Wichita County Medical Society Magazine previously published a version of this article to promote “Walk With a Doc,” an outreach program for anyone interested in taking steps for a healthier lifestyle. The Wichita County Medical Society hosts its Walk With a Doc events the second Saturday of each month.


Make no mistake about it – your kidneys play a big role in your overall health. Located in back just below the rib cage, one on each side of your spine, your kidneys are responsible for filtering blood, and removing wastes and excess water from your body, through your urine. If your kidneys shut down, your nerves, muscles, and other tissues in your body might not work properly.
When this occurs, your physician might recommend kidney dialysis to do the job your kidneys cannot.

What is Dialysis?

Dialysis is a process of purification of blood. It involves removing excess water, solutes, and toxins from the blood in those who have lost the ability to perform these functions in a natural way because their kidneys have shut down.

There Are Two Forms of Dialysis: Hemodialysis (Blood Dialysis) and Peritoneal Dialysis

Hemodialysis (or blood dialysis) removes waste and water by circulating blood outside of the body through an external filter called a dialyzer (also called an artificial kidney). To achieve this, a doctor has to place a catheter in you to access your blood vessels to get the blood flow necessary for dialysis.

Peritoneal dialysis is another way to treat kidney failure. With this treatment, a tube is inserted into and out of the peritoneal cavity (your abdomen area). A solution called dialysate – which is water with salt, glucose, and other additives – flows through a tube into the patient’s belly.  Patients perform Peritoneal Dialysis at home by themselves, after undergoing thorough training by the dialysis team.

Having a vital organ such as the heart, liver, or kidneys shut down can be fatal, unless the organ is transplanted. But very often patients wait months or years for a suitable organ for transplantation. Fortunately, in the case of kidney failure – unlike heart or liver failure – dialysis offers a temporary solution until while the patient awaits a suitable donor kidney.

How Did We Get Here? Kidney Diseases and Failure

Kidneys can temporarily shut down from acute kidney injury (AKI), or permanently shut down from chronic kidney disease (CKD). If the patient needs dialysis, it would only be temporary. CKD on the other hand means your kidneys can’t filter blood the way they should, and if not managed the condition can lead to kidney failure (end stage kidney disease). Once you reach this stage, you will need dialysis or a transplant.

Two main factors that can lead to kidney failure are diabetes and hypertension (high blood pressure). High concentrations of sugar in the blood and high blood pressure over many years can ruin the filtering membranes in the kidney. This can result in further complications.

The first sign of kidney disease from diabetes is when the patient loses excess protein in his or her urine. This can go unnoticed unless urine is tested specifically for protein. According to the most recent statistics by the American Diabetes Association, more than 30 million Americans – or close to one in ten people – has been diagnosed with diabetes.

Not only is the combination of poorly managed diabetes and hypertension bad for your kidneys, they can lead to heart attack, stroke, or other fatal complications. Some patients successfully escape these fatal complications, but still develop late-stage kidney damage. They will require kidney replacement.

Prevention: What You Can Do to Protect Your Kidneys

To avoid kidney failure and other complications, you need to create a healthier you, with medications and lifestyle changes. This includes eating a healthy diet, being physically active, maintaining a healthy weight, and quitting bad habits (smoking or alcohol consumption, for example). All of these can prevent or slow the progression of kidney disease.

Contact Dr. Reddy here. 

Monday, March 25, 2019

The Trouble With Teenage Sleep – and How to Improve It


By Ryan Lowery, MD
Pediatric Resident at the University of Texas at Austin Dell Medical School
Member, Texas Medical Association

A 14-year-old patient once told me, “I feel tired all the time.” The patient’s mom was in the room and said that her daughter’s “energy level was very low.” She would often take a long nap after school before waking up to complete her homework, hang out with friends, or attend soccer practice. As I asked more questions to clarify what the patient was feeling, it became evident that increased sleepiness was affecting her daily life.

One of the main challenges for doctors working with teenage patients with similar complaints is trying to determine whether he or she is experiencing increased sleepiness or increased fatigue. Increased sleepiness is generally defined as a greater desire to sleep or inclination to fall asleep. Fatigue, on the other hand, is more related to low energy levels. The two can certainly be related, but it is important to understand the differences because they can have two very distinct causes. Increased fatigue, for example, might be related to low blood levels, medications, mental health issues, or thyroid problems. Sleepiness is usually caused by inadequate sleep most commonly related to a poor sleep schedule or poor sleep environment. Although sleepiness may be more common than true fatigue, the consequences of sleepiness can be just as detrimental and dangerous to a teenager’s health and development.

Teens simply don’t sleep enough. 

The American Academy of Pediatrics (AAP) recommends that children ages 13-18 sleep at least eight to 10 hours per night. Many parents say this is rarely the case for their children, and data show less than 10 percent of teenagers get adequate sleep on school nights. Part of the problem is that they must get up early for school. Middle and high schools often start classes before 8:30 am.

Teens are internally wired to stay awake later and sleep later
than in childhood, which can interfere with school performance.
Teens’ “internal clock” resets.

As we move from childhood to teenage years, the sleep-regulating “internal clock” humans have shifts so that teens are internally wired to stay awake later and subsequently sleep later than they did before. As a result, teenagers might have more difficulty waking up for school, miss early classes, fall asleep during class, or take long naps after school. Many catch up on sleep on the weekends by sleeping until well after noon.

Ramifications.
Teenagers don’t just get sleepy, however. Missing school, sleeping during class, and having trouble paying attention can lead to academic troubles. A child who previously did well in school may start to have problems in the classroom as he or she hits the teenage years and develops this new sleep cycle. The ramifications can even be dangerous: Unintentional injury remains the leading cause of death in teenagers, and most of those injuries result from driving accidents. Getting behind the wheel while sleepy affects the brain in many of the same ways as driving drunk. A “drowsy driver” will have delayed response time, poor attention to surrounding traffic, and increased likelihood of falling asleep at the wheel. Each of these can lead to a fatal accident.

The negative effects of sleepiness extend beyond the classroom and the car.

Recommendations:

Adolescence can be tough enough without struggling to stay awake. Parents, I suggest you help your teen adopt healthy sleep patterns. Here are a few tips:

  • Implement a “no screens” policy before bedtime so the bedroom does not turn into a texting, gaming, or screen-viewing zone. Medical experts advise children ages 14-18 should limit screen time to less than two hours a day.
  • Do away with afternoon naps, as these can often worsen an already interrupted sleep cycle. The same argument goes for sleeping in on the weekends. In trying to “make up” for lost sleep, teenagers (really, any of us) often set ourselves up for failure once our inability to fall asleep Sunday night leads to a poor school (or work) performance on Monday morning.
  • Limit the amount of caffeine and sugar your teen consumes – especially before bed. The AAP says high caffeine intake by someone as young as 12-years-old is linked to shorter periods of sleep, greater difficulty falling asleep, and more sleepiness during the day.
  • You might consider becoming an advocate for your teen by making your community leaders aware of the need to start school later in the morning

Not all the teenage problems will disappear with better sleep, but many teenagers will start to experience benefits. If you have further concerns or questions about sleep, please talk to your physician or a sleep specialist.

Tuesday, March 19, 2019

Broker Websites Expand Health Plan Shopping Options While Glossing Over Details


By Julie Appleby

Kaiser Health News

This article originally appeared on Kaiser Health News.

Some websites consumers use to buy their own health insurance don’t provide full information on plan choices or Medicaid eligibility, and appear to encourage selection of less comprehensive coverage that provides higher commissions to brokers, according to a report released Friday by the left-leaning Center on Budget and Policy Priorities.

These direct-enrollment broker websites — including eHealth, ValuePenguin, GetInsured.com and some named after the insurance carriers they represent — are not the state-based marketplaces or the federal exchange, known as healthcare.gov.

The commercial sites promise more options to consumers shopping for health insurance. They can offer Obamacare plans, for instance, as well as lower-cost but less comprehensive plans, such as short-term policies and other types of coverage that don’t meet the federal Affordable Care Act’s requirements.

About 42 percent of enrollments for 2018 ACA plans were arranged through sales agents or brokers, with many of them relying on such alternative websites to enroll their clients, noted the report.

But consumers who use alternative portals, the report warned, don’t have the same shopping experience as applicants accessing state or federal marketplaces. That’s because government sites must provide full information on all available ACA choices and cannot steer consumers to non-ACA plans. The government marketplace also is responsible for accurately processing applicants’ eligibility for Medicaid or premium subsidies. The commercial sites generally don’t have those responsibilities.

Two years after sharp financial cuts by the Trump administration for enrollment outreach and funding for navigators and other assistants helping people sign up for ACA plans, the administration encouraged consumers to seek out brokers for help.

For next year’s enrollment period, it is considering changing the rules to allow federally funded navigators to also use the alternative websites to enroll consumers.

There are differences among the alternative websites. “Not all entities have these problems,” the report concludes. “But the program lacks safeguards to protect consumers from harm.”

It found that some direct enrollment websites:

Use default settings, chat boxes and other design methods to highlight alternatives that earn the web brokers higher commissions, such as low-cost, short-term insurance plans, which cover less and can reject people with preexisting conditions. Either fail to inform or provide inaccurate assessments of whether applicants or their family members might qualify for Medicaid or premium subsidies to help them get coverage. Fall short of providing full information on premium costs and deductibles for all the plans available in a region.
The commercial websites are “under-policed,” said report author Tara Straw, a senior policy analyst at the center.

The administration, she said, should more closely monitor website design and how well the sites inform consumers of their potential eligibility for government assistance in purchasing coverage.

Because of the drawbacks, consumers who use some of these websites are at a disadvantage, lacking the ability to adequately comparison shop, the report warned.

As a result, some may choose non-ACA plans, such as short-term insurance, which may not be their best option. Others may be discouraged from applying for coverage at all if the websites inaccurately indicate they might not qualify for a subsidy or Medicaid.

“That’s the problem,” said Straw. “The websites can say, ‘We’re telling people to complete the application [to assess subsidy eligibility],’ but who is going to do that when they’re showing all the plans at the unsubsidized price?”

Comparison shopping on some of the websites is limited.

An example outlined in the report focuses on Duval County, Fla., where the eHealth website shows a list of ACA policies described as “17 of 17 plans” available. Each of those 17 shows the costs of premiums, deductible amounts and other details. At the bottom of the screen, however, eHealth lists the names of 32 additional plans available from Florida Blue, the state’s largest insurer, without any specifics on cost and coverage.

If consumers stopped there, they would not know that on Florida Blue’s website they could find 15 plans that are less expensive than the lowest-cost plan listed on eHealth, according to the report.
“Without visiting multiple websites, consumers would have difficulty finding and comparing their plan options,” the report said. “This is the type of fractured shopping experience the marketplace is designed to remedy.” It noted, however, that one web broker, HealthSherpa, did list all 49 plans available in Duval County.

An eHealth spokeswoman countered that the website makes it easy for consumers to get additional information on available plans it may not sell directly.

“When they get to the bottom of the page, they see 32 additional plans available through the federal marketplace, with a hyperlink directly to that marketplace,” said eHealth’s Lisa Zamosky.
To avoid having to visit multiple sites, Straw offered consumers simple advice: “Go to healthcare.gov.”


Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Tuesday, March 12, 2019

Female Athlete Triad: The Condition Teen Girls in Sports Need To Know About


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

Participating in sports is very beneficial for teens. Athletes have better cardiovascular fitness; better school performance; and decreased drug, alcohol, and tobacco use. Yet in recent years, as more girls have become active in sports, our awareness of the potential negative effects of athletics on the female body has increased.

Female athlete triad is a condition in which inadequate calorie intake negatively affects the menstrual cycle and bone health. This can lead to serious problems such as decreased strength and endurance, injuries, and poor growth and development.

Understanding Energy Requirements 

Female athletes need enough energy for exercise in addition to what is required for normal growth and development. Girls who participate in sports that emphasize leanness – such as gymnastics, dance, figure skating, and long-distance running – may be at an increased risk for low energy availability, even if they have a normal body mass index (BMI).

Here is what teen athletes should do:

  • Active teens need to consume approximately 2,300 calories per day, even up to 2,900 calories per day for those who are very active.
  • Calories should come from a balanced diet of carbohydrates, protein, and fat.
  • Girls who are unable to meet these dietary goals may need to see a dietician or decrease the amount of exercise they are doing.

Menstrual Period Abnormalities

If girls are not eating enough calories to keep up with the energy they expend, their menstrual periods can become irregular or even stop completely.

  • Girls who have not started their period by age 15, or girls who go three or more months without a period should be evaluated by a doctor.

Bone Health

Healthy teenage girls gain 2-4 percent in bone mass every year. When girls have irregular periods, or no periods, they are at risk of instead losing 2 percent of bone mass each year. This can lead to osteoporosis and sports-related injuries such as broken bones.

  • All teens should consume 1,200 mg of calcium and 600 international units (IU) of vitamin D per day for healthy bone growth.
  • Girls who are not having regular periods should increase their daily calcium and vitamin D intake to 1,500 mg and 800 IU, respectively. Good sources of calcium and vitamin D include milk, yogurt, green vegetables, or fortified orange juice and cereal. 
  • The addition of calcium and vitamin D supplements may be necessary for teens whose dietary intake is limited.

Overall, the health benefits of being active in sports outweigh the possible risks. Girls should be encouraged to participate in athletics. Teens, parents, coaches, and doctors just need to keep in mind the increased energy requirements for female athletes. They also should be on the lookout for poor eating habits, irregular periods, or injuries that might point to female athlete triad. Prevention and early treatment of this condition can help promote optimal growth and development, prevent serious injuries, and allow female athletes to perform to the best of their abilities.
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