Dr. Jane Explains

Open This Book & Say "Ahhh"

A Honduras Mission: We Helped Each other

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I recently traveled to Catacamas, Honduras with a Baylor Scott and White “brigade” of medical providers.  I learned so much.  Working with Predisan Health Ministries was both boldly informative and, at the same time, humbling.  A Christian based non-profit organization, Predisan’s intent is to “Proclaim Jesus and heal lives”.  Their efforts have engaged teams of medical providers and health advocates to fortify the physical, mental, and emotional health of the Honduran people.  There is no way I can adequately describe my experience. It was so powerful.  I would, however, love to share five “take-aways” that I learned while overseas:

  1. Honduras is Central America’s second poorest country and approximately 63% of the population live in poverty. The poor are vulnerable to disease (The Borgen Project), becoming ill and many dying due to lack of affordable health care, clean water and adequate sanitation methods..
  2. Diabetes is among the most common chronic disease and cause of death in Honduras. Approximately 5.7% of the population has been diagnosed with diabetes (compared to 7.4% of the Texas population). In Honduras, an estimated 53% of those with diabetes are undiagnosed(Central American Diabetes Initiative CAMDI). Common morbid complications of diabetes include kidney failure, blindness, lower extremity amputations, and heart disease.
  3. Honduran food tastes really good. I loved the fresh beans, chicken, tortillas, fruit, and rice. The traditional carneada (orange and spice-soaked meat dish) sounds delicious. I plan to try that next trip.  No medical information here, just good-food talk.
  4. Honduras has one of the highest rates of depression in the world with 7% of their population suffering significant depression according to the Washington Post.  Globally, depression is the second leading cause for disability.  Violent conflict and disease along with lack of social and medical resources make it more difficult to diagnose and treat patients. Interesting fact: The country with the lower rate of depression is Japan (2.5%).
  5. A stethoscope is a good device, but the IWatch and iPhone can be so helpful. A Honduran patient in the central clinic complained of shortness of breath, lower leg swelling, and cough. On exam, I found she was in heart failure. Without access to X-ray, electrocardiogram, or immediate blood test results, our diagnostic capabilities were limited. The cardiologist among us had an IWatch. We had the patient place her two fingers on the watch face and within seconds we had our diagnosis: Atrial fibrillation with rapid ventricular response. The treatment strategy became clear and we were able to better manage the patient. I also used several iPhone Apps for medication references and pill picture identification. Thank you, technology!

Predisan Health Ministries works with the government to empower the medical community to serve its people. If you are interested in donating or volunteering with Predisan, go to Predison.org for more information.

What you did not know back then may hurt you now (no fair!)

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Back in the days when coconut oil was the suntan lotion of choice, many of us experienced sunburns beyond “bad”.  I recall several of my high school friends fell asleep under at-home sun lamps. Their red and swollen faces were a painful reminder that too much ultraviolet exposure was never good for anyone.

Thank goodness most people are far more careful about sun exposure today.  It is widely known that cumulative sun exposure can cause skin cancer.   More dangerous are repeated episodes of severe sunburns, usually before age 18, as that can result in melanoma (the deadliest form of skin cancer) later in life.

The sun’s ultraviolet light (UV) has two main components that can damage skin cells and lead to skin cancer.  UVB rays are the primary the cause of sunburn and most responsible for skin cancer.  UVA rays also contribute to sunburn but generally cause skin damage that leads to tanning, skin-aging, and wrinkles. The best way to reduce the effect of sun exposure is the generous use of a broad-spectrum sunscreen.

Most commonly, sunscreens are rated by their sun protection factor (SPF) number which refers primarily to the amount of UVB protection it provides.  The SPF is an approximate measure of the length of time the sun’s UV radiation would take to begin reddening the skin versus the amount of time without sunscreen.  For example, if 10 min in the sun would normally redden your skin, a properly applied SPF15 sunscreen would allow you to stay in the sun without burning for approximately 150 minutes (15 times longer).  To note, not all skin tones are the same, so the SPF is not applicable to every skin type. 

The difference between sun protection factors is very little.  SPF 15 blocks 93% of the UVB rays, while an SPF of 30 (twice the factor) blocks 97% of the UVB rays, and an SPF of 50 (over 3 times the SPF15 factor) blocks 98% of the UVB rays.  Purchasing anything over 50 SPF offers very little extra protection.

The Skin Cancer Foundation recommends a water-resistant, broad-spectrum sunscreen with an SPF of 30 or higher.  Apply an ounce (two tablespoons) 30 minutes prior to sun exposure.  Take time to put it on correctly and cover all exposed skin.  Remember, no sunscreen is completely waterproof so re-apply every two hours or immediately after swimming or sweating.  

Broad spectrum sunscreen can protect you from both UVA and UVB rays.  In addition, barrier clothing such as a hat and shirt or a cover up can also provide sun protection.  However, not all clothing provide the same security.  It is important to choose outdoor clothing specifically designed to protect the skin. The ultraviolet protection factor (UPF) will appear on the label. Loose fitting clothing will have generally have a tighter weave over skin-tight stretch fabric and is generally a better choice for extended time in the sun.

Have fun in the sun this spring but protect yourself and those you love!  Skin cancers are the number one cause of cancer in the United States and are, also, the most preventable. Thankfully, parents today are more commonly seen applying generous amounts of sunscreen to their children than past generations. If we had known then what we know now, perhaps hunting for that deep-dark tan may not have been such a quest.

My Dry Skin is Cracking Me Up

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The seemingly incessant hand-washing between patients is a routine ritual that leaves my hands, and the hands of many healthcare workers, wanting for moisture.  The deep skin fissures that sometimes appear burn as though I had rubbed cayenne pepper-laced hand cream on them.  As irritating as this cycle is, my complaints pale in comparison to one of my patient battling a severe form of skin dryness known as ichthyosis. I have watched his skin flakes, like snow, fall to the exam room floor as I gently removed his socks.  While not painful for him, it is  terribly annoying and understandably embarrassing.  He needed an urgent solution.

So for the myriad of other unsung people also with this persistent dry skin, I am going write out a treatment strategy: “Skin Care 101”: a seven step-by-step approach to managing severe dry skin.

  1. Cool it down. Instead of hot showers and baths, use cool or warm water.  Limit shower and bath time to under 10 minutes. Blot your skin dry; do not rub the skin and use moisturizer generously immediately after drying the skin (while it is still moist) so it will better absorb the ointment.
  2. Lay off the lotions.Instead, use an ointment or cream. Lotions tend to contain additives that can irritate or dry the skin.  Olive oil, jojoba oil, and shea butter are fine. Severe dry skin may require lactic acid, urea, glycerin, lanolin, mineral oil, petroleum, or hyaluronic acid (per the American Academy of Dermatology). Discuss these options with your medical provider.
  3. Send away your scents.Avoid scented skin care products and consider avoiding deodorant soaps when dry skin conditions worsen. These products may contain alcohol or other irritants that are too harsh for dry, sensitive skin.  If you are using topical retinoids or alpha-hydroxy acids, hold treatment for a few days in order to allow your skin to retain its natural oils.
  4. Cover up.Consider moisturizing gloves and socks at night. I realize that this does not seems very glamorous for bedtime, but it really helps the skin retain the moisture. There are several brand on the market specifically for hand and feet dryness.
  5. Keep the cream close.Keep a hand cream and lip balm with you during the day so that are more likely to replenish your hands and lips regularly.
  6. Wash and wear your clothing with care. Consider hypoallergenic laundry detergent. Use silk underclothing; it will glide over your skin more easily and be less likely to rub against dry and irritated skin.
  7. Watch the flame.Avoid sitting close to high temperatures such as a heater or furnace. Instead, consider bundling up and using a humidifier to maintain air moisture.

You should consult your medical provider to be certain that you have no medical conditions causing the severe dry skin. Low thyroid, autoimmune diseases, and inflammatory skin conditions such as psoriasis or eczema are among other causes that need to be considered and treated.

For my patient, the prescription of urea cream along with his written list of instructions should help lessen discomfort and soothe his dry skin. While there is no definitive cure for the scaling and dryness, we can keep ahead of the condition by keeping his skin healthier.  As for my embattled hands, “cracking me up” really is no laughing matter and I choose to fight! My weapon of choice is an unsurmountable supply of Cerave moisturizing cream and an iron will to win!  I got this.

A “Shot” of Humility

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A doctor’s first lesson in the treatment of patients is learning to live with humility.  It was Friday clinic and I was counseling a patient about his Shingrix vaccine. “You will be fine,” I reassured him. “The vaccine is safe and effective.”  I also let him know that I would be receiving my shot the same day.  “Perhaps you will feel a little bit achy tomorrow, but otherwise, you should be able to go about your usual activities this weekend”.  The next morning I called him to deeply apologize in case I had not properly prepared him for its side effects.  I know I was not prepared!  Statistically speaking, I found out that I was the one in six person who will experience the vaccine’s full side effects and I was miserable.

Thankfully, he suffered little of the side-effects the vaccine manufacturers described.  I, on the other hand, had pronounced fatigue and achiness that had left me napping and uncomfortable for most of the weekend.  After a couple of miserable, disgruntled, self-pity filled days I was quickly back to normal and back to work on Monday.  I have no regrets about receiving my vaccine.  My temporary symptoms were far-better than alternatively suffering from the burning pain of a shingles outbreak or, even worse, a post-herpetic neuralgia, a lingering chronic pain complication from a shingles viral infection. 

This newer Shingrix vaccine is over 90% effective in preventing the disease while It’s predecessor, “Zostavax” was found to be only marginally effective over time and is no longer considered effective a preventative vaccination.

Shingles is caused by the reactivated chicken pox virus.  It lays dormant in our body for years after a childhood infection.  Surprisingly, there are some people who have had chicken pox but never experienced its classic red-blistery rash.  According to the Centers for Disease Control and Prevention (CDC), approximately 99% of Americans over 40 have had chicken pox even if they do not remember an infection.

The CDC recommends all healthy adults 50 years and older receive at least two doses of Shingrix two to six months apart.  If you have had shingles, received less effective Zostavax, or are not sure if you had the chickenpox, you should receive the two doses of Shingrix.

Anyone who has had a severe allergic reaction to any components of the Shingrix vaccine should avoid the immunization. Your medical provider will screen you prior to your vaccination. Example of when you should postpone the vaccination include, but are not limited to, situations such as you currently have active shingles, a fever, a severe respiratory infection, or if you are pregnant or breastfeeding.  Be sure to let your medical provider know if you are on any anti-viral drugs such as acyclovir or valacyclovir as you may need to hold your medication for a few weeks prior to receiving the vaccine.  

Currently, I am planning ahead for “Shingrix – the Sequel” (round #2).  It will be Ibuprofen, hot baths, and no weekend plans for me.  My lesson was a good one.  As a medical professional, humility is a great teacher and constant companion.  It enables me to communicate both sides of the vaccination experience.  

Go ahead: Put some fat in it!

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My family always makes a fuss when it comes to our grocer’s yogurt isle. There are so many different brands of yogurt and we are all individually selective when it comes to our favorite morning food. To make matters more difficult, my family members have each opted to customize their yogurt selection based on fat content. When it comes to yogurt, my daughter is non-fat, my husband is low-fat, and I am full-fat. The question boils down to: Who has the healthiest breakfast diet? It would seem that lessdairy fat would be the best answer; however, that is not necessarily true.

Without doubt, dairy products with greater percentages of fat contain more calories which most people will want to avoid if they choose a calorie-restricted diet. However, studies found that when people purposefully reduce fat in their diets, they tend to replacethose calories with sugar and/or carbohydrates. The compensatory increase in both sugars and carbohydrate could lead to worsening effects on circulating insulin levels and lead to an increased risk for developing diabetes. A 2016 study published in the journal Circulation, Dr Dariush  Mozaffarian and colleagues studied dietary fat intake in 3,333 adults over 15 years. The researchers found that people who had higher levels of three different types of full-fat dairy had, on average, a 46% lowerrisk of developing diabetes compared to people who tended toward lower fat dairy products. But what about the weight gain with full fat diets?

My family is always concerned that full-fat diet may cause them to “pinch-an-inch”.  Contradictory! A study published in the American Journal of Nutritionanalyzed the effects of full-fat versus low-fat dairy on obesity. Researchers discovered that among 18,438 women, those who consumed the most high-fatdairy products lowered their risk of being overweight or obese by 8%. 

According to my taste buds, the full-fat flavor of yogurt is far better than the 0% fat yogurt chosen by my daughter (let’s not even get into my whole milk habit!). By cutting back on dairy fat, you may not only be cutting back on the deliciousness but focusing on one nutrient in the diet may be less beneficial overall. So now what do I tell my daughter when she reaches for the 0% yogurt? Back away, I am going for the 5% Fage*!

*pronounced “fa-yeh” yogurt

Circulation, Volume 133, Issue 17, April 2016

The American Journal of Clinical Nutrition, Volume 103, Issue 4, 1 April 2016

Vitamin D: When too much is toxic

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“Sally’s” mother called me in a panic. My young patient had misunderstood her Vitamin D instructions and had  been taking her weeklyprescribed 50,000IU Vitamin D capsule instead daily for the last fifteen days. She was experiencing nausea, headaches and mild dizziness. My first thought was, “it is just a vitamin and she is young and healthy and should be fine”. However, to be sure, I contacted Poison Control. I am so glad I did.

My Poison Control representative informed me she needed an immediate Emergency Room evaluation for electrolytes and an ECG. The Baylor Scott and White Plano emergency room doctor quickly agreed to accept Sally for immediate evaluation.

Vitamin D hypervitaminosis (vitamin D toxicity)is a potentially serious condition.  It may be more common than we think. More recently medical providers are recognizing that patients have Vitamin D deficiencies. For patient with exceptionally low levels,  large doses of prescribed vitamin Dmay be necessary in order to help prevent bone loss, fatigue, and muscle weakness among other complications. , Because it is a natural vitamin, many people may feel it is a benign drug. But it is not.

Vitamin D toxicity can cause a buildup of calcium in the bloodstream which can lead to nausea, vomiting and weakness, such as my patient was experiencing. If the calcium levels become too high, a patient may experience dehydration from urinary frequency, along with bone pain, and (over time) kidney stones.

Elevated calcium may even lead to electrical changes of the heart resulting in  abnormal heart rhythms .  Thus, necessitating the need for an ECG (electrocardiogram) for my patient in the emergency room.

I was reassured after reviewing Sally’s labs and ECG on-line. The emergency room doctor released her to home. My recommendation is to place Sally’s vitamin D on hold until February, then to place her on a daily dose of over the counter Vitamin D supplement. 

My patient learned that following both verbal and written prescribing instructions is very important. I was reminded that Vitamin D weekly prescribing should be clearly understood by the patient and that Poison Control is always a great resource for all medical providers and their patients. While vitamin D replacement has several advantages, too much of a good thing can be disastrous. Always check with your medical provider if you are taking beyond your prescribed dose of any medication, including vitamins.

*Sally is used in place of patient’s name in order to protect her privacy

Why coffee may not be your first morning eye-opener!

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Garfield, the cat wonders “Is there life before coffee?” in one of my favorite cartoons. Well, Garfield, there needs to be more time before coffee to achieve peak benefits of the coveted caffeine-loaded beverage. 

According to researcher Stephen Miller PhD, the best time to drink coffee may be an hour after you awaken. It seems that fully-loaded (caffeinated) coffee interferes with our natural variation of blood cortisol levels.

According to researchers, drinking that first morning cup of Joe could cause the body to produce less morning cortisol. The problem is two-fold. Caffeine would therefore be less effective as a morning “wake-me-up” and could compromise the benefits of cortisol’s stressor effect for the body.

 Our stress hormone, cortisol naturally peaks in the morning. Cortisol puts our body on alert to stressors and is responsible for the “fight or flight” reaction that causes our heart rate to increase and blood pressure to respond to physical and emotional stressors. for example, if we are ill or have an accident, cortisol helps our body recover by adjusting our blood sugar, pulse rate and activating our immune response.

Help your body be at its healthy-best! Take an hour in the morning to get up, get dressed and ready to go. THEN begin your morning cup of happiness. A change in habit could lead to a positive change in health.

Herpes virus responsible for approximately 50% of Alzheimer’s

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The herpes virus could be a cause of at least 50% of Alzheimer’s Disease cases. According to a recent paper published in the Frontiers in Ageing Neuroscience journal, the same virus that causes cold sores could be linked to an increased risk of dementia.

The HSV1 (herpes simplex virus type 1) is very common and (unfortunately) remains permanently within the body. The virus can only be resolved by the body’s natural immune system or by anti-viral drugs (which can put its actions on hold).

There is evidence that in older individuals, the HSV1 may interfere with brain cell functioning and have harmful effects on cognition leading to dementia.  An estimated 5.5 million American live with Alzheimer’s (2017). Approximately 5.3 million are age 65 and older and about 2000,000 individuals are under age 65. In a different perspective: One in 10 people ages 65 and older have Alzheimer’s dementia (10%).

There is good news. It is highly probable that the disease may be less likely if affected individuals with HSV1 were provided anti-viral treatment. Better yet, HSV1 could be prevented with early childhood (infant) vaccinations carried out in a subsequent series of future “booster” vaccinations.

Your doctor can perform a blood test to determine if you have HSV1. A topic worth discussing at your next checkup.

What You Need to Know About Acute Flaccid Myelitis (AFM)

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Following an uneventful respiratory infection, a child develops sudden loss of use of one or more limbs. Some children will have neck pain. In rare instances, difficulty swallowing, urinating, or breathing could be presenting signs and symptoms. An MRI scan demonstrates abnormalities along the spinal cord.  Sometimes, nerve conduction studies (nerve response tests) or testing of the fluid around the spinal column is needed for diagnosis.

Since fall 2014, the Centers for Disease Control and Prevention (CDC) have reported almost 400 confirmed cases of AFM (acute flaccid myelitis) in the Unites States. Most of the cases involve children. We do not understand why some children develop the disease and others do not. This year, over 90% of cases have been in children less than 18 years of age. To date, no deaths from AFM have been reported.

What is most concerning is the accelerated numbers of cases in the past few years. Although less thanone in a million people in the United States are diagnosed with AFM each year.

AFM affects the spinal cord which results in weakness of the extremities. Affected patients may have difficulty with control of their arms and legs and require assistance with activities of daily living (eating, walking, weight-bearing, etc.). These children will usually experience respiratory infections prior to developing severe neurological symptoms. It is likely that a virus seen in common respiratory infections may be a cause (in other words, antibiotics can not prevent the infection). The virus shares many similarities the polio virus that was rampant in the 1950’s. Polio

There is evidence that enterovirus may be a contributing factor. A specific sub-type of the virus (EV-D68) seems to have commonality among many sufferers. In the past, other viruses  such as adenoviruses (responsible for the common cold among others) and West Nile virus have been responsible.

How do you prevent it? Good hand washing to minimize germ exposure. Stay up to date on vaccines and maintain protection from mosquitos; especially with recent flooding in our state and increased chances of exposure to stagnant water filled with mosquito larvae.

If your child develops  sudden weakness of the limbs, it is important they  seek medical attention immediately. While approximately half of all cases will see full recovery within four months, many children are left with residual weakness.