Dr. Jane Explains

Open This Book & Say "Ahhh"

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.

Don’t let the flu get you!

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The flu season is exceptionally active and will most likely worsen. Preparations are in place at our clinic. We have extra medical providers available for walk-in urgent needs for weekdays and weekends. Working late into the night, we are on the ready!

 

This year, approximately 80% of flu cases are the H3N2. A dangerous type of Flu A strain (there are primarily A and B strains), H3N2 infection can be deadly to young infants and children and the elderly or immunocompromised.

 

Flu shots are highly encouraged this year. Unfortunately, the flu shot may only be about 10% effective against H3N2 virus. The vaccine’s lack of efficacy is not due to changes in the genetics of the flu, but to changes in the virus “seed” used in the vaccine preparation. Apparently as the laboratory flu virus grew in eggs, it picked up mutations foreign to human flu (per Dr Fauci in The New England Journal of Medicine 2018).

 

The Centers for Disease Control and Prevention (CDC) has estimated that flu kills 12,000-56,000 Americans annually (number depends on the severity of the flu outbreak). Despite issues with the flu shot, it has good coverage for other types of flu viruses. In addition, even if you get the flu, you can catch other flu viruses, so protection is needed.

 

There is medication that can be used to decrease severity, contagiousness, and days of illness (Tamiflu). Just be sure it IS the flu. We are seeing other viral illnesses and strep throat. It is generally BEST to be seen and not managed over the phone. Complications of the flu, including pneumonia, are not uncommon.

 

Most of all, don’t let the flu get you! Careful handwashing and avoid sharing eating utensils with sick people. If you have the flu, stay home until you are fever-free for at least 24- 48 hours and/or symptom-free for several days. If you have further questions, please consult your medical provider.

Shingrix offers improved opportunity for shingles prevention

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Give it time and we all find that medicine just keeps getting better with age. Welcome in, Shingrix! A more effective shingles prevention drug than the currently used Zostavax.  In addition, we now have the nod from the Centers for Disease Control and Prevention (CDC) to begin the shingles vaccine at age 50 (as opposed to the starting age of  60 with Zostavax).

 

Shingles affects mainly older people and is the result of reactivation of the varicella-zoster virus which causes chickenpox and is dormant in those who have had the disease. When the sleeping giant awakes, it causes a painful rash that can be debilitating and leave long-lasting pain. Zostavax was approved in 2006 as a standard shingles immunization for people age 60 and older. Now there is a new kid on the block.

 

Yes, we have been recommending Zostavax for the last several years for all our patients age 60 and older and it has been somewhat effective and better than no prevention. However, we are finding that (unlike good wine), the vaccines effectiveness does not age well as it’s effectiveness declines significantly in the first 5 years. But better news is here!  In clinical trials, the Shingrix remained up to 90% effective in preventing shingles in people age 70 and older compared to reductions in lifelong effectiveness as low as 32% in similar age groups with Zostavax.

 

A two-shot (series) Shingrix vaccine is expected to cost $280. By the mid-2018’s, we should hear if insurance companies will cover the costs.

 

Vaccines are constantly evolving and we should all consider offering this as an option for our patients. It may be reasonable to suggest patients obtain Shingrix at discount pharmacies until immunizations are covered by insurance companies and we are able to keep stock in our clinics.

 

Personally, I love progressive change. I’ll look forward to offering a more effective shingles vaccine for my patients.

 

For the last 30 years, I have enjoyed my morning Dannon coffee yogurt. Over the decades, I would eventually add whipped crème, then years later, nuts, and now Dude Sweet Chocolate dark chocolate granola. My breakfast yogurt just keeps getting better! It’s a silly analogy but I like to think that preventative options keep getting better. It just takes trials and tincture of time.

The dogsniffer-er; when cancer detection goes to the dogs (or not)

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“We have a cancer-sniffing dog coming to the fire station next week”, “Glen” told me at his latest office visit.  We were lucky enough to detect his prostate cancer early at a prior physical. Glen is confident in my care, but he is unsure what to expect from these cancer-sniffing dogs. He has been told that these highly trained animals can detect cancer “odors” with a few sniffs. That is so interesting!

 

 I had to investigate, so here you go:

 

Specially selected and trained dogs certainly can sniff out cancer in some patients. An article attributes talent and success lies within the personality of particular dogs and their owners. According to  the Journal of Breath Research March 2017 (related article 2013). In other words (as you would suspect), there is some unpredictable results. The cancer-detecting  sensitivity rates in dogs may be as high as 78.6% . This is really good, however, this also means that one in four tests are false negative. Therefore, there may be false reassurances that someone does not have cancer when indeed they do.  We could all argue that any test is better than none and early detection can be life-saving in so many cancers.

 

Why can’t technology keep up? Here is your answer:

 

Early detection of colon, breast, lung and ovarian cancer are particularly important when it comes to successful eradication of disease and survival. Fast forward to the latest information on a new bloods DNA test that can detect early (Stage I) cancers.

 

The test found early stages of colon cancer 71% of the time, breast and lung cancer 59% of the of time and ovarian cancer 68% of the time.  Pretty darn good. Not yet FDA-approved, I suspect we may hear soon when these tests will be available.

 

As a clinician, I preface my gynecologic exams with the caveat that “the pelvic exam is not a good screening test for ovarian cancer…”; in fact, fewer than 1 in 5 ovarian cancers are caught early enough to ensure survival. With a five-year survival at 40% or less by time of detection, the outlook is rather gloomy. In fact, a dog-cancer sniffer may perform better than my physical exam for early ovarian cancer detection. With a high rate of false negatives however, before I bring these super hounds into the office, I may choose to wait on these latest DNA tests.

 

 

**False negatives give you a bunch of people who actually have cancer, but are told they don’t because the screening test was negative. False positives give you people who don’t have cancer, but are told they might, and undergo many more tests only to determine that they were fine all along. Chasing a false positive can be frustrating, expensive, and psychologically stressful for a patient.