Education

“Providing our patients with medical care and health education that paves the way for improved physical and mental well-being, for a better quality of life.”

Choose a category …

COVID-19

We check staff and arriving patients at the front door for fever, and we are not currently accepting walk-in patients, as we need to prescreen for fever and respiratory symptoms. Please come alone into the office for an appointment unless you need another person’s assistance for medical reasons, and please do not arrive more than 15 minutes early. We If you have fever or respiratory symptoms, please contact us by text (210-690-2273), and we can schedule a Video Visit.

WE ARE NOW OFFERING RAPID COVID-19 TESTING ONSITE TO OUR PATIENTS. IF YOU THINK YOU MAY HAVE COVID-19, PLEASE CONTACT US VIA TEXT OR PHONE TO SCHEDULE A VIDEO VISIT FOR PRESCREENING. A DOCTOR WILL ORDER THE COVID-19 TEST IF APPROPRIATE, AND WE WILL DIRECT YOU TO OUR TESTING SITE (A SEPARATE PART OF OUR FACILITY.) YOU SHOULD GET THE RESULTS THE SAME DAY. WE MAY ALSO SCREEN FOR STREP AND INFLUENZA (“FLU”) IF APPROPRIATE.

The information below is from the CDC. Go to the CDC website for more information:

CDC COVID-19

Steps to Prevent Illness

中文 | Español

There is currently no vaccine to prevent coronavirus disease 2019 (COVID-19).
The best way to prevent illness is to avoid being exposed to this virus.

The virus is thought to spread mainly from person-to-person.

  • Between people who are in close contact with one another (within about 6 feet).
  • Through respiratory droplets produced when an infected person coughs or sneezes.

These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.alert icon

Older adults and people who have severe underlying chronic medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness. Please consult with your health care provider about additional steps you may be able to take to protect yourself.

Take steps to protect yourself

Illustration: washing hands with soap and water

Clean your hands often

  • Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.
  • If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry.
  • Avoid touching your eyes, nose, and mouth with unwashed hands.
Illustration: Woman quarantined to her home

Avoid close contact

Take steps to protect others

man in bed

Stay home if you’re sick

woman covering their mouth when coughing

Cover coughs and sneezes

  • Cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow.
  • Throw used tissues in the trash.
  • Immediately wash your hands with soap and water for at least 20 seconds. If soap and water are not readily available, clean your hands with a hand sanitizer that contains at least 60% alcohol.
man wearing a mask

Wear a facemask if you are sick

  • If you are sick:  You should wear a facemask when you are around other people (e.g., sharing a room or vehicle) and before you enter a healthcare provider’s office. If you are not able to wear a facemask (for example, because it causes trouble breathing), then you should do your best to cover your coughs and sneezes, and people who are caring for you should wear a facemask if they enter your room. Learn what to do if you are sick.
  • If you are NOT sick: You do not need to wear a facemask unless you are caring for someone who is sick (and they are not able to wear a facemask). Facemasks may be in short supply and they should be saved for caregivers.
cleaning a counter

Clean and disinfect

  • Clean AND disinfect frequently touched surfaces daily. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.
  • If surfaces are dirty, clean them: Use detergent or soap and water prior to disinfection.

To disinfect:
Most common EPA-registered household disinfectants will work. Use disinfectants appropriate for the surface.

Options include: 

  • Diluting your household bleach.
    To make a bleach solution, mix:
    • 5 tablespoons (1/3rd cup) bleach per gallon of water
      OR
    • 4 teaspoons bleach per quart of waterFollow manufacturer’s instructions for application and proper ventilation. Check to ensure the product is not past its expiration date. Never mix household bleach with ammonia or any other cleanser. Unexpired household bleach will be effective against coronaviruses when properly diluted.
  • Alcohol solutions.
    Ensure solution has at least 70% alcohol.
  • Other common EPA-registered household disinfectants. 
    Products with EPA-approved emerging viral pathogens pdf icon[7 pages]external icon claims are expected to be effective against COVID-19 based on data for harder to kill viruses. Follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method and contact time, etc.).

From the World Health Organization:

Diabetes

DIABETES: American Diabetes Association
The American Diabetes Association provides excellent, current information about this disease, from prevention to complications to treatment.

Diabetes: Frequently Asked Questions

Diabetes: May I Screen You?

DIABETES: National Diabetes Education Program

DIABETES: National Diabetes Information Clearinghouse

DIABETES: Texas Diabetes Institute  The TDI is part of the University Health System here in San Antonio.

Peripheral Neuropathy

Medical Power of Attorney: downloadable form

LEGAL: Durable Power of Attorney for Health Care
You can download this form to designate others to make health care decisions for you, should you become unable to do so yourself.

Advance Directives: Information from the Texas Medical Association

LEGAL: Advance Directives
This link will take you to the Texas Medical Association site, where you can download forms and information concerning the Directive to Physicians, also known as Advance Directives.

Living Will

Advance Directives: Living Will
You can download this pdf file to prepare a Directive to Physicians, also known as a Living Will. The file includes information about what is required to complete this form.

Durable Power of Attorney for Health Care

Advance Directives: Durable Power of Attorney for Health Care
By clicking on this link, you will be downloading an Acrobat pdf file that you can print out and complete. Please provide a copy to your physician.

Do Not Resuscitate

Advance Directives: Do-Not-Resuscitate Order 
The Texas Department of State Health Services makes this standard form available on its website. This link will allow you to download an Acrobat pdf file version that you can print out and complete. Please provide a copy to your physician.
View/Download file

Attention Deficit Disorder

Attention Deficit Disorder (ADD) is a common condition that typically starts in childhood. It has been estimated to affect 5-7% of school age children. It is sometimes is associated with a hyperactivity component (ADHD). This occurs more commonly in males than females. It is often the hyperactivity that gets noticed first by parents and teachers.

Children with ADD or ADHD are noted to have problems with maintaining focus and are unable to pay attention at school. This inattentive behavior at school is manifested as making careless mistakes in schoolwork or homework, not listening to instructions, forgetful about assignments or daily activities, appears disorganized, and is easily distracted by minor extraneous stimuli. The ADD/ADHD child is often impulsive and has difficulty waiting his or her turn, blurts out answers before the question is completed and interrupts others frequently. The hyperactivity component is demonstrated by leaving the seat in the middle of class, talking excessively, difficulty in engaging in quiet behaviors, and runs around inappropriately. These children may also have a mood disorder associated with the ADD. They often get isolated and made fun of by other children because of their problematic social interaction with non-ADD children.

In the past most physicians and psychologists felt that children outgrew ADD. Now we believe that a significant percent of these children, maybe as high as 50%, do not grow out of the condition. Many adults learn ways to cope with the problems associated with ADD. They also find that certain jobs and career fields are more suitable to their impairment. However, the basic problems of inattention, impulsivity, and hyperactivity continue to cause some personal, social, educational, and occupational problems in their lives. In adulthood the hyperactivity becomes more of a restlessness with impatience and fidgetiness as the primary symptoms. The impulsivity is now more verbal with saying the wrong thing, interrupting, or speaking out of turn. Sometimes things like impulsive buying maybe a symptom of ADD. The most problematic symptom is the inattention, which manifests as trouble staying on task and completing work assignments. It results in poor organization skills and trouble with making and maintaining a schedule. The inattention results in social problems because these adults commonly forget anniversaries, birthdays, and other important dates. ADD in adults often prevents advancement in their careers and limits more advanced educational opportunities.

Treatment for ADD mainly involves use of medications. Behavioral and psychotherapy do not have much of a role in treatment of ADD. The traditional medications are all psycho stimulants such as Ritalin, Adderall, and Concerta. Strattera is in a new class of medication that works on norepinephrine, a chemical in the brain. This medication is useful in the group of patients that are intolerant of the traditional stimulants.

If you believe that you may suffer with ADD you should consult your pediatrician or family physician. There are many good treatment options available.

– – – Mark Smith, MD – – –

Premenstrual Syndrome

Premenstrual Syndrome

PMS (Premenstrual Syndrome) and PMDD (Premenstrual Dysphoric Disorder) usually present with both physical and mood symptoms. PMS and PMDD affect approximately 20-30% of menstruating women. The average age at which women seek treatment is in the early 30’s. There is not a set criteria for diagnosis of PMS. However, the more severe version of PMS referred to as PMDD does have a set criteria for diagnosis. Recent population-based studies have found no association between PMS and any demographic or personal habits such as education, income, employment status, or marital status. There is a higher rate of PMS/PMDD in Hispanic women and a lower rate among Asian women compared to Caucasian females.
Emotional symptoms are the most common reason that women seek treatment, with irritability being by far the most common symptom. Other emotional symptoms include depression, anxiety, sadness, crying spells, anger, and mood lability. The most common physical symptoms are breast tenderness, fatigue, insomnia, abdominal bloating, weight gain, appetite increase, hot flashes, headache, and muscle/joint aches.
PMS is diagnosed when women report at least one of the symptoms listed above during the five days before menses in each of the three prior menstrual cycles. The symptoms are relieved within 3-4 days of the onset of menses without recurrence until the middle of the next cycle. The symptoms cause dysfunction in some aspect of the patient’s life — personal, work, social, etc.
PMDD is diagnosed when most menstrual cycles during the past year have 5 or more of the following symptoms:
1. Markedly depressed moods or feeling of hopelessness
2. Marked anxiety or tension
3. Marked mood swings
4. Persistent anger or irritability
5. Loss of interest in past enjoyable activities
6. Difficulty concentrating
7. Lethargy and fatigue
8. Marked change in appetite
9. Change in sleep, insomnia, or hypersomnia
10. Sense of being overwhelmed or out of control
11. Other physical symptoms: breast tenderness, abdominal bloating, headache, swelling of extremities, muscle/joint aches
Symptoms start 4 days prior to menses and end 4-5 days after start of menses. The disturbance interferes with some aspects of the patient’s life. The problem is not related to other underlying problems such as depression or anxiety.
Treatment for PMS/PMDD has improved significantly in the last few years. The serotonergic antidepressants (SSRIs) such as Prozac, Zoloft, and Paxil have been proven to be extremely effective in treating the majority of symptoms. The SSRIs improve both mood and physical symptoms as well as the patient’s overall functioning, including work productivity and social relationships. They work rapidly with significant improvement seen within the first cycle of treatment. They can be used on a continuous basis or intermittently during the premenstrual period. Intermittent dosing offers advantages with lower costs and possible reduction in some side effects such as weight gain and decreased sex drive. The major disadvantage is with intermittent dosing is that women have to track their start and stop dates. Other treatments that have demonstrated some usefulness with PMS/PMDD are exercise on a regular basis and calcium 600mg twice daily. Chaste berry (vitex agnus castus) is an herbal treatment that has shown some promise for treatment of PMS/PMDD. Further study of this herbal treatment is ongoing.

Mark Smith, M.D.

Peripheral Neuropathy

    Peripheral neuropathy refers to any disease or dysfunction involving  the peripheral nervous system. The peripheral nerves are the nerves outside the brain and spinal cord. These nerves are involved in the sensory input from the extremities and in movement of the extremities. The different types of neuropathies are often classified as sensory or motor neuropathies. Another way of classifying the neuropathies is based on the number of nerves involved. Involvement of just one nerve is called a mononeuropathy while the term polyneuropathy refers to the involvement of more than one nerve.  Peripheral neuropathies affect 4-7 % of the general population but in the diabetic population this number may be as high as 30%.

Peripheral neuropathy affects both the sensory and motor fibers of the nerve. However, weakness is rarely a symptom of the neuropathy. This happens because as the muscle fibers lose their nerve connections they undergo a compensatory reinervation (reconnection) from the surrounding muscle fibers. Sensory nerve endings cannot utilize this same mechanism to stay connected to the central nervous system. This is the reason that most peripheral neuropathies initially present as burning, tingling or numbness. Weakness may become obvious only as the neuropathy markedly worsens. Most neuropathies progress slowly over months or even years. However, there is one important type of neuropathy that can rapidly progress and usually involves the motor fibers initially. This type of neuropathy is called Guillain-Barre syndrome. It often starts with weakness and numbness and rapidly progresses to paralysis and respiratory failure. If not promptly treated it can be fatal. This type of neuropathy is rare and almost always follows a respiratory or gastrointestinal viral infection. The sensory neuropathies involving the hands and feet are the most common type. They almost always present with pain often described as a tingling, burning,  buzzing or prickling sensation. Patients often describe a tightness or cold/burning sensation.

There are many causes of neuropathy.  Finding the underlying cause of the neuropathy is often much more difficult the making the diagnosis.  Toxicity from metals such as lead, arsenic and iron overdose can cause neuropathy. Organic solvents used in the chemical industry have been shown to cause some neuropathy. Exposure history and job history are often useful in finding these causes.  However, these are not extremely common causes and can be easily overlooked. Both viral and bacterial infections can cause certain types of neuropathies.   Autoimmune disease and cancers have been implicated as possible causes of peripheral neuropathy. Treatments of some conditions with medication and radiation have been associated with neuropathy. However, diabetes, alcohol abuse and hypothyroidism account for well over 50% of all peripheral neuropathies. Entrapment syndromes such as carpal tunnel syndrome and cubital tunnel syndrome are other relatively  common causes of neuropathy.

Diagnosis of peripheral neuropathy and its underlying cause is often very difficult. The medical history is the most useful diagnostic tool. Electrical testing of the nerves provides objective data that the history and the physical exam may not reveal. The electrical nerve tests give more precise information on the extent and distribution of involvement of the neuropathy. Laboratory testing may be useful in obtaining the exact etiology of the neuropathy. This is important because some of the identifiable causes are treatable.. Common laboratory tests useful in the evaluation of peripheral neuropathy are fasting blood sugar, vitamin B12 level, folic acid level , thyroid panel and complete blood count.

Treatment of peripheral neuropathy starts with treatment of the underlying medical condition if identified. Protection of the extremity from injury due to the numbness  is very important. This includes checking the extremity daily for any signs of early injury. Proper fitting foot wear and proper treatment of any pressure points or skin breakdown is extremely important. Since peripheral neuropathy often involves pain to the extremity pain management is vitally important. Several groups of medications have shown usefulness in treating neuropathic pain. However, no one group is always successful and often finding the best treatment requires some trial and error effort. In some patients combinations have been shown to be more successful than a single agent. The anticonvulsants are the most successful group for treating the neuropathic pain. This group includes Neurontin (gabapentin), Lyrica, Tegretol and Lamictal.  The antidepressants are also extremely useful in treating neuropathic pain. This group includes Elavil (amitriptyline), and Pamelor (nortriptyline). These are older types of antidepressants belonging to the tricyclic antidepressant family. This group of medications commonly cause sedation and should be cautiously in the elderly. A newer class of antidepressants called the SSRI (selective serotonin reuptake inhibitor) group is much safer but is less consistent in helping with neuropathic pain.  Cymbalta is a newer dual acting agent that has recently been shown to be very effective in treating chronic pain.  Some of the opioid pain meds such as Vicodin are  still useful for treating the pain associated with the peripheral neuropathies.  Tramadol is a safer general pain medication that has been shown to be useful in the treatment of chronic pain. Topical agents such as the Lidoderm  patch and capsaicin are useful in the controlling the pain of peripheral neuropathy.

In conclusion, peripheral neuropathy is a relative common problem associated with significant pain and dysfunction. There are multiple causes but diabetes alone causes about 1/2 of the reported causes. The history usually makes the diagnosis but  electrical  nerve studies are extremely useful in determining severity and extent of the neuropathy. Treatment is difficult, but several medications have been shown to be useful in treating the pain associated with the neuropathy.

Osteoporosis Prevention and Treatment

Osteoporosis

Osteoporosis is a disease that affects ten million Americans of which 8 million are women. One in two women and one in eight men over age 50 will get osteoporosis related fractures.
It is a decrease in the density or thickness of your bones. The bones get thinner and weaker as we get older. Unfortunately, there are no obvious warning symptoms. It is therefore known as the “silent disease”. Having weak bones means they may break after a minor injury or fall. It may happen without any injury.

Prevention

Osteoporosis is a preventable disease. The best way to prevent weakened bones is by having enough calcium and vitamin D in your diet and regular exercise.

1. Follow a diet with enough calcium and vitamin D.
a. Women need 1000 to 1500 mg/day of calcium.
b. It means at least three 8 ounces glasses of milk per day. You can also eat three ounces servings of yogurt. Other choices are dark leafy vegetables, orange juice and cereals. If you don’t have this much calcium in your diet, ask your doctor if you should take supplements.
c. A natural source of vitamin D is sunlight. In only 15 minutes each day, you can get enough sunlight to keep a healthy vitamin D level.  However, sunlight exposure does increase your risk of skin cancer.
2. Exercise
Try to do weight bearing exercises three times a week. It helps the uptake of calcium by your bones. Examples are walking, jogging, stair climbing and hiking.
3. Medications
a. Estrogen- oral estrogen can be combined with oral progestin to prevent osteoporosis. If a woman has had a hysterectomy, only estrogen is given. With the recent studies of Prempro having an increased risk of breast cancer, stroke and heart attacks, and other problems, you need to ask your doctor if estrogen is safe for you to take. You doctor might consider non-estrogen alternatives for prevention.
b. Evista (Raloxifene)- approved to be used for both prevention and treatment of postmenopausal osteoporosis. It is a “selective estrogen receptor modulator”. It can cause hot flashes or increase the risk of blood clots in some women.
Risk factors
a. Postmenopausal status
b. Premature menopause (before age 45)
c. Caucasian race or Asian ethnicity
d. Thin, small body build
e. Family history of osteoporosis
f. Certain medications, e.g., steroids
g. Use of tobacco, excessive alcohol or caffeine

Screening tests
Bone densitometry or DEXA scans can be ordered to check the thickness of your bones. It will tell you what your risk for a fracture is. Consult with your doctor to see if this test is indicated.
Treatment
Some medications can stop bone loss of calcium. They will keep your osteoporosis from getting worst.
a. Biphosphanates- there are two medications called alendronate (Fosamax) and risedronate (Actonel). They can be used for treatment and prevention of osteoporosis. Consult with your doctor to see if treatment is indicated.
b. Calcitonin (Miacalcin)- This is a hormone that is given via a nasal spray. You do one “puff” every day.
c. Teriparatide (Forteo)- is an injectable hormone that stimulates new bone. Side effects are nausea, dizziness and leg cramps. Only approved to be used for 2 years.

Information
1. National Osteoporosis Foundation offers a 22 page free booklet about osteoporosis (1-800-223-9994).
2. National Institute on Aging offers free facts sheet about menopause, osteoporosis and preventing falls (1-800-222-2225).
3. Public library and bookstores have books about osteoporosis.
4. Websites: www.ahrq.gov- Agency for Healthcare and
Research Quality
.
www.nof.org- National Osteoporosis Foundation.
www.nia.nih.gov- National Institute of Aging.

Hepatitis A

Hepatitis A

Hepatitis A is a viral infection that multiplies only in the liver cells and the lining of the gastrointestinal tract. Hepatitis A is a hardy virus that may survive for several months in sea water, fresh water, waste water and the soil. It is resistant to freezing and may be spread in ice cubes.

Infection occurs primarily from close person to person contact via hands or sexual contacts. Ingestion of contaminated food is a common source of Hepatitis A outbreaks. The potential spread by IV drug use or blood transfusion is believed to be extremely low. The incubation period is 15 to 50 days with an average of 25 to 30 days. Approximately 70% of infected adults will develop symptoms such as jaundice, nausea and vomiting. However, only about 30 % of infected children will develop symptoms. The problem is that these asymptomatic individuals will shed the virus and continue to spread the disease. Children may shed the virus in their stools for up to 6 months. This is often a major factor that perpetuates community wide outbreaks.

Due to childhood immunization practices the number of reported cases of Hepatitis A has dropped from 32,000 in 1990 to 7,700 in 2003. Childhood vaccination and vaccination of higher risk groups including close personal contacts with an infected person, bisexuals, gay males, travelers outside the USA and IV drug abusers could markedly reduce the remaining 7,700 cases in the United States.

The main signs and symptoms of Hepatitis A are abrupt onset of fever, malaise, decreased appetite, nausea, vomiting, abdominal pain and headache. Occasionally individuals manifest muscle aches, diarrhea, joint aches, cough, hives or intense itching. Physical signs include a tender swollen liver, a tender swollen spleen, tender swollen lymph nodes and jaundice. About 10 – 20% of Hepatitis A infections will develop a prolonged relapsing course that may last several months. Approximately 1% of adults with the infection will develop fulminant liver failure. The overall fatality rate is low but does approach 2% in adults over the age of 40.

There is no specific treatment for Hepatitis A. Treatment is supportive and includes rest, adequate nutrition and avoidance of agents toxic to the liver such as alcohol and Tylenol. Caregivers and close contacts should be given the Hepatitis A vaccine (a series of 2 vaccinations, given 6 or more months apart) and immune globulin if not already fully vaccinated. Administration of immune globulin is not contraindicated in pregnancy or while breast feeding.

Mark Smith, MD

Genital Warts, What You Need to Know

Genital Warts

Genital warts are usually small, skin-colored bumps that look like flat domes or small cauliflowers. They are not tender and typically do not bleed with contact. They can be on the inside or outside of the genital areas including the vagina, vulva, cervix, urethra, penis, scrotum, and anus. They are caused by a virus called Human Papillomavirus (HPV). This virus is very different from the common wart virus seen in other areas of the body. Not everyone exposed to HPV gets genital warts. Studies have shown that _ of Americans ages 15 to 49 years old have the antibody to HPV. Why a certain percent develop genital warts is unclear, but it may have to do with the individual’s immunologic response and the serotype of the HPV.

You can get the infection by having oral, vaginal, or anal sex with someone who is infected. HPV can live inside your body for weeks, months, or even years before the warts appear. This makes it impossible to know exactly when exposure to the virus occurred. Certain kinds of HPV may increase a women’s risk of getting cervical cancer. Other risks of cervical cancer are smoking, many difference sex partners, having sex at an early age, and developing another sexually transmitted disease. A Pap Smear is the best way to detect early cervical cancer or its precursor, dysplasia. It is extremely important that women with a history of HPV (treated or untreated) or who have had a sexual partner with a history of HPV (treated or untreated) keep their Pap Smear up-to-date. HPV in males may slightly increase the risk of getting cancer of the penis or anus.

Treatment of genital warts is more complicated that treating simple warts that develop on hands, arms, feet, etc. Genital warts are treated by your doctor. Do no use over-the-counter treatments for genital warts. Basically there are two ways to treat genital warts. The first is ablative (destructive) therapy with surgery; laser or freezing with liquid nitrogen. The second is chemical treatment. Some are patient-applied and some are physician-applied. The chemical methods take up to several weeks to work. The most popular patient applied treatment is condylox (podofilox). This is applied twice a day for three days then off for four days. This cycle may be repeated for up to four cycles. Please see your physician for further advise as to which treatment is best for you and your situation.

Mark Smith, M.D.

Fibromyalgia

Fibromyalgia

Fibromyalgia is a syndrome characterized by widespread pain and tenderness at specific points across the body. It occurs most commonly in the 4th and 5th decade and affects women 10 times more commonly than men. Overall about 3-4 % of the US population is affected. Associated symptoms include fatigue, stiffness, insomnia, headache, abdominal pain and poor concentration. Fibromyalgia is often associated with other chronic conditions such as  Temporomandibular Joint Syndrome (TMJ), Irritable Bowel Syndrome (IBS), Chronic Fatigue Syndrome (CFS)  and depression.

The cause of fibromyalgia is unknown but there appears to be  a problem with the central pain processing center in the brain. This problem results in the sensory signals coming to the brain being magnified. It is this magnification that turns a relatively innocuous sensation  into a painful sensation. Thus, a sensation with a 2-3 (out of 10) pain level become a 8-9 level. How this happens is unclear but does appear to involve some of the deeper sensory centers of the midbrain. The American College of Rheumatology has published a set of criteria used to make the diagnosis of fibromyalgia. The criteria are :

  1. History of widespread pain for greater than 3 months duration
  2. Pain along the spine and in all four quadrants of the body (right/left and above/below the waist)
  3. Tenderness in at least 11 out of 18 standard points throughout the body to pressure of 4 kilograms (9 pounds).

Testing for fibromyalgia with lab and radiological testing is unnecessary and not part of the diagnostic criteria used to make the diagnosis. However, these tests are often very useful in excluding other painful disorders. Appropriate testing may include:

  • Complete Blood Count (CBC)
  • Thyroid Panel (TSH and free T4)
  • Sed rate
  • Rheumatoid Tests (RA or CCP)
  • Antinuclear Antibody (ANA)
  • C-reactive Protein (CRP)
  • Creatinine Phosphokinase (CPK)

Radiological testing has a very limited use in the diagnosis or treatment of fibromyalgia.

Treatment of fibromyalgia is difficult due to the diffuse presentation of the symptoms. Also, there is no treatment for the underlying cause of fibromyalgia. Psychotherapy is useful in dealing with the emotional response people have to the pain and limitation in function.  Physical therapy and exercise programs with a graded program that slowly increases the intensity and the duration of the exercise is extremely useful. Patients should set realistic but progressive goals. A flexibility and stretching program is useful in maintaining function. A patient log to monitor progress is useful to demonstrate improvement or identify a problem.

Medications have been shown to useful in most patients with fibromyalgia.  However, the degree of pain reduction with medication alone is 35-50%.  The main groups of medication used for treatment are:

  1. Tricyclic antidepressants – Elavil and Pamelor
  2. Selective serotonin reuptake inhibitors  (SSRIs)- Zoloft, Celexa, Prozac and Lexapro
  3. Selective serotonin and norepinephrine  reuptake Inhibitors – Effexor and Cymbalta
  4. Anticonvulsants – Neurontin and Lyrica.

Many of these medications are now available generically (7 of the 10 medications listed.)

Narcotic pain medications are seldom suggested for use in fibromyalgia due to their high addiction potential. These medications may worsen cognitive function and increase depressive mood changes. However, there are certain patients for which the antidepressants and the anticonvulsants are inappropriate or simply do not work. These patients may need pain medications to maintain their activities of daily living especially as the disease progresses. Tramadol is a medication that works in  a similar fashion to the narcotics. However, it is not a true opioid narcotic and not as physically addicting as the narcotics. Tramadol appears to a slightly beneficial effect on serotonin and norepinephrine.  It is a useful medication in the treatment of fibromyalgia. The nonsteroidal anti-inflammatory medications are marginally useful in this condition but are cheap and nonaddicting.

Fibromyalgia is a common chronic pain syndrome that has the potential to incapacitate people. There is no cure for this problem and response to treatment varies from patient to patient. The best treatment appears to be multifactorial ,  often requiring psychotherapy, physical/exercise therapy, education, a supportive family, motivation by the patient’s doctor and appropriate medication.

COPD

COPD: Chronic Obstructive Pulmonary Disease

COPD is a term used to describe emphysema and chronic bronchitis. It is the fourth leading cause of death in the United States. The rate of COPD mortality in women tripled in the U. S. from 1980 to 2000. Early diagnosis and treatment including drug treatment and pulmonary rehabilitation are key components in slowing progression of the disease and improving the quality of life.

COPD is caused by chronic inflammation of the small airways and gradual destruction of the alveoli (air sacs). The small bronchioles collapse or are blocked by mucous. Air becomes trapped and causes hyperinflation of the lungs. As the air sacs die and bronchioles are plugged the exchange of oxygen and carbon dioxide is impaired. This impairment drops the patient’s oxygen concentration and raises the carbon dioxide concentration in the blood.

Risk factors for COPD include old/middle age, genetic factors, exposure to second hand smoke, history of childhood respiratory infections, and prolonged exposure to air pollution. However, the most important risk factor is a history of cigarette smoking.

Symptoms of COPD are:
➢ Shortness of breath
➢ Chronic cough
➢ Wheezing
➢ Chest tightness
➢ Increased sputum production
➢ Change in color of sputum
➢ Blood in sputum
➢ Fatigue
➢ Sleep difficulty
➢ Headaches, restlessness, dizziness

Treatment of COPD includes limiting continued exposure to the causative irritants including cigarette smoking and pollutions. Influenza and pneumococcal vaccinations are important to prevent infections that can cause further lung damage. Drug treatment includes long-acting bronchodilator inhalers. Short term, bronchodilators may be useful for acute exacerbations. Inhaled and oral steroids are useful as the condition worsens. Mucolytic agents are sometimes useful to help patients clear their airways. Cough medications are not usually helpful. Antibiotics are occasionally useful during acute exacerbations, but are not useful for chronic management.

Mark Smith, MD
March 13, 2006

What Do My Lab Tests Mean?

WHAT DO MY LAB TESTS MEAN?

The tests we discuss below have links to a website that can give you more information than the brief information here; the site also discusses tests not reviewed below, and symptoms that can be associated with the abnormalities. Another source of information about lab tests is at http://www.nlm.nih.gov/medlineplus/laboratorytests.html.

Liver Tests: (ALT, AST, ALK Phosphatase, Bilirubin)

http://www.labtestsonline.org/understanding/analytes/liver_panel/glance.html

Alkaline Phosphatase is an enzyme (protein) found in the liver, bone, and intestinal tissues. In the liver, it is mainly located in the ducts (tubes) that run throughout the liver. Some causes of elevated levels include:

  • Drug reaction (medication side effect)
  • Anticonvulsant use (phenytoin/Dilantin, Phenobarbital)
  • Alcoholism
  • Diabetes mellitus
  • Liver Disease (especially obstruction of the ducts), including hepatitis, cirrhosis
  • Gallstones
  • Bone Disease, including Paget’s Disease
  • Bone Cancers, pancreas cancer, some blood cancers (multiple myeloma), other cancers
  • Hyperthyroidism, Hyperparathyroidism
  • Lymphoma
  • Leukemia
  • Cancer metastases to the bone
  • Kidney disease, severe
  • Infection of the bone (osteomyelitis)
  • Pregnancy
  • Fractures, extensive, associated with healing
  • Infections involving the liver (tuberculosis, abscess)
  • Mono

Some causes of decreased levels include:

  • Anemia from B-12 deficiency
  • Celiac Disease
  • Hypothyroidism
  • Malnutrition
  • Zinc or Magnesium Deficiency
  • Vitamin D Intoxication

ALT (Alanine Transaminase) is an enzyme found in the liver, pancreas, and skeletal muscle. It acts as a catalyst in the process necessary for amino acid production; the body uses amino acids to make proteins. Some causes of elevated levels include:

  • Drug (medication) effect
  • Obesity
  • Liver Disease (obstruction and infection)
  • Fatty liver (steatosis)
  • Liver Cancer
  • Congestive Heart Failure
  • Reye’s Syndrome
  • Mononucleosis
  • Muscular Dystrophy

Some causes of decreased levels include:

  • Cancer

AST (Aspartate Transaminase) is a catalytic enzyme found in the liver, skeletal muscle, and cardiac tissue. Often both the AST and ALT will be elevated for the same reason. Some causes of elevated levels include:

  • Drug (medication) effect
  • Alcoholic hepatitis
  • Liver Disease (including infection, especially hepatitis; cirrhosis)
  • Blockage of the bile drainage, including gall stones in the bile duct
  • Liver Cancer
  • Congestive Heart Failure
  • Myocardial infarction (heart attack)
  • Pancreatitis
  • Stroke
  • Reye’s Syndrome
  • Mononucleosis

Some Causes of decreased levels include:

  • Dialysis

Bilirubin (Total) is produced in the liver, spleen, and bone marrow. It is a by-product of hemoglobin breakdown. Bilirubin is found in direct (conjugated) and indirect (unconjugated) fractions. Some causes of elevated levels include:

  • Hepatitis (viral, alcohol-related, toxin-related, drug-related)
  • False elevation due to drugs/chemicals in the blood
  • Inherited (genetic) disorders, such as Dubin-Johnson syndrome, Gilbert’s disease
  • Obstruction of the bile system
  • Cancer
  • Infection (abscess)
  • Anemia, including B12 deficiency and sickle cell anemia
  • Alcoholism
  • Destruction of red blood cells (inherited, severe infections, immune diseases)
  • Mononucleosis
  • Pulmonary Embolism
  • Transfusion Reactions
  • Malaria
  • Toxic Shock Syndrome
  • Certain Medications

Some causes of decreased levels include:

  • Certain Medications (but not considered to be clinically significant)

Lipids

Cholesterol is a fat. It is found in all body tissues and plays a vital role in cell membranes. Over 90% of the cholesterol in our blood is made in our liver. This cholesterol is made primarily from saturated fats. One type of cholesterol subfraction (LDL) is associated with damage to the inner lining of the blood vessels. Optimally, the total cholesterol should be under 200. More important than the total cholesterol are the subfrations, noted below. Note that low cholesterol is unknown to cause any disease, although it can be seen in some diseases.
Some causes of increased levels include:

  • Genetics (most common cause)
  • Celiac disease
  • Pancreatitis
  • Hypothyroidism
  • Liver/gallbladder disease
  • Kidney failure
  • Certain medications, including beta blockers, contraceptives, anabolic steroids

Some causes of decreased levels include:

  • Acute illness
  • Malnutrition
  • Liver disease
  • Certain cancers
  • Certain medications, especially those used to treat cholesterol

http://www.labtestsonline.org/understanding/analytes/cholesterol/glance.html

HDL Cholesterol is a protective subfraction of cholesterol. The higher the level, the better.

http://www.labtestsonline.org/understanding/analytes/hdl/glance.html

LDL Cholesterol is a sub fraction of cholesterol associated with heart disease and stroke. There are different cutoffs for “normal”, depending on risk factors for heart disease (like diabetes, high blood pressure, smoking, and more.)

http://www.labtestsonline.org/understanding/analytes/ldl/test.html

Triglycerides (TG) are a long chained fatty acid. TG are absorbed through the intestines and stored in fat cells. TG are also synthesized in the liver from fatty acids as well as from proteins and glucose above the body’s current needs and then stored in fat cells. The levels vary, and are especially high after a meal. Even levels after fasting can change from day to day.
Some causes of elevated levels include:

  • Alcoholism
  • Diabetes out of control
  • Genetics
  • Pancreatitis
  • Hypothyroidism
  • Renal (kidney) failure

Some causes of decreased levels include:

  • Malabsorption
  • Malnutrition

http://www.labtestsonline.org/understanding/analytes/triglycerides/faq.html

Electrolytes

Potassium is a positively charged cation found mostly inside our cells. It is involved with water balance, ph balance, membrane transplant, and electrical conduction in the muscle and nerve cells. Potassium levels too high or too low may cause problems with our nerves and muscles. Some causes of elevated levels include:

  • Lab error (a common cause, due to red cells “leaking” potassium after they die)
  • High potassium diet (including certain fruits, substitute salt)
  • Renal (kidney) failure
  • Abnormal adrenal gland function (Addisons’s disease and hypoaldosteronism)
  • Muscle injury
  • Dehydration
  • Diabetes
  • Fever
  • Breakdown of red blood cells
  • Lab error (a common cause, due to red cells “leaking” potassium after they die)
  • Diuretic drugs of a certain type (such as triamterene, spironolactone, amiloride)
  • ACE inhibitor drugs (the “prils” – lisinopril, benazepril, captopril, fosinopril and others)
  • ARB drugs (the “sartans” – valsartan, losartan, olmesartan, irbesartan, others)
  • Anti-inflammatory drugs including Advil/ibuprofen, Aleve, many others
  • Beta blocker drugs

Some common causes of decreased levels include:

  • Diuretics of a certain kind, such as furosemide, and HCTZ (hydrochlorothiazide)
  • Diarrhea, vomiting and other causes of dehydration
  • Less common causes of low levels:
  • Abnormal adrenal gland function
  • Renal (kidney) disease
  • Malabsorption
  • Low magnesium
  • Laxatives

http://www.labtestsonline.org/understanding/analytes/potassium/glance.html

Sodium is a positively charged electrolyte found mostly outside cells. It is involved with water balance, pH (acid/base) balance, and nerve and muscle function. It’s found in table salt, but blood levels are not usually related to salt intake.
Some common causes of elevated levels include (almost always due to excess fluid loss):

  • Dehydration
  • Vomiting

Some uncommon causes of high sodium:

  • Abnormal adrenal gland function (Cushing syndrome)
  • Congestive Heart Failure
  • Renal (kidney) failure
  • Too much salt intake with too little water intake
  • Inadequate levels of the hormone ADH
  • Some common causes of decreased levels include:
  • Loss of sodium – diarrhea, excess sweating, diuretics
  • Abnormal adrenal gland function (Addison’s disease)
  • Kidney disease
  • Some less common causes of low sodium:
  • Too much water intake
  • Congestive heart failure
  • Liver failure/cirrhosis
  • Diabetes
  • Thyroid Disease
  • Bowel Obstruction
  • Some brain and lung diseases with abnormal levels of hormone (ADH)

http://www.labtestsonline.org/understanding/analytes/sodium/glance.html

Other

Sedimentation Rate (Sed Rate) is a simple measure of how fast the red blood cells settle down to the bottom of a tube of blood. The cells settle faster when certain proteins are in the serum part of the blood. These proteins are elevated in infection and inflammatory conditions of the body. The elevated level of these proteins increase the sed rate. The sed rate is a very sensitive test, but not very specific. In other words it tells you something is going on, but not what that something is. (A related test is C-Reactive Protein). A normal sed rate, however, does not mean you do not have an inflammatory disease. In other words, a high sed rate is a useful test result; a normal or mildly elevated sed rate is not helpful. Some causes of elevated levels include:

  • Anemia
  • Arthritis
  • Infection
  • Autoimmune diseases like Lupus
  • Specific inflammatory diseases: temporal arteritis and polymyalgia rheumatica
  • Certain cancers, and especially multiple myeloma
  • Allergies
  • Old age
  • Pregnancy
  • Kidney failure
  • Certain drugs

Some causes of decreased levels include:

  • Congestive Heart Failure
  • Certain red blood cell diseases, including sickle cell anemia and polycythemia

http://www.labtestsonline.org/understanding/analytes/esr/glance.html

Mark Smith, MD
Dennis Oliver, MD

Weight Loss: a Physician Guide. Dr. Smith’s recommendations.

1. No eating within 3 hours of bedtime.
2. Eliminate fried foods.
3. Decrease Dairy products, especially cheese.
4. Drink 4 glasses (16 oz) of water a day.
5. Eat leaner cuts of meat like filet mignon, chicken, salmon etc.
6. Minimize beer, alcohol, and sodas.
7. Get only one helping of carbohydrates at each meal. Dessert may count as that helping.
8. Serve yourself reasonable portions at each meal.
9. Wait 15 minutes before getting seconds.
10. Never eat a meal in front of TV or in bed.

Osteoporosis Prevention and Treatment

Temple of Zeus

Osteoporosis

Osteoporosis is a disease that affects ten million Americans of which 8 million are women. One in two women and one in eight men over age 50 will get osteoporosis related fractures.
It is a decrease in the density or thickness of your bones. The bones get thinner and weaker as we get older. Unfortunately, there are no obvious warning symptoms. It is therefore known as the  “silent disease”.
Having weak bones means they may break after a minor injury or fall. It may happen without any injury.

Prevention

Osteoporosis is a preventable disease. The best way to prevent weakened bones is by having enough calcium and vitamin D in your diet and regular exercise.

1. Follow a diet with enough calcium and vitamin D.
a. Women need 1000 to 1500 mg/day of calcium.
b. It means at least three 8 ounces glasses of milk per day. You can also eat three ounces servings of yogurt. Other choices are dark leafy vegetables, orange juice and cereals. If you don’t have this much calcium in your diet, ask your doctor if you should take supplements.
c. A natural source of vitamin D is sunlight. In only 15 minutes each day, you can get enough sunlight to keep a healthy vitamin D level.
2. Exercise
Try to do weight bearing exercises three times a week. It helps the uptake of calcium by your bones. Examples are walking, jogging, stair climbing and hiking.
3. Medications
a. Estrogen- oral estrogen can be combined with oral progestin to prevent osteoporosis. If a woman has had a hysterectomy, only estrogen is given. With the recent studies of Prempro having an increased risk of breast cancer, stroke and heart attacks, and other problems, you need to ask your doctor if estrogen is safe for you to take. You doctor might consider non-estrogen alternatives for prevention.
b. Evista (Raloxifene)- approved to be used for both prevention and treatment of postmenopausal osteoporosis. It is a “selective estrogen receptor modulator”. It can cause hot flashes or increase the risk of blood clots in some women.
Risk factors
a. Postmenopausal status
b. Premature menopause (before age 45)
c. Caucasian race or Asian ethnicity
d. Thin, small body build
e. Family history of osteoporosis
f. Certain medications, e.g., steroids
g. Use of tobacco, excessive alcohol or caffeine

Screening tests
Bone densitometry or DEXA scans can be ordered to check the thickness of your bones. It will tell you what your risk for a fracture is. Consult with your doctor to see if this test is indicated.
Treatment
Some medications can stop bone loss of calcium. They will keep your osteoporosis from getting worst.
a. Biphosphanates- there are two medications called alendronate (Fosamax) and risedronate (Actonel). They can be used for treatment and prevention of osteoporosis. Consult with your doctor to see if treatment is indicated.
b. Calcitonin (Miacalcin)- This is a hormone that is given via a nasal spray. You do one “puff” every day.
c. Teriparatide (Forteo)- is an injectable hormone that stimulates new bone. Side effects are nausea, dizziness and leg cramps. Only approved to be used for 2 years.

Information
1. National Osteoporosis Foundation offers a 22 page free booklet about osteoporosis (1-800-223-9994).
2. National Institute on Aging offers free facts sheet about menopause, osteoporosis and preventing falls (1-800-222-2225).
3. Public library and bookstores have books about osteoporosis.
4. Websites: www.ahrq.gov- Agency for Healthcare and
Research Quality
.
www.nof.org- National Osteoporosis Foundation.
www.nia.nih.gov- National Institute of Aging.

Diabetes: May I Screen You?

Trees

Diabetes Mellitus

Do I need to be tested for diabetes?

That question comes up nearly daily in our practice of primary care patients, and the chances are that for you, the answer is yes.

The recommendations of one expert group says that anyone 45 or older should be tested for diabetes mellitus type 2 (the major type of diabetes), every 3 years. However, there are lots of special cases where they recommend screening sooner than age 45 and more often. Consider whether you fall into one of the following groups:

-overweight (which is define as a body mass index, or BMI, over 25; you can determine what your BMI is by using the calculator under “Links & Resources : Specific Resources” of our website.
-sedentary lifestyle
-first degree relative (parent, brother or sister) with diabetes
-high risk ethnic population – Asian, African-American, Latino, Native American, Pacific Islander)
-history of diabetes during pregnancy or a larger than expected baby at delivery
-blood pressure over 140/90
-high triglyerides (over 249) or low HDL (under 36)
-polycystic ovarian syndrome
-history of higher than normal sugar
-acanthosis nigricans, a condition of dark velvety lines seen about the back of the neck or in the armpits
-history of blood vessel disease

A normal sugar is under 100, in a fasting state. Diabetes is diagnosed when the sugar in a fasting state is over 125. People who fall in between are considered at risk for diabetes, and might be referred to as “pre-diabetic.”

Please do ask your doctor to screen you for diabetes if you fall into any of these categories. (Remember not to eat or drink before being tested!) You can go to www.diabetes.org to look for more information.

Influenza 101, by Brian Senger, MD

INFLUENZA 101

Although the flu is a rather common illness, during its peak season from November through February, it can also be a very serious illness. Complications from the flu result in approximately 20,000 deaths annually in the United States alone. These complications include pneumonia, bacterial infection and sinus infection. While it is usually the elderly who develop complications, no one is immune. Because different strains of influenza virus are present each year, it’s possible to get the virus every year. That’s also why it’s necessary to get a flu vaccine every year.
The flu vaccine is 70-80% effective in protecting you from the flu. But with all of the illnesses out there, how do you know if you have the flu and what can you do about it? Flu symptoms differ from those of the common cold. If you are suffering from the following symptoms, you may have the flu: sudden onset of symptoms, high fever/chills, headache, severe muscle aches, sore throat and dry cough. It usually takes 2-5 days for the symptoms to disappear. To minimize your discomfort, make sure you get plenty of rest, drink plenty of fluids, and take a non-aspirin pain reliever for fever and aches.
If you visit your doctor within 48 hours of the onset of influenza, he or she  may elect to treat you with an antiviral medication called amantidine, oseltamivir, or ramantidine. This will only decrease the duration of the illness by a day or so and does have the possible side effects of dizziness and decreased concentration. If you and your doctor decide on the antiviral medication, be sure to let him or her  know if you have kidney disease. This will affect the dosage.
Fortunately, there is a bright spot in all of this! The influenza vaccine may help prevent loss of work days and other complications and is available in the late summer and fall.  Make sure you get your annual flu shot early so that your body has the time to develop the antibodies to fight off influenza. And remember,
Prevention is the best medicine!

Michelangelo

Diseases

[bmicalc]

Cancer of the colon: have you been screened?

SCREENING FOR CANCER OF THE COLON

Cancer of the colon and rectum is the third most common malignant cancer in men and in women in the US, and ranks second as a cause of death from cancer. 90% of cases occur in people over the age of 50. Hence, routine screening for colon cancer starts at age 50 in most people. There are some genetic disorders that can lead to an increase in the risk of colon cancer. Colon cancer at a younger age in a parent or a sibling, for example, could indicate a higher risk of colon cancer. However, the majority of people who are diagnosed with it do not have these risk factors. Low fiber, high fat or low vegetable/fruit diets may predispose to colon cancer, as may cigarette smoking.

Colon cancer very often arises from polyps in the colon, which in themselves are benign overgrowths of tissue. Fortunately, if polyps are discovered and removed, the risk of colon cancer declines significantly. The best test, then, is one that can detect polyps as well as cancer. Cancer that is detected early is more likely to be curable. Unfortunately, because of the size of the colon and its storage capacity, colon cancer may exist for many years before it is discovered, without causing any symptoms.

The available tests include stool testing for microscopic blood (misses most polyps and a substantial number of cancers, but it is easier to do); barium enemas, in which a liquid is put into the colon followed by x-rays (requires a preparation similar to that required for the colonoscopy, may miss some polyps and cancer, and requires a colonoscopy if anything is found); flexible sigmoidoscopy, in which the part of the colon closest to the anus is examined visually (the downside is that one does not examine all areas at risk for cancer); colonoscopy, in which the entire colon is examined visually, and virtual colonoscopy, in which contrast is given followed by a CT scan of the colon. The advantages of flexible sigmoidoscopy and colonoscopy are that any visible polyps or cancer can be biopsied and/or removed at the time of the procedure. While they are very safe procedures, there is a small risk of perforation of the colon. There are studies recently completed and on-going about virtual colonoscopy; while it is more comfortable than regular colonoscopy, and there are some suggestions that it might even be able to pick up cancers and polyps missed by regular colonoscopy, anything seen on virtual colonoscopy would then require a regular colonoscopy.

The interval for rechecking for cancer and polyps depends on the test; if only stool tests are done, it should be done yearly; if the flexible sigmoidoscopy is done, it should be accompanied by annual stool tests and repeated each 3 to 5 years; if colonoscopy is done, it can be done each 8 to 10 years. After age 75, screening may be stopped if prior screening has been negative, unless the patient is in exceptionally good health.

I recommend to my patients that they undergo a colonoscopy as the screening procedure of choice. You should discuss colon cancer screening with your doctor when you reach 50, or even older if you have not had this done.

If you would like to read more, you can go to this website:
http://www.cancer.gov/cancerinfo/wyntk/colon-and-rectum

Dennis Oliver, MD

Pets and Diseases

Pet Related Diseaess

Many human infections can pass between humans and animals. A study done in 1987 suggested there were about 4 million pet related infections in the United States that year. The number of household pets has only grown since that time. In 2002 the number of dogs was estimated at 62 million and the number of cats at 68 million in the United States. Exotic animals present even more of a problem because they can transmit disease from one area of the world to another. This makes diagnosis very difficult at times. This article will take a brief look at various pet related diseases from some of the more common parasites, bacteria, viruses.

Parasites are organisms that live in or on other organisms. Toxoplasmosis is a very common parasitic infection. Cat feces are the vector to humans due to the excretion of the spores in the cat feces. Thus, cleaning the litter box and gardening in contaminated soil are the main risks in developing the disease. Toxoplasmosis in adults is usually asymptomatic, but may cause a mono-like illness. Pregnant women should avoiding cleaning the litter box because infection in the third trimester can cause serious congenital problems.

Round worms are found in both dogs and cats. Puppies are often born infected. Children are especially prone to infection because they often handle animal feces or soil contaminated with animal feces. The immature stage of the round worms is called larvae. The larvae may migrate from the intestine to the liver, lungs or eyes. This may result in serious illness.

Hookworms cause an infection of the skin. Fecal material from infected dogs or cats gets into the soil in the form of cysts. Walking barefoot in this contaminated soil allows the cysts to gain access through a break in the hosts skin. The larvae cause a reddish itchy raised area at the site of the infection. The larvae then migrate under the skin leaving a reddish irritated track through the skin.

Tape worms are common in both dogs and cats. Humans become infected through fecal contamination or through fleas. Human infections are usually not serious but can on occasion cause serious heart and liver problems.

Fungal infections with ring worm are the most common shared infection among humans and domestic pets. It appears to be most common in children. It usually results in a minor superficial infection that can be treated with topical medication.

Bacterial infections are another common source of infection spread between humans and animals. Salmonella is common in turtles, iguanas, chicks, ducklings, dogs and cats. Campylobacter is found in cats and dogs. Both of these bacteria are common causes of gastroenteritis in humans. In fact there are about 200,000 cases of gastroenteritis per year related to these bacteria in humans per year. Cat scratch fever is related to a bacteria carried in cat saliva. This bacterium is called Bartonella henselae. The infection is usually caused from a scratch after the cat has been licking its claws. The infection may show up weeks later and often presents with fever, malaise and swollen lymph nodes. Methicillin resistant staphylococcus aureus ( MRSA ) can be passed to humans from cats and dogs. In cases of recurred infections in households the pet may be the carrier that causes the recurrences. Psittacosis is also known as parrot fever. It presents in humans as a flu like syndrome and occasionally pneumonia. It can be found in parrots, cockatiels, parakeets and macaws. Mycobacterium marinum is an infection of the skin resulting from exposure to fish tank water. It usually causes cutaneus granulomas but can become life threatening in immunocompromised individuals.

Viral infections such as rabies are uncommon in properly cared for pets because of vaccinations. However, pets interact with local wildlife and may develop these more serious infections. Lymphocytic choriomeningitis is a virus that hamsters, guinea pigs and mice carry. This virus in humans usually presents as flu-like syndrome. This disease has caused more serious infections in those humans with a weakened immune system.

The best way to prevent pet related diseases is good flea/tick control and good veterinary care for pets. Good hand washing after handling pet waste and proper disposal of the waste are also important ways to minimize pet related disease. Pregnant women, infants, HIV patients, transplant patients, patients on chemotherapy or chronic steroids, and the elderly should avoid contact with any pet waste, reptiles, chicks, ducklings, kittens, puppies and any animal that appears ill. Any sick pet should be seen by a vet for proper diagnosis and treatment. If you become ill while caring for a sick pet you should see your family doctor and let him know of the ill pet.

Pets provide great companionship to millions of families in the United States. They have been shown to reduce stress and depression. However, on occasion they may carrier certain infections that can be spread to their human house mates. Good cleaning techniques and proper veterinary care can prevent the vast majority of these infections.families in the United States. They have been shown to reduce stress and depression. However, on occasion they may carrier certain infections that can be spread to their human house mates. Good cleaning techniques and proper veterinary care can prevent the vast majority of these infections.

Mark Smith, MD

toucan

Psoriasis

Psoriasis

Psoriasis is a chronic skin condition usually identified by reddish raised plaques with a silvery scale. The condition affects 2-5% of the US population and about 1 in 3 have a first degree relative with the disease.

Psoriasis is believed to be an autoimmune disease that may be set off by a viral infection. This infection stimulates the immune system to form lymphocytes that react to certain proteins in the skin. Flares of psoriasis are often associated with psychological stress, infections, and certain meds. Infections are believed to stimulate the immune system to a more reactive state. The list of drugs which are associated with a flare include beta blockers (a high blood pressure medication), nonsteriodal anti-inflammatory agents (such as Aleve or ibuprofen), anti-malarial medication, and withdrawal of steroids. The exact cause of how these medications cause the psoriatic flare is unknown.

The condition most commonly affects the elbows and knees. However, it may occur anywhere on the body and nails. Nail changes include separation from the bed , pitting, scaling and discoloration. Minor skin trauma is often associated with initiation or worsening of the condition.

Treatment of psoriasis is difficult. Topical treatment is often the first step. The topical steroids have been the initial choice but new immune modulating agents are becoming increasingly useful. Both of these types of medications work by suppressing the immune response. Topical steroids come in different strengths allowing the milder flares to be treated with the lower potency steroids and the more severe flares to be treated with the higher potency steroids. The steroids are very effective treatment but their use is limited by their long term side effects. The immunosuppressants commonly used in the United States are Elidel and Prograf. Other topical treatments that are still used include vitamin D derivatives, topical retinoid and coal tar extracts.

Other treatments for psoriasis include light treatment with ultraviolet light. It is unclear if tanning is useful in treating psoriasis but some studies have shown sunbathing to be use in clearing psoriatic plaques. The most aggressive treatments for this condition are the oral immunosuppressant and chemotherapy agents. These are powerful medications reserved for the more aggressive types of Psoriasis. They require very close monitoring to watch for the significant side effects that may develop with their use. Some of these side effects include bone marrow suppression, kidney damage and liver failure.

Mark Smith, MD

Trigeminal Neuralgia

Trigeminal Neuralgia

Trigeminal neuralgia (TN) is an uncommon condition characterized by intense recurrent attacks of piercing facial or jaw pain. The disorder was first described back in the Roman times. The nerve most affected is a cranial nerve called the Trigeminal Nerve. This nerve has three branches: 1) ophthalmic branch which innervates the area of the forehead and the eye, 2) maxillary branch which innervates the area around the nose, cheek and upper lip, and 3) mandibular branch which innervates the area around the jaw. The attacks may involve any one of the branches or all 3 branches at once. The maxillary branch is the most commonly affected. The right side is the more commonly affected than the left side. Trigeminal neuralgia affects about 4.5 people out of every 100,000 population. There is a slight female predominance. TN is unusual under the age of 40 years old with a peak incidence between the ages of 60-70 years of age. There does not appear to be a racial predilection.

The exact cause of TN is unknown but current theories believe that the superior cerebellar artery may cause compression of the nerve root. This compression of the nerve root causes a loss of the myelin insulation between the nerve fibers within the nerve bundle. This would be similar to all the insulation coming off the individual phone lines in the phone cable. The results of this would be chaos for the phone systems served by this phone cable. When the nerve becomes dysfunctional intense episodic pain appears to be the results.

The diagnosis of TN is difficult since there is no specific test for the condition. The history usually includes paroxysmal episodic attacks lasting 1 second to 2 minutes. They must occur in the trigeminal nerve distribution. They are usually intense stabbing or sharp pains. Sometimes specific triggers such as smiling, chewing, brushing teeth or talking can set off an episode. The history is important to rule out other causes of facial pain. TN is almost never associated with vertigo, vision changes, or hearing loss. TN is almost always on one side. The physical exam is usually normal since the patient is almost always asymptomatic when seeing the physician. Tests like MRI are not very useful in diagnosing TN.

Treatment maybe medical or surgical. Medical treatment usually involves carbamazepine, an antiseizure medication. If carbamazepine  fails or the patient is intolerant to this medication, other anti seizure medications have been found to be effective. Some of include gabapentin, Lamictal, Depakote, and Topamax. More recently Botox injections have been shown to help control TN. Topical Zostrix and transcutaneous nerve stimulation (TENS) are two  treatments being tested for the treatment of TN. Treatments to decompress the nerve root include a gamma knife (a form of radiation), radiofrequency ablation and balloon compression.

In summary, TN is a relatively uncommon neurological disorder, but due to its intense symptoms can be quite debilitating. It is due to the intensity of the pain that treatment is often required.

Mark Smith, MD

Restless Leg Syndrome

RLS: Restless Leg Syndrome

RLS is a neurologic condition that affects sleep and daytime functioning. The underlying cause is believed to involve abnormalities of iron and dopamine metabolism. Patients with RLS may have a compelling urge to move their legs, which worsens at night. Patients with RLS may have difficulty describing their symptoms and may present with daytime fatigue and general sleep difficulties.

The prevalence of RLS is believed to occur in 5-10% of the U.S. population. The prevalence increases with age and women are more likely to report symptoms. RLS is likely an under reported cause of insomnia related symptoms, chronic fatigue and mood disturbance.

Diagnostic criteria include- unusual urge to move limbs, active movement of limbs relieves the urge, rest brings on the urge and nighttime symptoms are worse than daytime symptoms. Most people report that the urge to move the limb is a sensation deep in the leg, but not a cramp. The legs are the primary focus, but the arms, back, and head can be involved. The spouse is often the one that forces the patient to seek help for the nighttime jerky movements. The history is often all that is needed to make the diagnosis of RLS. Medication history is helpful since some medications can aggravate RLS. Some of the common drugs that may worsen the condition are: Reglan, SSRI antidepressants, the TCA antidepressants, calcium channel blocker anti hypertensives and anti seizure medications. Alcohol and caffeine may worsen the condition. Moderate exercise before bed may decrease symptoms.

Treatment of RLS includes avoidance of medications, alcohol and caffeine. The four main groups of medications found to be useful in the treatment of RLS are: Dopamine agents (Mirapex and Requip), Benzodiazepines (Klonopin, which is clonazepam), Opioids (Codeine, Methadone), and anitepileptics (Neurontin, which is gabapentin,  and Topomax). The dopamine agents are considered to be the first line treatment for RLS. They appear to be the most effective for mild, moderate or severe RLS. This class of medications is also used in the treatment of Parkinson’s disease. However, no link between RLS and Parkinson’s disease has been discovered.

Mark Smith, MD

Lab Tests – What Do They Mean?

WHAT DO MY LAB TESTS MEAN?

The tests we discuss below have links to a website that can give you more information than the brief information here; the site also discusses tests not reviewed below, and symptoms that can be associated with the abnormalities. Another source of information about lab tests is at http://www.nlm.nih.gov/medlineplus/laboratorytests.html.

Liver Tests: (ALT, AST, ALK Phosphatase, Bilirubin)

http://www.labtestsonline.org/understanding/analytes/liver_panel/glance.html

Alkaline Phosphatase is an enzyme (protein) found in the liver, bone, and intestinal tissues. In the liver, it is mainly located in the ducts (tubes) that run throughout the liver. Some causes of elevated levels include:

  • Drug reaction (medication side effect)
  • Anticonvulsant use (phenytoin/Dilantin, Phenobarbital)
  • Alcoholism
  • Diabetes mellitus
  • Liver Disease (especially obstruction of the ducts), including hepatitis, cirrhosis
  • Gallstones
  • Bone Disease, including Paget’s Disease
  • Bone Cancers, pancreas cancer, some blood cancers (multiple myeloma), other cancers
  • Hyperthyroidism, Hyperparathyroidism
  • Lymphoma
  • Leukemia
  • Cancer metastases to the bone
  • Kidney disease, severe
  • Infection of the bone (osteomyelitis)
  • Pregnancy
  • Fractures, extensive, associated with healing
  • Infections involving the liver (tuberculosis, abscess)
  • Mono

Some causes of decreased levels include:

  • Anemia from B-12 deficiency
  • Celiac Disease
  • Hypothyroidism
  • Malnutrition
  • Zinc or Magnesium Deficiency
  • Vitamin D Intoxication

ALT (Alanine Transaminase) is an enzyme found in the liver, pancreas, and skeletal muscle. It acts as a catalyst in the process necessary for amino acid production; the body uses amino acids to make proteins. Some causes of elevated levels include:

  •   Drug (medication) effect
  •   Obesity
  •   Liver Disease (obstruction and infection)
  •   Fatty liver (steatosis)
  •   Liver Cancer
  •   Congestive Heart Failure
  •   Reye’s Syndrome
  •   Mononucleosis
  •   Muscular Dystrophy

Some causes of decreased levels include:

  •   Cancer

AST (Aspartate Transaminase) is a catalytic enzyme found in the liver, skeletal muscle, and cardiac tissue. Often both the AST and ALT will be elevated for the same reason. Some causes of elevated levels include:

  • Drug (medication) effect
  • Alcoholic hepatitis
  • Liver Disease (including infection, especially hepatitis; cirrhosis)
  • Blockage of the bile drainage, including gall stones in the bile duct
  • Liver Cancer
  • Congestive Heart Failure
  • Myocardial infarction (heart attack)
  • Pancreatitis
  • Stroke
  • Reye’s Syndrome
  • Mononucleosis

Some Causes of decreased levels include:

  • Dialysis

Bilirubin (Total) is produced in the liver, spleen, and bone marrow. It is a by-product of hemoglobin breakdown. Bilirubin is found in direct (conjugated) and indirect (unconjugated) fractions. Some causes of elevated levels include:

  • Hepatitis (viral, alcohol-related, toxin-related, drug-related)
  • False elevation due to drugs/chemicals in the blood
  • Inherited (genetic) disorders, such as Dubin-Johnson syndrome, Gilbert’s disease
  • Obstruction of the bile system
  • Cancer
  • Infection (abscess)
  • Anemia, including B12 deficiency and sickle cell anemia
  • Alcoholism
  • Destruction of red blood cells (inherited, severe infections, immune diseases)
  • Mononucleosis
  • Pulmonary Embolism
  • Transfusion Reactions
  • Malaria
  • Toxic Shock Syndrome
  • Certain Medications

Some causes of decreased levels include:

  • Certain Medications (but not considered to be clinically significant)

Lipids

Cholesterol is a fat. It is found in all body tissues and plays a vital role in cell membranes. Over 90% of the cholesterol in our blood is made in our liver. This cholesterol is made primarily from saturated fats. One type of cholesterol subfraction (LDL) is associated with damage to the inner lining of the blood vessels. Optimally, the total cholesterol should be under 200. More important than the total cholesterol are the subfrations, noted below. Note that low cholesterol is unknown to cause any disease, although it can be seen in some diseases.
Some causes of increased levels include:

  • Genetics (most common cause)
  • Celiac disease
  • Pancreatitis
  • Hypothyroidism
  • Liver/gallbladder disease
  • Kidney failure
  • Certain medications, including beta blockers, contraceptives, anabolic steroids

Some causes of decreased levels include:

  • Acute illness
  • Malnutrition
  • Liver disease
  • Certain cancers
  • Certain medications, especially those used to treat cholesterol

http://www.labtestsonline.org/understanding/analytes/cholesterol/glance.html

HDL Cholesterol is a protective subfraction of cholesterol. The higher the level, the better.

http://www.labtestsonline.org/understanding/analytes/hdl/glance.html

LDL Cholesterol is a sub fraction of cholesterol associated with heart disease and stroke. There are different cutoffs for “normal”, depending on risk factors for heart disease (like diabetes, high blood pressure, smoking, and more.)

http://www.labtestsonline.org/understanding/analytes/ldl/test.html

Triglycerides (TG) are a long chained fatty acid. TG are absorbed through the intestines and stored in fat cells. TG are also synthesized in the liver from fatty acids as well as from proteins and glucose above the body’s current needs and then stored in fat cells. The levels vary, and are especially high after a meal. Even levels after fasting can change from day to day.
Some causes of elevated levels include:

  • Alcoholism
  • Diabetes out of control
  • Genetics
  • Pancreatitis
  • Hypothyroidism
  • Renal (kidney) failure

Some causes of decreased levels include:

  • Malabsorption
  • Malnutrition

http://www.labtestsonline.org/understanding/analytes/triglycerides/faq.html

Electrolytes

Potassium is a positively charged cation found mostly inside our cells. It is involved with water balance, ph balance, membrane transplant, and electrical conduction in the muscle and nerve cells. Potassium levels too high or too low may cause problems with our nerves and muscles. Some causes of elevated levels include:

  • Lab error (a common cause, due to red cells “leaking” potassium after they die)
  • High potassium diet (including certain fruits, substitute salt)
  • Renal (kidney) failure
  • Abnormal adrenal gland function (Addisons’s disease and hypoaldosteronism)
  • Muscle injury
  • Dehydration
  • Diabetes
  • Fever
  • Breakdown of red blood cells
  • Lab error (a common cause, due to red cells “leaking” potassium after they die)
  • Diuretic drugs of a certain type (such as triamterene, spironolactone, amiloride)
  • ACE inhibitor drugs (the “prils” – lisinopril, benazepril, captopril, fosinopril and others)
  • ARB drugs (the “sartans” –  valsartan, losartan, olmesartan, irbesartan, others)
  • Anti-inflammatory drugs including Advil/ibuprofen, Aleve, many others
  • Beta blocker drugs

Some common causes of decreased levels include:

  • Diuretics of a certain kind, such as furosemide, and HCTZ (hydrochlorothiazide)
  • Diarrhea, vomiting and other causes of dehydration
  • Less common causes of low levels:
  • Abnormal adrenal gland function
  • Renal (kidney) disease
  • Malabsorption
  • Low magnesium
  • Laxatives

http://www.labtestsonline.org/understanding/analytes/potassium/glance.html

Sodium is a positively charged electrolyte found mostly outside cells. It is involved with water balance, pH (acid/base) balance, and nerve and muscle function. It’s found in table salt, but blood levels are not usually related to salt intake.
Some common causes of elevated levels include (almost always due to excess fluid loss):

  • Dehydration
  • Vomiting

Some uncommon causes of high sodium:

  • Abnormal adrenal gland function (Cushing syndrome)
  • Congestive Heart Failure
  • Renal (kidney) failure
  • Too much salt intake with too little water intake
  • Inadequate levels of the hormone ADH
  • Some common causes of decreased levels include:
  • Loss of sodium – diarrhea, excess sweating, diuretics
  • Abnormal adrenal gland function (Addison’s disease)
  • Kidney disease
  • Some less common causes of low sodium:
  • Too much water intake
  • Congestive heart failure
  • Liver failure/cirrhosis
  • Diabetes
  • Thyroid Disease
  • Bowel Obstruction
  • Some brain and lung diseases with abnormal levels of hormone (ADH)

http://www.labtestsonline.org/understanding/analytes/sodium/glance.html

Other

Sedimentation Rate (Sed Rate) is a simple measure of how fast the red blood cells settle down to the bottom of a tube of blood. The cells settle faster when certain proteins are in the serum part of the blood. These proteins are elevated in infection and inflammatory conditions of the body. The elevated level of these proteins increase the sed rate. The sed rate is a very sensitive test, but not very specific. In other words it tells you something is going on, but not what that something is. (A related test is C-Reactive Protein). A normal sed rate, however, does not mean you do not have an inflammatory disease. In other words, a high sed rate is a useful test result; a normal or mildly elevated sed rate is not helpful. Some causes of elevated levels include:

  • Anemia
  • Arthritis
  • Infection
  • Autoimmune diseases like Lupus
  • Specific inflammatory diseases: temporal arteritis and polymyalgia rheumatica
  • Certain cancers, and especially multiple myeloma
  • Allergies
  • Old age
  • Pregnancy
  • Kidney failure
  • Certain drugs

Some causes of decreased levels include:

  • Congestive Heart Failure
  • Certain red blood cell diseases, including sickle cell anemia and polycythemia

http://www.labtestsonline.org/understanding/analytes/esr/glance.html

Mark Smith, MD
Dennis Oliver, MD