Thursday, August 29, 2013

Act 'FAST' with Stroke Symptoms

The National Stroke Association has adopted the acronym"FAST" to help people remember the most common signs and symptoms of a stroke and to encourage receiving prompt medical attention if someone could be experiencing a stroke.

What is a stroke? A stroke is the sudden death of brain cells in a localized area due to inadequate blood flow. There are two major types of stroke--- ischemic stroke and hemorrhagic stroke. An ischemic stroke occurs when a vessel that supplies blood to the brain is blocked. This type of stroke may be caused when a clot forms in a narrowed artery, or from a clot that travels from some other area of the body (often the heart) and becomes lodged in an artery in the brain. The second type of stroke is known as a hemorrhagic stroke. This type of stroke occurs when a blood vessel in part of the brain becomes weak and bursts open, causing blood to leak into the brain.

What are some of the most common stroke symptoms? Stroke symptoms typically develop suddenly. Depending on the type of stroke experienced and the specific area of the brain involved, some of the most common symptoms are:
  • Weakness of the face, arm or leg. Typically this occurs only on one side of the body.
  • Confusion, trouble speaking or difficulty understanding.
  • Trouble with vision in one or both eyes.
  • Dizziness, difficulty with walking or loss of balance or coordination.
  • Development of a sudden, severe headache.
Who is at risk for having a stroke? High blood pressure is the number one risk factor for strokes. Another is a rhythm disturbance of the heart known as atrial fibrillation. Others are the same as in heart attack risk---diabetes, high cholesterol and cigarette smoking.

How are strokes treated? The way in which strokes are treated hinges on a number of factors including; 1) the type of stroke (ischemic, hemorrhagic, etc.), 2) the presence of predisposing medical conditions (atrial fibrillation, uncontrolled hypertension, etc.), and 3) the time interval between the onset of symptoms and receiving medical attention. For example, if the stroke is caused by a blood clot, a "clot-busting" drug (t-PA), may be given to dissolve the clot. For this drug to work, however, treatment must begin within 4 1/2 hours of the onset of symptoms. Treatment of a hemorrhagic stroke involves measures to control bleeding, reduce pressure in the brain, and to control blood pressure.

What happens after the stroke? Following emergency treatment, the goal after a stroke is to try to recover as much function as possible and to prevent future strokes. Most stroke survivors receive treatment in a rehabilitation program to help regain strength, improve balance, and address speech and language deficits. Improvement can continue for months and even years following a stroke. To prevent recurrent strokes, surgery, to open partially blocked arteries or to address an aneurysm that is at risk of bleeding, is sometimes required.

Act FAST! Now for the components of the FAST acronym to help you remember some of the most common features of a stroke:

F stands for "face". During a stroke, the muscles of the face may be involved. Asking the person suspected of having a stroke to smile can bring out an asymmetry of facial muscles, indicating weakness on one side.

A stands for "arms". Another common symptom is weakness of the muscles of the arms or hands. By asking the person to raise both arms to the side, a loss of motor control on one side or the other may be noted.

S stands for "speech". With many strokes, an area of the brain that controls speech may be affected. Slurring words or difficulty understanding speech should alert someone to the possibility of a stroke.

T stands for "time". Time is of the essence in the treatment of strokes. As mentioned, "clot-busting" drugs must be given within a few hours of the onset of symptoms, and the sooner the better. These drugs have been shown to reduce long-term disability for ischemic strokes. If someone is experiencing signs of a stroke, make note of the time of onset of symptoms and call "9-1-1" immediately.

Friday, August 23, 2013

Help, I’ve been bitten by a tick!

Worldwide, ticks are second only to mosquitoes as vectors in transmitting disease to humans. Ticks are not insects, but are arthropods, similar to spiders. The most common illnesses caused by ticks are Rocky Mountain Spotted Fever, Erlichiosis, Tularemia, and Lyme Disease. As with mosquitoes, it is the organisms in the tick's saliva that are primarily responsible for causing disease, not the bite itself.

A tick is crawling on my arm! As long as it is handled properly, there is little to no risk of becoming ill if the tick has not yet attached itself. Only ticks that are attached and feeding can transmit a disease. When removing the tick, wear protective gloves so you don't spread bacteria from the tick to your hands. If bare hands are used to remove the tick, be sure and wash with soap and water. Once removed, don't crush the tick as this could transmit disease. Instead, rinse it down a sink or flush it in a toilet.

What do I do if I find a tick that is attached to the skin? Even if the tick has attached itself, the risk of acquiring a tick-borne infection is quite low. For example, there is only a 1-2% chance of acquiring Lyme disease from an observed tick bite, even in an area where the disease is extremely common. In most cases, ticks remain attached and feeding for a number of hours before the organisms that cause disease are transmitted. It is true, however, that the earlier that the tick is removed from the skin, the less risk there is of becoming infected.

What is the best way to remove an embedded tick? A number of methods of removing ticks have been suggested. Many of these, such as the use of a smoldering match, fingernail polish, or coating with Vaseline, are not advisable. These methods increase the possibility of the tick passing infected saliva into the host's bloodstream. The goal is to remove the entire tick and in particular the head and mouthparts. The proper method for tick removal is as follows:
  1. Use tweezers to grasp the tick as close to the skin surface as possible.

  2. Pull backward with even, steady pressure. Since the tick's mouthparts are barbed, not spiral, twisting does not make removal easier.

  3. Avoid squeezing or crushing the body in order to minimize expressing potentially infectious saliva from the tick.

  4. After removing the tick, disinfect the skin and hands thoroughly with soap and water. Thoroughly cleanse the bite area with soap and water or a mild disinfectant.
It would be helpful for your doctor if you can provide information about the tick bite, such as the size of the tick, if it was attached to the skin, and how long it was attached. If possible, save the tick (putting it in a small container in the freezer is a good method) for identification in case you become ill.

What do I do after removing the tick? In most instances, the site of the tick bite heals in a few days without complications. Application of an antibiotic cream to the area may help prevent a local infection. Otherwise, taking Benadryl for itching or a mild analgesic such as acetaminophen (Tylenol) or ibuprofen (Advil) may be all that is necessary. You should continue to monitor for signs or symptoms of tick-borne disease for at least a month after the tick bite. You should call your health care provider if any of the following develop:
  • You develop a red, bulls-eye rash at the site of the tick bite or a skin rash with tiny purple or red spots.

  • The area of the bite becomes more swollen or painful, or drains pus.

  • You develop flu-like symptoms such as fever, headache, muscle aches, or joint pain up to a month after a bite.
What can be done to reduce the likelihood of a tick bite?
  • Use a chemical repellent with 20-30% DEET on the skin. The insecticide, permethrin, is also effective when applied to clothing personally or during the manufacturing process.

  • Ticks may be seen more easily for removal when wearing light-colored clothing

  • Avoid tick habitat (wooded or bushy areas with high grass and leaf litter)

  • Conduct a full body check upon return from potentially tick-infested areas. Use a hand-held or full-length mirror to view all parts of your body. Also check your children and pets.
In some cases, early treatment with antibiotics is recommended. This is particularly true in areas with a high incidence of Lyme disease (parts of New England, parts of the mid-Atlantic states, and parts of Minnesota and Wisconsin).

Friday, August 16, 2013

Management of Minor Ankle Sprains

Ankle sprains are the most common sport-related injury, with an estimated 28,000 occurring daily in the U.S. Fortunately, most of these injuries are Grade I or mild sprains of the ligaments on the lateral aspect (outside) of the ankle. Grade I sprains are characterized as a stretching of the ligament with mild pain and minimal loss of function. Recently, the National Athletic Trainers' Association released a Position Statement that thoroughly discussed the conservative management and prevention of mild to severe ankle sprains in athletes.

Much of the information in this statement pertained to the more serious Grade II or III injuries. These injuries involve partial or complete tears of the ligaments that support the ankle with considerable pain and loss of function. These can take months to heal and sometimes even require surgery. The Position Paper provided information to doctors related to these more serious sprains, such as when to perform magnetic resonance imaging (MRI) following an ankle injury and when immobilization is the best initial treatment. In addition to information regarding higher grade sprains, the Position Paper offered a number of important "take home" messages that applied to anyone who inadvertently "rolls" their ankle, sustaining a minor sprain.
  • RICE therapy (rest, ice, compression, and elevation) continues to be the most accepted and effective management of acute ankle sprains. Rest means keeping the ankle comfortable by avoiding activities that cause discomfort for at least 24 hours after the injury. Ice is typically applied for 20 to 30 minute periods following the acute injury and can be repeated at hourly intervals for the first couple of days. Compression is usually administered via an ACE wrap or soft ankle brace. Elevation (usually in combination with ice and compression) is especially beneficial in preventing swelling immediately after the injury.
  • The Ottawa ankle rules, a means of determining the likelihood of an ankle fracture following an ankle sprain, were deemed to be reliable. These rules, developed to help doctors decide when to perform x-rays, involve a determination of the location of bone tenderness and the patient's ability to bear weight following the sprain. From the perspective of a lay person assessing their own injury, being able to bear weight and walk more or less normally after an ankle injury practically eliminates the possibility of a significant fracture.
  • Non-steroidal anti-inflammatory drugs (NSAIDs) were found to reduce pain and swelling and improve short-term function after ankle sprains. The NSAID, piroxicam, was mentioned in the position paper, but the widely available non-prescription NSAIDs, ibuprofen or naproxen, taken at recommended dosages, should be equally effective.
  • Functional rehabilitation was found to be more effective than immobilization in managing minor ankle sprains. In other words, the use of a boot, avoiding bearing weight while on crutches, or the use of some other device to keep the ankle from moving is not the best way to manage a minor ankle sprain. Functional rehabilitation includes the use of range-of-motion, flexibility, and strengthening exercises with progressive weight bearing as tolerated. The following link outlines a comprehensive functional rehabilitation program.
Another important point from the Position Paper is that the most common cause of a repeat ankle sprain is an incompletely rehabilitated ankle following an initial sprain. Even though most minor ankle sprains will heal without long-term consequences, the importance of functional rehabilitation cannot be overemphasized. In the case of more serious sprains, medical evaluation and the guidance of a physical therapist or athletic trainer is the best course of action in order to assure complete recovery and avoidance or re-injury.

There was far more information included in the Position Paper than was covered in today's Health Tip, including return-to-play recommendations, taping and bracing considerations, and management of chronic ankle sprains. To learn more about the management of ankle sprains, you can read the entire Position Paper published in the Journal of Athletic Training.

Friday, August 9, 2013

Health Tip: A "Formula" for Losing Weight

We occasionally receive messages from eDoc clients expressing frustration with not being able to lose weight, despite eating a low-calorie diet and getting regular exercise. Once issues such as hypothyroidism are ruled out, the cruel reality is that weight loss occurs only when the number of calories that we burn exceeds the number that we consume. We burn calories through our basal metabolism, activities of daily living, and exercise. Basal metabolism or basal metabolic rate (BMR) refers to the number of calories that we consume in order to maintain our current weight and to support certain "basal" functions, such as brain activity, breathing, and pumping blood throughout the body. The BMR varies from individual to individual because of differences in body weight, height, gender, and age. By knowing our basal metabolic rate, we can come closer to being able to estimate the maximum number of calories that we can eat and still lose weight.

One way of estimating the daily caloric intake is by applying the Harris-Benedict Principle. This equation takes into consideration those factors (age, height, weight, etc.) that affect basal metabolism, as well as factoring in the person's activity level. This equation will be fairly accurate in all but the very muscular (under-estimates calorie needs) and the very fat (over-estimates calorie needs). Here's how the equation works:

1. As mentioned, the BMR varies depending on whether you are a man or a woman:
  • For men, the BMR equals 66 + (6.23 times your weight in pounds) + (12.7 times your height in inches) - (6.8 times age in years).

  • For women, the BMR equals 655 + (4.35 times your weight in pounds) + (4.7 times your height in inches) - (4.7 times your age in years).

  • As an example, if you are a 48 year old woman whose weight is 168 pounds and height is 5 ft. 6 inches, the calculations would go as follows:

  • BMR = 655 + (4.35 X 168) + (4.7 X 66) - (4.7 X 48)

  • BMR = 655 + 730.8 + 310.2 - 225.6

  • BMR = 1470.4 calories per day. This is the number of calories that you could eat if you were completely sedentary and that would support your current weight and basal metabolism. In other words, you would neither gain nor lose weight.
 2. Since almost everyone is active to some degree, the next step is to factor in your estimated activity level. This is done by multiplying your BMR by an activity factor (these are the same for men and women). They are as follows:
  • Sedentary = BMR x 1.2 (Office Job - Not very active)

  • Lightly Active = BMR x 1.375 (1-3 days/wk light exercise)

  • Moderately Active = BMR x 1.55 (moderate exercise 3-5 days/wk)

  • Very Active = BMR x 1.725 (intense exercise 5-7 days/wk)

  • Athletic = BMR x 1.9 (Hard exercise daily. Active job. Training for sports contest/competition)

  • So, keeping with the previous example, in a moderately active woman whose BMR is 1470 calories, she would burn approximately 2279 (1470 X 1.55) calories in a day.
Now comes the weight loss part. In order to lose weight, this individual would have to consume fewer than 2279 calories per day or would have to increase her exercise level so that she was burning more than 2279 calories per day. In order to lose a pound of weight a week, our subject would need to create a calorie deficit of 500 calories per day or approximately 3500 calories per week. She could do this by burning an extra 250 calories and cutting back by 250 calories from her diet or any other combination that will result in 500 fewer calories. Obviously, one day's worth of dieting or a particularly vigorous exercise session will not make much difference. Weight loss typically requires that you create a caloric deficit for a longer period of time to be successful.

The Harris-Benedict principle is not exact, but does provide a more accurate estimate of daily caloric expenditure than many other methods. It is best applied with the use of diet and exercise diary to keep track of the number of calories that are being consumed as well as the number of calories expended through exercising.

Friday, August 2, 2013

Travelers' Diarrhea, "peel it, boil it, or forget it"

Every year, an estimated 10 million international travelers are affected by traveler's diarrhea (TD), a gastrointestinal disorder that causes loose stools and abdominal cramping. For Americans, the risk for developing TD is particularly high in the developing countries of Latin America, Africa, the Middle East, and in Asia.

What causes TD? TD is caused by consuming food or water that is contaminated with an infectious agent. Approximately 80% of the time, the source is a type of E. coli bacteria (enterotoxigenic), that produces toxins within the bowel. Other bacteria (Campylobacter, Salmonella, Shigella) as well as a variety of viruses (Hepatitis A, Norwalk Virus, Rotavirus), and parasites (Giardia, Cryptosporidium) are less common causative agents.

Are certain people at risk for developing TD? Travelers to areas of the world with substandard water purification or sanitary practices are at particular risk for the development of TD. Young adults, people taking certain medications including stomach acid-blockers (Prevacid, Prilosec, others) or immune-suppressants (prednisone, methotrexate, others), and people with certain diseases, such as diabetes or inflammatory bowel disease are at particular risk.

What are the symptoms of TD? Most people with TD have the sudden onset of diarrhea, passing 4 to 5 loose stools per day. This may be accompanied by abdominal cramps, nausea, vomiting, generalized weakness or discomfort, or low-grade fever.

How is TD treated? Traveler's diarrhea usually resolves on its own within 48 hours and is rarely life threatening. Drinking clear liquids or oral rehydration solutions to prevent dehydration and loss of electrolytes is usually all that is required. A rehydrating solution can be prepared by mixing together:
  • 1/2 teaspoon salt
  • 1/2 teaspoon baking soda
  • 4 tablespoons sugar
  • 1 liter safe drinking water
Taking antimotility agents (Imodium, Lomotil) can relieve TD-associated diarrhea and cramps, but they may also prolong the duration of the illness. Antibiotics can shorten a course of diarrhea and discomfort, but taking them is generally unnecessary. However, when symptoms warrant, such as with the development of bloody diarrhea, high fever, or severe cramps, antibiotics belonging to the fluoroquinolone group ( Cipro, Norfloxacin) have been shown to be effective.

Can medications prevent TD? Certain antibiotics have been shown to be effective at preventing travelers' diarrhea, however, the CDC does not generally recommend that they be used. The reasons for this include the relatively benign nature of TD, the possibility of adverse effects from taking an antibiotic, and the risk of the development of antibiotic-resistant organisms. Bismuth subsalicylate preparations, such as Pepto Bismol, taken as 1 oz of liquid or two 262.5-mg tablets four times daily can reduce the risk of becoming infected with the common bacteria that cause TD. This medication is not recommended for children, pregnant women, or people who are allergic to aspirin.

How else can TD be prevented?The risk of developing TD can be greatly reduced with attention to the following measures:
  • Tap water and dairy products, particularly those that are unpasteurized, are some of the most likely sources of contamination associated with the development of TD. When travelling in high risk countries it is safer to drink bottled water, pasteurized milk, hot tea or coffee, or canned or bottled drinks.
  • Avoid eating raw fruits and vegetables unless washed (with purified water) and peeled by yourself. It is best to avoid eating salads and fruits or vegetables that cannot be peeled, such as grapes and berries.
  • Avoid eating raw or undercooked meats or seafood.
  • Avoid purchasing food or drinks from street vendors or from sources where the sanitation is suspect.
  • Unsterilized water, either from tap, well or ground sources, must be purified by boiling, filtering, or treating with iodine or chlorine. The Centers for Disease Control (CDC), advises that water should be brought to a rolling boil for at least 1 minute. At altitudes greater than 6,500 feet (2000 meters), boiling time should increase to around 3-5 minutes. Several manufacturers, including Katadyn, Sawyer, and MSR, offer portable filtration systems that are effective in removing bacteria and parasites. When shopping for a filter, make sure that it has a pore size no larger than 0.1 microns. Recognize also that most "backpacking" filters will not remove viruses unless their microfilter has an extremely small pore size (0.01 microns) or has a disinfecting stage (usually incorporating iodine). Water disinfecting tablets containing iodine (Potable Aqua) or chlorine (MSR Aquatabs) are also effective when used as directed.
Other sources of contamination that people may not think about while travelling include getting water in the mouth while showering, rinsing with tap water after tooth brushing (use bottle or filtered water instead), and drinking beverages chilled with ice made from tap water. Medical attention should be sought for severe or persistent symptoms of TD to determine the exact cause and proper treatment.