Shingrix for Shingles Prevention

Remember a few weeks ago I wrote about THIS problem?

Credit: www.zostavax.ca

About 2 weeks ago, the FDA approved Shingrix, a new vaccine for the prevention of shingles in people aged 50 years and older.  They also took the very unusual step of stating that people should get Shingrix rather than Zostavax, the only other vaccine available to prevent shingles.

Not only did the FDA state a clear preference for Shingrix over Zostavax, they also recommended that people who have already been vaccinated with Zostavax should be RE-vaccinated with Shinrix.

Wait, what?!

To my knowledge, the FDA has never done this, showing such a clear preference for one vaccine over another, to the point of saying that a previous vaccination is essentially invalid. Why would the agency do this?

It is much more effective than Zostavax

In the clinical studies, Shinrix was well over 90% effective in preventing shingles and its most devastating consequence, postherpetic neuralgia, in all age groups.  By contrast, Zostavax is only 18-64% effective, and is least effective in patients over 80 years of age, who are at greatest risk of a shingles outbreak.

The protection lasts longer

The protection given by the Zostavax vaccine has not been evaluated in long-term studies.  I found a reference to one long-term study of Zostavax that is supposed to be completed in 2024.  However, no studies that I could find have followed people who received Zostavax longer than about 2 years. (Any science types out there who can find one, please post it in the comments!)

Shingrix studies, by contrast, were carried on for up to 5 years and showed that the vaccine remains effective for prevention of both shingles and postherpetic neuralgia.  The question remains, though, will the protection be lifelong?  After all, if you vaccinate someone at age 50 they have hopefully MANY more than 5 years to live shingles-free.

No live virus

Shingrix is not a live virus vaccine, therefore there is no restriction on vaccinating people who are immune compromised or live with someone who is immune compromised.

What are the downsides of vaccinating with Shingrix rather than Zostavax?

Two shots, not one

The Shingrix dosing schedule calls for a second, booster dose of vaccine 2-6 months after the first dose.  This may be a problem with Medicare, because there are no Medicare-covered vaccines that call for a second dose within one year.  We will have to see how the coverage determinations shake out at the Medicare level.

Much higher rate of side effects

Shingrix’s package insert reports over 50% of patients who received the vaccine complained of body aches, fatigue and headache afterwards.  88% of people reported pain at the injection site (compared with 14% of people who got a placebo shot).  Recipients also reported fever, shaking chills and GI symptoms in fairly large numbers.

Younger people had more problems than older people, probably because they were making a more robust immune response.

A LOT of vaccine

From a population health standpoint, a 90% effectiveness rate sounds fantastic.  However, from a cost standpoint it might not be so great.  Here’s a crash course in how we determine how many people you have to treat in order to prevent an illness or condition.

For Shingrix, 11.1 people aged 80+ got shingles in 1000 person-years if they did NOT get the vaccine, and 1.0 people if they did.  That’s great, right?  90% effective.  But in order to determine how many people you need to vaccinate to prevent one case of shingles, the math is different.  It’s 1 divided by the difference in ABSOLUTE risk.  1/((11.1-1.0)/1000)

You need to vaccinate 99 people over age 80 in order to prevent one case of shingles over 5 years. That’s a LOT of vaccine, but much better than 435 patients with Zostavax.

The bottom line

Shingrix isn’t even available to order yet for doctors’ offices and pharmacies, and already it’s creating a stir.  The unprecedented endorsement by the FDA favoring Shingrix over Zostavax will likely force Zostavax off the market soon.

Shingrix IS much more effective than Zostavax at preventing both shingles and postherpetic neuralgia.  That higher effectiveness comes at the cost of being a more uncomfortable vaccine to receive, and having two get two shots instead of one.

If the goal is preventing shingles, Shingrix is clearly the way to go.  I will hit the age to be eligible to receive the Shingrix vaccine in a few years.  Will I get it?  Probably, because I’ve already had one bout of shingles and I really don’t want to have it again.

QUESTION: Have you had Zostavax?  Will you get Shingrix?

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Should Everyone Wear Sunglasses (Even Kids)?

A friend of mine mentioned recently that he’s been spending a lot of time at Cedar Point and mentioned he was surprised how few kids wear sunglasses.  All the parents wear sunglasses, especially at the waterpark, but very few of the kids are wearing sunglasses.

Does it matter?  Well, it turns out my friend is right to be concerned.  (And kudos to him, in his pics his absolutely adorable son is always wearing shades!)  According to the Vision Council (an eye care industry group), eye health depends on protecting the eyes from UV radiation.  Many people either are unaware or don’t believe that protecting the eyes from UV radiation from the sun is a critical, year-round concern.

There are 3 types of UV radiation – UVA, UVB and UVC.  UVC is filtered by the earth’s atmosphere and not a concern.  UVB is the type of UV radiation that stimulates vitamin D production in the skin, and is partially filtered by the atmosphere.  This is why those of us in northern Ohio can’t get vitamin D from the sun for the wintry half of the year, the sun is too low in the sky and the rays pass through too much air on the way to us.

The type of UV radiation that is most dangerous to the eye is UVA.  The earth’s atmosphere does NOT filter UVA.  If the sun is in the sky your eyes are being exposed to UVC radiation, no matter what season or time of day it is.  Wearing sunglasses as much as possible is important to protect your eyes when you are outdoors.

Here are 3 common misconceptions about sunglasses and sunglass use.

Kids don’t need sunglasses

Children receive about 3 times as much UV exposure per year as adults.  This is because they generally spend more time outdoors than adults do.  However, only 7.4% of adults report their children always wear sunglasses.

UV radiation damage is cumulative which means it builds up over time.  Damage can lead to aging of the skin, skin cancer, cataracts and damage to the retina.  Beginning in childhood, daily sunglass use will decrease the damage and preserve children’s eye health.

The darker the lens, the better the protection

This is not true.  UVA radiation passes right through lenses no matter what their color.  They must be coated to block UV radiation.  Polarized lenses are even better at blocking the UV rays.

In fact, it could be argued that dark lenses without UV protective coatings are the worst option of all, because they cause the pupils to dilate and allow more UV light through to the retina.

When you go to buy sunglasses check for labels to indicate the protection they give.  Make sure you choose lenses that are labeled as protective against both harmful types of ultraviolet light.

Wearing a hat is good enough

Not true.  While wearing a hat protects somewhat against direct UV exposure, it does nothing to stop REFLECTED UV light.

Credit: visioncouncil.org

So how do we get our kids to keep sunglasses on their face?  Hats are hard enough, right?  First of all, having a child pick out their own sunglasses makes it more likely they will wear them.  Make sure to get good quality glasses that fit the child’s face and don’t pinch or rub.

In addition, polarized lenses are more comfortable from a vision standpoint because they reduce glare and block more light.  Kids are more likely to keep them on because they don’t squint as much and they can see better.

Teenagers typically don’t want to be told what to do.  Make sure they understand they will have less problems with red, irritated bloodshot eyes if they wear sunglasses regularly.  Just like with kids, letting them pick out a couple of pairs of cool sunglasses they like will go a long way towards getting them to wear them regularly.

Kids, teens and adults all need to protect their eyes from harmful ultraviolet radiation.  The fronts of the eyes, the lens and the retina are all susceptible to damage which accumulates over time.  You and your family only get two eyeballs and it’s up to us to protect them!

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Diabetic Amputation Rates Rising

Mary is a lady I have taken care of for several years.  Every time she comes in I check her heart and lungs.  Then, when I go to check for swelling in her legs, we have a good laugh.  See, the first time I saw her, I checked for swelling and only then realized something pretty important.

Mary’s lower left leg is missing.

She is diabetic and developed gangrene in her left leg some time before she started seeing me and had to have her left leg amputated below the knee.  She is a very sweet lady but now has some significant trouble getting around.

Why would Mary need to get her leg amputated?  There are a number of possible reasons.  Diabetics can lose feeling in their feet and if they hurt themselves they may not feel it.  They don’t generally have good circulation and wounds take longer to heal.  Diabetics also have immune systems that don’t work right and they have trouble fighting infections.

Unfortunately Mary is in good company.  The rates of diabetic amputation are risking across the country.  For instance, in California, the rate of diabetic amputation rose 31% between 2010 and 2016.  Some counties like San Diego and Riverside counties had over 60% increases.  Across the United States the rate of diabetic amputation rose 27% between 2010 and 2014.  Before 2009 the rates had been dropping.

Why is this happening?  Why are people losing toes and feet, ankles and legs to diabetic amputation?

There are a number of possible reasons.

  1. More diabetics.  The number of Americans with diabetes is on the rise.  This doesn’t explain it all, though, because even just looking at diabetic patients the rates are rising.
  2. Access to care.  Before the Medicaid expansion that came with the Affordable Care Act many low-income diabetics went without care for their illness.  Also, coverage for podiatric care (which includes care for foot wounds and chronic foot infections) is not consistent across the country and across insurers.  If you can’t afford medication and see the specialists you need, you’re at increased risk for complications like amputation.
  3. Health literacy.  Many diabetics don’t understand why they need to see the doctor regularly.  They don’t know all the bad things that can happen as a result of diabetes.  They don’t know they could lose their vision, have a heart attack, wind up on kidney dialysis, have a diabetic amputation.  Education is key.
  4. Lifestyle factors.  If you’ve ever tried to lose weight you know how hard it is to change your lifestyle.  Eating a healthy, mostly-plant-based fresh-food diet, exercising regularly and drinking water are critically important for diabetics but many patients seem to think as long as they take their pills or their shots that’s all they need to do.  NO medication can make up for a crappy lifestyle!

If you are a diabetic, please make sure to see your doctor regularly.  If your doctor wants you to check your blood sugar and blood pressure, PLEASE do it, and keep a written log.  (It’s really hard for us to scroll through your glucometer’s tiny screen, so please bring us an organized log.  It will save time for more important things!)

Don’t smoke.  Whatever you need to do to quit, do it.

Get.  Serious.  About your diet.  NOT kidding.  What we put in our mouths determines the majority of health for ALL of us, not just diabetics.  Even if you have a low income, you can make healthy choices in your diet.

Walk.  Get outside and walk.  Go to the mall and walk.  It doesn’t matter WHERE you walk, as long as you do it.  Research has shown that walking is an excellent intervention for those who have circulatory problems in their legs.  It actually helps grow new blood vessels around any blockages that are there.

Look at your feet every day.  If you can’t reach them, get a mirror on a stick or have a family member check your feet.  All parts of them, tops and bottoms and between the toes.  Report ANY wounds or cuts or scaly, red areas to your doctor, even if they’re not painful.  Remember, diabetics lose feeling in their feet and it can be subtle so that they don’t realize the sensation is not normal.  Wear sturdy protective shoes to keep from injuring your feet, especially if you know the sensation isn’t normal.  Cute little sandals and flip-flops will NOT protect your feet from injury.

A diabetic amputation is a huge deal.  Amputation affects independence, the ability to walk and drive and get done the things that we need to do every day.  We need to do a better job preventing the need for diabetic amputations. That means being aggressive about diabetes and blood pressure treatment, protecting our feet, staying active and being engaged with our doctor and an active member of the treatment team.

God gave you two legs, two feet and ten toes.  There’s a reason for that, and we need to do everything we can to keep all those parts in good working order!

QUESTION: Do you know anyone who has lost part of their foot or leg to diabetic amputation?

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Toxoplasmosis

My family and I got some surprising news about our cat Domino this week.  You may remember I wrote a few weeks ago that she was sick with pneumonia.  The vet treated her with rounds of two different antibiotics and the pneumonia just wasn’t clearing up.

We were wondering if she might have a lung tumor causing the pneumonia not to get better as expected.  Then Dr. Kontur said “Let me do one more test.”

Turns out, the test came back “screaming” positive!

Domino has toxoplasmosis.

Toxoplasmosis is an intestinal infection with a parasite called Toxoplasma gondii that is found in some animals including cats.  Dr. Kontur tells me it usually affects young cats and older cats with asthma (like Domino) and can cause pneumonia.  Treating the infection requires antibiotics and hopefully it will clear up easily.

So why am I writing about toxoplasmosis today?  Because Toxoplasma can infect humans too.  Toxoplasmosis can be transmitted from animal feces, soil or sand contaminated with animal feces, and by eating raw or undercooked meat or seafood.

Most people who get toxoplasmosis from their cats or any other source have no symptoms at all.  In addition, those who do get sick generally just get flulike symptoms (headache, fever, body aches and fatigue).  Healthy people are at little or no risk of long-term harm from toxoplasmosis.

Who IS at risk?  Pregnant women and those whose immune systems are not normal are most at risk.  People with HIV infection, inherited immune deficiencies, or receiving chemotherapy for organ transplant, cancer or autoimmune diseases are at risk.

Pregnancy is definitely not much of a concern for me, my childbearing days are done.  However, I do have a cancer patient in my house.  As many of you know, my husband was diagnosed over 6 years ago with multiple myeloma.  As a result, we are very conscious of infection risk where he is concerned.

If you or someone you know is at risk for toxoplasmosis, there are a few things you should keep in mind.

  • Clean out your cat’s litter box every day.  It takes 1-5 days for Toxoplasma organisms to become contagious after passing in the cat’s stool.
  • If possible, have someone who is NOT pregnant and is NOT immune compromised clean the litter box.
  • Fully cook meats and seafoods before eating them.
  • Wash your hands thoroughly with soap and hot water after gardening and after cleaning a cat litter box.
  • If your kids have an outdoor sandbox, keep it securely covered to keep feral cats and other animals out of it.

For healthy people toxoplasmosis is not generally a serious health problem.  However, it can cause pregnant women to miscarry their babies and can cause infection in the unborn baby.  In additon, people with immune suppression can develop breathing problems, neurologic problems like seizures, and can affect the eyes and vision as well.

We are so blessed that Dr. Kontur discovered Domino’s toxoplasmosis infection!  Here’s hoping her infection clears up quickly and easily (although she HATES being force-fed pills).  And clearing up Domino’s infection will help protect Russ from any possibility of infection in the future.

If you’re looking for a new vet for your four-legged family member, please give Dr. Kontur a call at Summit Animal Hospital in Northfield.  She rocks!

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How To Get Kids To Swallow Pills

It seems like more and more, I’m seeing older children and teenagers, fully adult-sized patients, who refuse to take medication in tablet form.  “I can’t swallow pills.”  “They make me gag.”  “I’m going to choke.”  I talk a lot with parents about how to get kids to swallow pills.

The problem with older kids and adults that won’t take pills is that a ten-day course of antibiotics for an adult can be quite a lot of liquid.  Some medications just aren’t made in a liquid because they aren’t meant for children, and sometimes they can’t be crushed or cut into pieces to make them easier to swallow.

Before we go into how to work with your kids to help them achieve this adult skill, I want to be very clear on how we use words.  I hear “I can’t” a lot, both from patients and parents.  If your child is eating solid food, he or she CAN swallow pills.  It is physically possible to do so.  A single bite of food is MUCH larger than any tablet that is made to be swallowed intact.

So what is the problem?  Your child (and maybe you as well) has bought into a self-limiting belief.  They BELIEVE that they are unable to swallow pills and if they try, something unpleasant will happen.  Maybe they half-swallowed a piece of hard candy once and had a choking sensation that scared them.  Maybe they DID swallow a piece of ice from their drink or a piece of hard food they didn’t chew well, and it hurt a little going down.  Whatever the reason, they firmly believe that swallowing something intact will hurt.

Your job as their parent is to help them prove to themselves that they CAN swallow it and it WON’T hurt.

How do we do that?  Candy to the rescue!  (Yes, you read that right, Dr. Jen is actually advocating you giving candy to your child.  In this instance, though, the candy isn’t candy but a training tool and a necessary evil, LOL!)

Start with a small package of really tiny candies.  Some examples are Tic-Tacs, M&M Minis, and Mini SweeTARTs.  You know your child, what would they like?  It just has to be really small.  Get one small package and tell your child if they are able to swallow the first (insert small number, like 3 or 5 or 10) whole, they can have the rest of the package to eat.  Use milk or juice to wash the candy piece down.  Watch them to make sure they don’t chew them first (and if they do, that’s OK, it just doesn’t count) and apply liberal amounts of praises and atta-boy/girl.

Gradually work up to larger and larger pieces of candy until they are able to swallow pieces as large as an average medicine tablet.  Examples are Skittles, plain M&Ms and Reese’s Pieces.  Once they are able to confidently swallow these, they should be ready for an ibuprofen or acetaminophen tablet in case of a headache or minor injury.  Be sure to use the correct weight-and-age-based dose for your child.

Also, since children’s supplements are usually formulated to be chewable and to taste good, they often contain sweeteners and flavors that really aren’t good for your child.  Not to mention that they are EXPENSIVE!  I recommend to parents that they move their child to a high-quality adult supplement as soon as they are able.

I started my children learning to swallow pills when they were five years old.  The first pill they took was Shaklee’s Optiflora probiotic, which is so tiny that if you drop it, you won’t find it again unless your flooring is really dark:

Shaklee OptiFlora

After the probiotic we moved on to Shaklee’s OmegaGuard which is also small.  (Plug for those of you who don’t like fish oil because they’re horse pills – OmegaGuard is little!)

Shaklee’s OmegaGuard

And now both my boys, at 15 and 10, take Shaklee’s Vitalizer Men.  I laugh when people ask me what I’m feeding my 6’2″ teenager who has sprouted up about 8 inches in the last 2 years.  He’s my Shaklee kid!

Shaklee’s Vitalizer Men

Your child CAN take pills, if he or she is able to swallow solid food.  It is physically possible.  It’s your job to help him or her past the fear and get the confidence to learn this adult skill.  Like so much of parenting, it just takes patience, persistence and lots of positive reinforcement.

They can do it!  And so can you 🙂

QUESTION: How did you help your kids learn to swallow pills?  Do you have a child that can’t or won’t do it yet?

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What Are The Health Benefits Of Having Pets?

My cat is sick.  She has been coughing for a few weeks, which is unusual for cats.  Yesterday I took her to the doctor and found out she has asthma (I didn’t know cat asthma was a thing…) and pneumonia.  Yesterday I started her on her medicine and she already seems to be feeling better.

Because my cat has been on my mind this week, I got to thinking about how much better my life is because she (and her sister) are in it.  I started to wonder if people with pets are healthier than those who don’t have companion animals.  What are the health benefits of having pets?

There was an interesting article in the Journal of the American Board of Family Medicine that explored this very topic.  I learned a new word – ZOOEYIA – which is the term for pets’ benefit to human health.

Turns out there is a huge amount of research of all different types of studies that supports the benefits of having pets on human health.  Pet ownership is pretty widespread.  It is estimated that 68% of us in North America, including over three quarters of all children, have at least one pet in their home.  (Here’s a sad fact – children are more likely to live with a pet than with their biological father or with a sibling.  That’s a topic for another day.)

There are four main ways pets benefit our health.

Builders of Social Capital

Having pets enhance feelings of happiness and belongings and reduce feelings of loneliness and isolation.  As I’m sitting here my cat is trying to climb into my lap (never mind that the computer I’m trying to use to write this post is already in my lap!) and get my attention.

Pets tend to decrease the impact of stressful events on our health.  Medicare patients that have pets see the doctor less often and have lower medical costs.

Harm Reduction

Having a pet is a great way to motivate someone to reduce their harmful behaviors.  One good example is cigarette smoking.  Cigarette smoke is harmful for cats and dogs just as it is for humans.

Many people who aren’t motivated to quit smoking for their own health are more willing to tackle smoking cessation for the benefit of a beloved pet.

Motivators of Change

I can’t tell you how often when I ask about exercise that patients say they walk the dog every day.  Hooray!  Your pup is making you healthier!  Kids with dogs are more physically active than kids who don’t have dogs.  Dogs are a great exercise “buddy” and are always up for a good brisk walk.

Participants in Treatment Plans

Having a pet can directly impact your health in a positive way.  There was a study published where a pet was better than a pill at controlling high blood pressure in response to a stressful life event.  Patients with mental health problems like anxiety and depression respond well to pets.

Having pets isn’t completely without risks.  Some pets can transmit so-called zoonotic diseases to humans.  People, especially small children, are at risk of being injured by animals.  And pet owners can take on a large financial burden if a beloved pet falls sick and needs expensive treatments.

All in all, however, having companion animals in your life enriches your life and helps improve your health.  If you choose to add a new furry or feathered family member, please consider adopting rather than buying from a pet store or breeder.  Most shelters have cats and dogs, of course, but many also have rabbits and reptiles and other species available for adoption.

QUESTION: Do you have pets?  Do you feel they improve your health?

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Treat Yourself Like Your Best Friend

My patient Anna was in the office today and she shared with me that a few weeks ago she was feeling poorly.  She was on vacation and had a day where she really didn’t feel well.  On further questioning and on exam it was obvious that her symptoms could have signaled a serious problem.

She took some OTC meds and rested, but didn’t seek medical care.

The problem is that medical professionals work very hard to teach people about what symptoms they should watch for and what symptoms may signal a serious problem.  For instance, suppose you twist your ankle and can’t walk on it AT ALL and it is obviously deformed? You would need to see the doctor ASAP to have it checked.

What if Anna’s best friend had been on vacation with her and had the exact same symptoms she was experiencing? She wouldn’t have thought twice about taking her friend to the emergency room to be checked out.  But because it was her own symptoms, she minimized them and chose not to seek care.

Why do we DO that?!  I’m not exempting myself from this sense of frustration.  This time last year I worked almost a whole day in the office with worsening abdominal pain that turned out to be appendicitis (see this post for more information).

We can easily minimize symptoms of illness or injury. Sometimes we don’t want to inconvenience others.  Also, nobody WANTS to be sick or hurt.  However, ignoring symptoms of illness can be very dangerous.  Illnesses are often easier to treat if they are caught early.

How do you know if you should see the doctor if you’re sick or hurt?  My best advice is to treat yourself like your best friend.  Look at your situation as if your best friend was feeling this way.  If you would take your friend to the emergency room or to the doctor, then you should go.

Many people die every year because they think their chest pain is heartburn.  Even though they KNOW chest pain can be heart pain.  Or they convince themselves the severe headache is just sinus trouble. The dizziness and numbness is just a pinched nerve.

YOU are important!  YOU deserve to be treated with care and respect, and have your symptoms taken seriously.  Especially by YOURSELF.  Treat yourself like you would treat your best friend.  You deserve it!

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How To Exercise In The Heat

Summer is finally here, for real!  We’ve had some really hot days over the last few weeks and workouts have been a challenge for me.  The heat just really seems to sap all your energy and leave you a soggy, sweaty mess with half your workout left to complete.

Credit: physiqueft.co.uk

You can get amazing workouts in the summer but, like when it’s super-cold, it takes more planning.  Here are 3 tips to help you safely exercise in the heat.

Work Out Indoors

I know, I know, it’s beautiful and you want me to stay INSIDE?  No, not necessarily, but if you find yourself skimping on your runs or hikes or whatever your exercise of choice is, moving the workout indoors can help you stay a little more comfortable so you can push yourself a little more.

If you’re a runner, give the treadmill a try, or do some cross-training in the weight room.  It’s only for a few weeks until the weather cools off.

Work Out Early Or Late

If you absolutely MUST work out outdoors (for instance if you’re like me and take your life in your hands trying to run on a treadmill, LOL!) shift your workouts to early mornings or late in the evenings when it’s cooler and the humidity is lower.

I personally LOVE running early in the morning.  It’s quiet, you have the trail to yourself and you can enjoy the rest of your day knowing you’ve done good for your body.

Stay Hydrated

If you play a sport like baseball or soccer where you don’t get to pick your workout times or where you practice, the key is staying hydrated.  Drink copious amounts of water to replace what you lose by sweating.  Watch for symptoms of dehydration like dizziness, muscle cramps and nausea.

If you play a sport where you sweat a lot in the heat, consider using an electrolyte replacement drink.  Electrolyte replacement drinks maintain better blood glucose levels than water alone, and also replace salts and minerals lost in sweat.

Be careful which electrolyte replacement drink you choose.  Many of them have artificial flavors, colors and sweeteners (yuck) that definitely don’t contribute to health or optimal sports performance.

I recommend Shaklee’s Performance which has been proven to hydrate better than water alone, is completely free of artificial ingredients, and was developed for NASA to keep the astronauts well-hydrated in space.

Through the end of July, Shaklee is running a summer athlete special on Performance.  When you buy 3 canisters of Performance (or Physique, Shaklee’s muscle recovery shake) you get 3 canisters at 50% off.  If you’re interested in this promotion please let me know – it’s only open to members but I can make some magic happen if you’d like to take advantage of it 🙂

If you’re struggling to get your workouts in because of hot weather, there are a few ways to make them safer and more comfortable.  Change up the time and/or place you work out.  Stay well hydrated, and consider adding a good electrolyte replacement to keep your stamina up.

We’ve got quite a bit of summer left!  Get out there and have fun 🙂

QUESTION: Are you having trouble getting your exercise in the hot weather?

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Shingles

You’re a woman in your mid-forties, generally healthy but under some stress with work and your family.  Going about your business every day as usual, you wake up one morning with the right side of your neck feeling stiff and sore.  No worries, probably just slept wrong, right?

Nope.  As the day goes on the pain gets worse.  Then the outer side of your shoulder starts to hurt, and the pain spreads into your upper back and then into the upper chest, which makes you a little nervous.  That evening you find what looks like an insect bite on your back.

After a restless, uncomfortable night in which Tylenol and Motrin are of NO help at all, you get up the next morning and find this:

Credit: www.zostavax.ca

You’ve got shingles.  And you’re miserable.

So what is shingles anyway?  Shingles, known as herpes zoster, is an illness caused by latent chickenpox virus.  Chickenpox is a herpesvirus, like the viruses that cause genital herpes, cold sores and infectious mono.  When a chickenpox infection clears up, the virus doesn’t go away completely but lies dormant in the cells of a particular part of the spinal cord.

When you’re under stress, sleep deprived or nutritionally depleted, or your immune system is depressed for any other reason (like old age or chemotherapy), the virus can reactivate.

Shingles is found on one side of the body, in a stripe of skin that is served by one or two spinal cord levels.  This is what’s known as a “dermatomal distribution.”  In the picture above, the affected skin is all served by one spinal nerve.  This is the nerve that is sick and being attacked by the reactivated chickenpox/shingles virus.

Shingles hurts.  It is a burning, electric pain.  The combination of pain and a blistering rash should make any medical person think of herpes and specifically shingles.  There’s no test needed to make the diagnosis of shingles, it is based on symptoms and the presence of a typical rash.  Sometimes if the rash is located in the area of the body covered by a pair of shorts, a culture needs to be done to distinguish shingles from genital herpes, because the treatment is different.

Treatment for shingles consists of a week of antiviral medicine to stop the virus from replicating.  Unfortunately, stopping the virus doesn’t make the rash or pain go away – they will slowly subside over several weeks.  We don’t have good treatment to relieve the pain of shingles.  Narcotics don’t work, and medication that relieves nerve pain can be very sedating in the doses needed to relieve the pain of a shingles outbreak.

Is shingles contagious?  In general the answer is no.  If someone who has never had chickenpox or been vaccinated against it touches the shingles rash, they can catch chickenpox.  Keeping the rash covered is all that is needed to protect loved ones if they are not immune to chickenpox.

We have a vaccine to decrease the risk of shingles, called Zostavax.  It is given at age 60 or thereabouts to adults who have had chickenpox.  If you have had shingles, you still benefit from the vaccine to boost your immunity.  If you are in your 60s and haven’t had the vaccine, talk to your doctor about whether this vaccine is right for you.

One of the biggest benefits of the shingles vaccine is that it really decreases the risk of permanent nerve pain after a shingles outbreak.  Yes, that’s right, this severe electric burning pain can be permanent.  This is called postherpetic neuralgia and it is a horrible problem that is so difficult to treat.  Much better to prevent it.

It is estimated that at least 25% of adults will have had shingles by the time they reach age 85.  YOU can decrease your risk of this terrible disease that can leave you in permanent pain.  Ask your doctor about the vaccine.

If you get shingles, what can you do to help it heal as quickly as possible?  The first thing to do is see your doctor as quickly as you can.  If you can’t see your doctor within 48 hours, go to the urgent care, because the antiviral medicine needs to be started within 48 hours of the rash starting.

As with other illnesses, you want to do everything possible to support your immune system.  This means getting plenty of sleep, eating healthy food and drinking plenty of fluids.  In addition, there is evidence that micronutrient deficiencies play a role in not only shingles outbreaks but in increasing the risk of postherpetic neuralgia, particularly zinc, calcium and vitamin C.  So taking a high-quality multivitamin is a good idea.

Shingles is common, it is serious and can have severe long-term consequences.  Recognizing it, getting it treated quickly, and taking steps to prevent it are important ways to protect your health from this major medical problem.

QUESTION: Have you or a family member had shingles?  What was your experience?

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The Importance Of Healthy Teeth

This week I saw a patient, Caroline, for a general physical.  She has some chronic health problems and only rates her health as “fair.”  As part of a routine physical I always ask about dental care.  Because she is on a limited income, she does not see the dentist regularly.

Is that important?  If you don’t have dental insurance, is it OK to skip your cleanings?  What is the importance of healthy teeth and gums?

Because I’m writing about this, I think you can guess my opinion!  It’s very important to keep your teeth and gums healthy.  I’d like to review what happens when you don’t take good care of your teeth.  What are the risks to your health?

When you don’t brush and floss regularly, plaque builds up on the teeth.  What’s plaque?  It is actually a biofilm of sticky bacteria on the surface of the teeth which extends under the edge of the gum.  It is removed when you brush with toothpaste, but builds up again over 12-24 hours.

If you look at the cuticle of your fingernail and push on it a little, you can see that there is a little space under the cuticle above the nail.  There is a similar space between your tooth and the gum.  Normally the space is very small and your toothbrush gets in there and cleans it out when you brush.

If you don’t brush regularly and the plaque builds up, your body mounts a local inflammatory reaction to protect your gum tissues from the bacteria in the biofilm.  The inflammation, over time, weakens the connection between the tooth and the gum.  The attachment point gets weaker and the gum gradually separates away from the tooth surface, causing formation of a pocket.  Food particles can get trapped and it is difficult for toothbrush bristles to get down in there and clear everything out.

Regular dental cleanings and exams to look for gum redness, swelling, easy bleeding and pocket formation are needed to identify problems early and get your gums back in good shape.  If left untreated, gingivitis can progress to periodontitis.  Severe cases can require surgery, tissue grafts and sometimes lead to tooth loss, bone loss, and abscesses.

Okay, Dr. Jen, but so what?  So I don’t have healthy teeth.  Why is that so important for the rest of me?

It turns out that the inflammation of chronic gum disease has a big impact on the health of the rest of your body.  I did a quick PubMed search and there have been an absolute wealth of studies published exploring the link between periodontal disease and various medical illnesses including diabetes, heart disease, autoimmune diseases like rheumatoid arthritis and systemic lupus erythematosus, and Alzheimer’s disease.

Without fail, it has been shown that better dental and gum/periodontal health results in better overall health.  Period.

So if you are one of those people who hates the dental chair, please explore the options to get more comfortable with regular cleanings.  Shop around and find a dentist and hygienist that you really like.  Some dentists will provide mild sedation for those who are really super anxious.

My hygienist, Barb, knows I don’t like getting scraped.  She cheerfully carries on a one-sided conversation while I’ve got a handful of instruments stuffed in my mouth and can only grunt in response, LOL!  While I don’t necessarily love the process, I do love having healthy teeth and gums and I know it’s a necessary thing.  Sort of like getting Pap tests, mammograms and colonoscopies to check for problems.  Uncomfortable but necessary for routine maintenance of your body.

It is very important for you to brush and floss regularly and see the dentist every 6 months for cleanings and checkups.  The health of your whole body depends on you having healthy teeth and gums!

PS – If you don’t have dental insurance I would recommend you check out the CWRU School of Dental Medicine’s student clinic.  They see both adults and children and provide extremely thorough care at reasonable rates.  When I was a student I used that clinic as I didn’t have dental insurance, and I can personally vouch for their excellent care!

QUESTION: Do you see the dentist twice a year?  If not, why not?

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