Wellness Wednesday: The Common Cold

What is a cold ?  

A cold is an upper respiratory infection caused by one of hundreds of viruses. According to mayoclinic.org, they normally last 1-2 weeks. They normally occur a few times each year even in healthy adults. Children have them more frequently than adults, and there are usually sicker than adults with it. 

Cold symptoms:

It is important that you can distinguish a garden variety common cold from something more serious. Here are the most common cold symptoms.

• Runny or stuffy nose 
• Itchy or sore throat 
• Cough 
• Congestion 
• Slight body aches or a mild headache 
• Sneezing 
• Watery eyes 
• Low-grade fever 
• Mild fatigue

Cold symptoms are caused my the immune system’s response to the virus. These responses can cause their own problems, such as excess secretions and swelling of the passageways. This combination of increased secretions and narrowed passageways can  in turn can foster secondary bacterial infections in the sinuses, ear or throat. These complications require treatment. 

When adults should contact the doctor:

• Fever of 103 F (39.4 C) or higher 
• Fever accompanied by sweating, chills and a cough with colored phlegm 
• Significantly swollen glands 
• Severe sinus pain

When the doctor should be called for children: 

• Fever of 100.4 F (38 C) in newborns up to 12 weeks 
• Fever that rises repeatedly above 104 F (40 C) in a child of any age 
• Signs of dehydration, such as urinating less often than usual 
• Not drinking adequate fluids 
• Fever that lasts more than 24 hours in a child younger than 2 
• Fever that lasts more than three days in a child older than 2 
• Vomiting or abdominal pain 
• Unusual sleepiness 
• Severe headache 
• Stiff neck 
• Difficulty breathing 
• Persistent crying 
• Ear pain 
• Persistent cough
• Pregnant women should call for any illness, just to make their caregivers aware and to discuss pregnancy safe management options. 

High fever, severe sore throat or body aches may indicate a special pathogen like influenza or strep which requires a specific treatment.  Without a doubt, there is little downside to calling your doctor and asking if they think you or your chlld needs to be examined or tested. 

Prevention of Colds

Cold viruses are spread by touch or particles in the air. We probably encounter them much more often than we get sick. Sometimes the immune system deals with them easily and we don’t really get sick. Getting sick happens when we encounter a particularly virulent (strong) virus, or when we are run down, or both. 

Prevention is a matter of not getting run down ( easier and than done) avoiding contact with sick people or viruses. Hand washing with soap and keeping surfaces with clean with antimicrobial cleaner is critical. When my kids were growing up, we established a tradition of washing hands whenever we arrived home from elsewhere. 

I also believe good oral hygiene is key to preventing upper respiratory infections. This means keeping up on the toothbrushing, flossing and dental repairs. A peroxide based mouthwash before bed is very helpful too. 

Treatment of Colds

Treatment is largely supportive. This means we try to ensure that patients hydrate well and rest. We also like them to keep their nasal passages clear and cough down so they do not get secondary bacterial infections from all the congestion. This can be accomplished with over the counter decongestants and cough suppressants. (Though it is important to note that aspirin is not given to children and cough syrup is not given to children under 4. )  Better yet decongesting is accomplished with frequent steamy showers and lots of herb tea, to keep the passages clear. Good oral hygiene probably hastens healing too.

Did you know that chicken soup is actually ideal for the cold sufferer ? There is actually an old research study showing it has anti-inflammatory effects, and certainly we know it helps to hydrate and nourish. While it is hydration that is often emphasized, people recovering from a cold need at least as many calories as normal. While one should feed a cold, one should NOT “ starve a fever”. 

I generally make my soup stock and my chicken soup from scratch. However that is not a quick proposition. For this reason, I like to keep some high quality canned chicken soup on hand just in case I am pressed for time and someone is under the weather. There, that is the ONE time I will recommend a “store bought, pre-made”  food. 

So in this case as in many, an ounce of prevention is worth a pound of cure. Stay in your exercise routine, sleep adequately, eat well, and practice good hygiene. Those things are a lot more fun than getting sick. If you do get sick, follow these measures. Treat yourself to some good soup, a steamy bath or shower, and a first rate Netflix binge. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Research on Zika continues at an accelerated pace. This last week Zika news includes the release of a new three-in-one test to test for Zika, Chickengunya and Dengue. Researchers say this cannot keep up though without an emergency spending bill from Congress. 

Puerto Rico has become a strong cause for concern. The director of the CDC has visited recently and expects “ hundreds of thousands” to be infected by Zika, among whom are thousands of pregnant women. Puerto Rico is believed to be an important route of infection to the United States. 

In Brazil, newest numbers show 29 % of Ultrasounds on babies born to Zika infected mothers show fetal anomalies with “ grave outcomes”. The newest research shows the prevalence much publicized defect called misrocephaly, but it is also becoming clear that other kinds of problems are likely Zika-related. These would include: lack of amniotic fluid, other forms of fetal brain damage, blindness,and stillbirth. 

There are 273 cases of Zika in the US States and 282 cases in the US territories including Puerto Rico. 

A small randomized controlled trial published in March of this year studied 78 first time mothers and their second stage of labor. The second stage is the time from becoming completely dilated to pushing the baby out. The old guidelines allow first timers pushing well to take 2 hours without epidural or three hours with epidural. Study subjects were allowed to push for one hour greater than current guidelines. In this study, when they did, C sections rates were cut in half without any other adverse effects noted  in either mother or baby. The authors remarked that the study was underpowered to detect small but clinically important differences. It does however, suggest that first timers were being “cut” as we say, too soon. 

As an Obstetrician, I would note that I have seen this study reported in the press. Many assumed that this meant that caregivers should now let patients push longer. Finally I got at look at the study itself. Nowhere in the press did it mention that all of the women in this study have epidurals. This makes it more difficult for many people to push effectively. Now it makes sense to me that more time made for more safe vaginal births. Certainly in many cases,  second stages with low quality epidural-influenced pushing should not be expected to make as much progress as second stages in women with strong epidural-free pushing. More time should be given for these patients. Normally, in a real labor population, some people have epidurals and some do not. Labor length averages are going to be influenced by his. However, If every single patient in a small study has an epidural, result swill skew toward the effect of the epidural-ized labor. Obviously. 

The old labor guidelines were made in the days before epidurals. In those cases, the women were probably unmedicated and thus pushing for all they were worth. In such cases, the old time allowances were probably appropriate. The idea is that, if your patient was going to deliver vaginally  safely, she should be able to do so within the old time allotments. Furthermore, if you persist in pushing her longer, you set yourself up for a variety of bad situations like stuck shoulders, a traumatized baby, or a traumatized mother, or a very late and thus risky C section. Hard coordinated pushing should result in continued progress of some degree. If it does not, the safety of vaginal birth should be questioned.

There are various signs we watch for during labor to tell if the baby can safely be delivered vaginally. It is so much more than the time duration of pushing. We watch the fetal heart tones, the evolving shape of the baby's head, the movement of the baby in response to the mother’s particular push in whatever particular position she is in. We factor all this in. I may know someone is stuck after only one hour, and I may let someone else safely go for four. It is a matter of not only knowing the labor guidelines, but but knowing the reasons behind them and knowing your particular patient very well. 

In the way cool department, researchers are using an iPhone app to begin a study of postpartum depression. They will be looking at a possible genetic predisposition for PPD. Using the iPhone will allow them to more easily get the enormous numbers (100K) they need to produce quality conclusions. 

In the good news department, Vox report that several more states, Missouri, Hawaii, Washington, South Carolina and Tennessee are considering bills to allow pharmacists to prescribe birth control pills. Ob/gyns support these bills because of the well established safety of these medications. 

The Supreme Court is hearing arguments about the ACA’s (Affordable Care Act) contraception mandate. A religious group called “ Little Sisters of the Poor”, one of the plaintiffs, are nuns, and they argue “ the birth control provision violates the laws of God.”

Governor Mike Pence of Indiana has signed a bill prohibiting abortions even for birth defects. He did this despite opposition from several of his female pro-life Republican colleagues in the House. Has he heard of the Zika virus ?

Stay tuned for more breaking news from the world of Ob/Gyn next week on Medical Monday. 

Food Friday: Easter Lunch Planning

Sorry, for some reason this did not go out as planned.... so here it is ! 

Every year we have a sizable party for friends and family. Every year I try to include some traditional dishes, but also some things to surprise and delight. Right now I am letting you in on the menu planning process. 

This year, Passover does not coincide with Easter. Most years, it seems like it does. Since I am Jewish we do not have leavened bread on those years. However, this year, we will be able to. 

Last week’s Food Friday went over many of the traditional foods from around the world. Because Easter occurs so early in the spring, it is before crops are really coming in. Thus even the festive menus include foods made from preserved things, like cured meats and fish. But, when you think about it, dried wheat ground into flour is a preserved thing, and so breads are among the traditional dishes, especially if they contain dried fruits and candied citrus peel.

For our bread this year, I am looking forward to a traditional Russian Easter Bread made by one of my Russian friends. My mother in law usually brings lamb, which is herb encrusted. My daughter is quite the chocolatiere, and I am going to try to persuade her to make a batch of handmade chocolates in fanciful shapes on Saturday. We like to make bugs and butterflies from molds. Her husband is the salad expert and produces an extraordinary spinach salad with candied walnuts and sliced strawberries. I will handle the new potatoes, smoked salmon with cream cheese and pickles, and new asparagus. Also I cannot resist making a meringue cookie in honor of one of the great grandmothers in the family. For them I will use only the whites of the egg, and so will liberate numerous yolks. To utilize these, I will make lemon curd. I have discovered that just about everyone in my family loves it. Few here in the states eat it. It is more popular in Britain. It is a rich lemony spread made with butter, sugar, yolks and lemon juice. You can even make it with lime juice. People use it like jam. It is a beautiful sunny color. 

And that is quite enough for the cooked sweets, since there will be the egg hunt in the nearby forest. There will be lots of treasures, such as spools of thread, coins, buttons, ribbon and more, but there will also be candy. Some of the eggs will be wooden and painted, and some will even be stone. In the past I found some that rang like bells. They went to the permanent egg collection. 

Make no mistake these gatherings are for more than fun and food. They forge the social bonds we need to be happy and healthy. So regardless of your religious , political, familial or cultural affiliations,  get together and make something nice. Renew old bonds and forge new friendships. 

Welcome to my spring holiday table. I would love to hear about yours. 

Wellness Wednesday: Wellness While Gardening

Gardening does not strike anyone as a particularly dangerous pastime. However there are a few tips and one critical point I’d like to share on the subject. 

I have been a committed gardener ever since I got married 33 years ago. It has been a soul feeding pastime for me. Gardening has gone hand in hand with family time, from the hands on science education for our kids to our present day culinary pursuits. 

I have gotten sunburns, rashes, cuts, scrapes, slivers and mosquito bites.  I have gotten dirty and dehydrated. I have lifted too much. I have risked heat stroke and frostbite. Thank goodness I have not gotten any ticks. But these are the concerns at hand. If you check the CDC (Centers for disease control ,they cover the list of precautions that would have prevented all these ills, and I will recoup them dutifully here. But there are a couple surprises, and at the end, one BIG POINT. 

• Your clothing and hat should protect against weather, insects, chemicals (even organic ones) sun and yes, dirt. Dirt is full of pathogens like various fungi, tetanus and toxoplasmosis. This is of special concern to those who are pregnant or have compromised immunity. Play in the dirt with gloves.  
• Make sure your every ten year tetanus shot is up to date. 
• Your skin should be protected by sunscreen or insect repellant as indicated. 
• Your hands should be gloved no matter what. Did I mention the gloves ? 
• Your eyes should be protected from flying debris and dirt. You are not pulling enough weeds if you do not have dirt flying toward your face. 
• Have water with you and hydrate throughout the day. Dehydration happens faster than you think. 
• Know the fertilizers and supplements you are dealing with. Read all labels and follow all directions. 
• Know your equipment, and make sure it is in good working order. If you are using sharp objects or powered equipment, keep your attention on what you are doing and keep small children out of harm's way. 

Here is the BIG POINT, and I will plead with you on this. Use organic methods. Please. The whole point of gardening is to get closer to nature and to produce something wholesome you can eat. Please do a little reading, and welcome yourself into the immensely gratifying world of organic gardening. If there is one thing that will save the world, it might be this. 

I am not even going to begin to address all the safety concerns of gardening any other way, such as with conventional herbicides, pesticides, or fertilizers. It would take too long and it would be depressing. So, get yourself one of the many excellent organic gardening resources, like maybe a book, the internet, or maybe your grandmother.  It doesn’t matter if you do container gardening in the middle of a cityscape, or if you have a farm. Chose this life affirming hobby, and do it in a life affirming way. 

Stay tuned next week for another Wellness Wednesday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

The CDC (Centers for Disease Control) predicts Zika will spread along the Gulf States of the US this Summer. The CDC has also said that since mosquito control in Florida is good, the risk there should be relatively low. As with regard to South America, and in particular Mexico, the CDC has noted that the Aedes mosquito, vector for the virus, is rarely seen above 6500 feet. 

Researchers studying a Zika outbreak in French Polynesia have identified a 1% risk of microcephaly among children born to mothers infected in the first trimester. Observers of the Brasil outbreak think the figure is too low given what they are seeing. It will take several more months to draw any conclusions.

As of Friday, there are 450 people in the United States who are infected by Zika. This does include Puerto Rico, where the Puerto Rican section of ACOG ( American College of Obstetricians and Gynecologists) are providing IUDS free of charge. (So proud of my brothers and sisters in ACOG ! )

In other news, concerns have been raised in an opinion piece in the journal Obstetrics and Gynecology that media coverage of controversial medical technologies may prevent certain women from getting the best treatment for their particular needs. They site the recent reluctance of doctors to use mesh implants, morcellators, or Essure sterilization even in patients for whom they are well suited. 

In the no-good-reason department, new research shows that sexually active teens with LARCs ( Long acting reversible contraceptives such as IUDs) are 60 percent less likely to use condoms that similar girls taking the pill. Birth control use in teens is distributed as follows: 2% use LARCs, 6% use Depo Provera injection, patch or ring. 22% use the pill. 

Also in the no-good-reason department, new research indicated 50% of pregnant women who quit smoking start again after childbirth. What percent of smokers quit during pregnancy ? 13 %. 

What about smoking pot in pregnancy ? One thing’s for sure, Ob care givers are not consistently counseling patients about it. These are the findings of new research published in the journal Obstetrics and Gynecology. I will say that as a caregiver, It is challenging to counsel against something that is so widely used, and for which people will rally. Neither the popular media and the research community  give us much in the way of support here. In fact, the facts on MJ use in pregnancy are not encouraging. If you are interested you can read the definitive information HERE, which is a summary document from the American College of Obstetricians and Gynecologists to its members. This is an area needing further attention. That is, if we value the brain power of the next generation. 

Steroids are given to mothers at high risk for preterm delivery. At this time, we give them from 24-34 weeks of gestation. However, new evidence indicates they may be helpful given even as early as 22 weeks. Hopefully the demand for this will be small. 

A new study published in JAMA ( Journal of the American Medical Association) reveals that vaccine aversion may be beginning to manifest in increasingly rates s measles and pertussis (whooping cough) in the United States.  No surprise here. 

Also In the vaccine department, there is good news. Chicken pox, also called Varicella, is now nearly 100% preventable. Think that’s no big deal ? Try telling that to someone like me who got it at the age of 24 ( and got seriously ill) or someone with a terrible case of shingles, which is reactivated chicken pox. New data says getting two shots instead one, one at age one, and the second around 4-6 years of age, confers near 100% protection. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology, here, (or hopefully in your inbox) next week, on Medical Mondays. 

Wellness Wednesday: Natural Home Cleaning

There are many cleaning products on the market now which are safe, effective and appealing. But they sure can be expensive. In this post, we will go over the general concerns with conventional cleaning methods, the basic principles of healthy cleaning, and finally the “ ingredients” you will need to make your own cleaning supplies for a fraction of the cost. 

Scary clean

Scary can come about in several ways: if you use toxic cleaning products, if you mix cleaning products, if you use standard cleaning products incorrectly, or, if you let something become so soiled over time that only the most powerful solvents will get it clean. 

Medline Plus, a resource of the National Institute for Health (NIH), has produced a page on household cleaning products which is worth bookmarking: 

Medline Plus Household Products

(click to view)

They start by explaining that many common household substances are potentially toxic enough to cause illness, birth defects, or even death.

You might think safe natural cleaning is all about what you clean with; but there is much more to it. 

Principles of Safe Cleaning 

• Keep up on your cleaning so things do not get really difficult to clean. 
• Read the label of any cleaner, natural or otherwise. Make sure you know what it is made of. They all should be powerful chemicals; that’s why they can get things clean. 
• Keep cleaning materials in their original container, with their labels on, so they can be identified. This holds true for homemade cleaning solutions, whose labels should include all their ingredients. 
• Store all cleaning materials, natural or otherwise, away from children and pets. 
• Never mix cleaning solutions. Bleach and ammonia for example, may react, ignite or explode. 
• Volatile hydrocarbons, even from naturals like mineral oil, can be combustible so they may not be used near open flame. 
• Before cleaning, prepare. 
• Assemble your supplies and materials. 
• Assemble your outfit ! Yes, in many cases, you need to wear protective clothes, put your hair up, wear some gloves, and have some eye protection. It won’t hurt either to have some music, TED talks, or audiobooks set up for easy listening. 
• Do one area at a time. 
• Turn the lights on, and clear away as many items and furniture as are practical. Open the windows or otherwise secure good ventilation. 

Then and only then, you can clean easily and safely. 

There are many “ recipes” on the internet for home made natural or less toxic cleaning solutions, all complete with tableaux style photos which invariably include bundles of lavender and the obligatory lemon wedge.  The very best resource I found was a link from the National Institute of Health to this page : 

Twelve Home Cleaning Recipes

( Lemon and Lavender not included.) 

Click on the title link to view precise recipes AND instructions to get the most out of these solutions. They have all been tested for both performance and safety at the Toxic Use Reduction Institute (TURI) at University of Massachusetts, Lowell. Very rigorous ! 

Their ingredients list

These are all available at standard grocery stores ( even Murphys’ oil) , as are jars and spray bottles. Labels can be obtained at an office supply store. I recommend writing down the recipes somewhere, i.e. in a note taking app, or even into your family cookbook. The labels do get drizzled on in the course of cleaning, and may run even with sharpie pen labelling. You will not want to lose the recipes. 

Cleaning is a chore, but it should not be unsafe or miserable. I recommend being well prepared, and using products that you like, whether homemade or purchased. If you make your own, you may also consider adding a few drops of your favorite essential oil to your solutions, to make your task smell as good as possible. I also am a big fan of taking the time to set up a pleasant listening experience. Happy cleaning. 

Next week we will explore safe gardening, as the gardening season approaches.

Food Friday: Chocolate

I’m devoting a whole post to chocolate. That’s how strongly I feel about it. The great Spring celebrations of Passover and Easter are coming up and it is time to think about festive foods. 

In our house we take our chocolate seriously. You might even say we are chocolate snobs. Our snobbery has been fostered by two things: our affinity for France, and our pursuit of fine organic foods. 

For my daughter’s graduation from high school, I took her to France. We wanted economical flights and lodging, and so we went during the drizzly spring break. We arrived shortly before Easter Sunday only to find the southern French countryside greened, blooming and decorated.

It turns out that in France, Easter is a bigger communal holiday than Christmas. Every storefront was beautifully decorated. The bakeries, pastry shops and chocolate shops were full of dazzling creations - figures of every sort, made in bread or chocolate, then festooned with sugar formations and woven ribbons. Chocolate was absolutely central to the Easter celebrations, and we saw chocolate like we had never seen before. 

Now we make our own creations at home. We feel fortunate if we just get it tempered correctly. To make our own, we have had to learn all about it. We have learned about the equatorial, often war torn regions where it  grows, and we have learned about the farming and labor practices entailed in chocolate production. We have learned that to get organic chocolate, we pay more, but that the workers involved get a better wage, and the land is left unpolluted. 

It turns out that these days, westerners like us have come to recognize the value of country specific cocoa beans. When I attended one chocolate tasting demonstration, even I could tell the difference in the tastes. 

But what about health ? Could all the health claims about chocolate be true ? As always, the devil is in the details. Healthfulness is compromised when lots of milk fat and sugar are added and when the chocolate is overly processed, (i.e. Dutch or alkali processed). It turns out chocolate needs to be appreciated almost like coffee beans, in its dark, somewhat bitter form, and certainly with its own fat, cocoa butter, which has its own health benefits. 

According to the clevelandclinic.org, cocoa beans confer healthfulness via the following compounds they contain: flavonoids, antioxidants, and flavanols. These potent compounds combat oxidative stress. This means they neutralize damaging compounds called free radicals which may accumulate the body. They can also, by various mechanisms, favorably impact lipids, lower blood pressure, and improve blood flow. 

Current recommendations provide for taking about 1 ounce of dark chocolate a few times per week. At my office, we always keep some on hand, “ for medicinal purposes only” : ) . 

Stay tuned for more holiday food info next week on Food Friday. 

 more reading : 

Metro UK

Medical News Today

Wellness Wednesday: Safe Cosmetics

We think of cosmetics as luxurious little compounds we use externally to improve our appearance. But they are mixtures of chemicals of which we should be aware. We place them on our skin, eyes and near our mouths, and may not realize that they could have potential health impacts. We also store them in our homes where they could be obtained by little ones who may use them in unsafe ways. 

This week’s post deals with these concerns. To explore this complicated area, I have researched on two main site, fda.gov, i.e. the Food and Drug Administration, and breastcancerfund.org. They both make the following strong recommendation: To read the labels of any products you buy. They advise us to know what these ingredients are, and to look them up on FDA.gov if there are any concerns. They also state that products with unlisted ingredients should not be used. 

FDA site 

http://www.fda.gov/Cosmetics/default.htm

The FDA site is rather comprehensive so I will not attempt to reconstruct or summarize it here. Instead, I will highlight some points that I felt were noteworthy. 

FDA.GOV states that “ FDA regulates products that we think of as “makeup” –such as lipstick, blush, foundation, face powder, eye shadow eye liner, and mascara--as cosmetics under the Federal Food, Drug, and Cosmetic Act.” The FDA pays particular attention to color dyes used in cosmetics. Coal-tar based dyes are common in hair dye. They are known to cause eye injuries or allergic reactions. However, the FDA cannot take action against them since the package insert provides instructions and discloses this risk. 

Hair straighteners are also a concern. Some can release formaldehyde.The FDA advise avoiding exposure to formalin, methylene glycol or formaldehyde. 

“ Progressive dyes” are hair dyes which produce the desired color change after repeated use. They contain lead acetate - made for external use only and are unsafe to have around children due to the risk of lead poisoning. 

Mascara is associated with a significant number of complications. Apparently eye injuries are a common result of mascara application while moving, i.e. while one is in the car. Mascara can also cause infection or irritation. It should be thrown out after three months or if the eyes get infected or inflamed. Mascara is not to be shared, even with friends or relatives. Bacteria which may be friendly to you may cause problems in someone else. 

Do not use Kohl, aka al-kajal, kajal, or summa. Kohl is a traditional dark black eye decoration in many areas of the world but is not approved for use in the US. It consists of salt and heavy metals (! ) such as lead. It is linked to lead poisoning. I remember when this was in vogue in the 70s. 

Permanent tints and dyes for eyebrow and lashes have caused serious injuries. Those containing coal tar colors are not safe for use. Makeup experts advise against eyebrow pencils anyway, saying that they appear too severe. Additional definition is best achieve with a subtly applied dark eye shadow.

Parabens have been in the news as a suspected undesirable chemical. Parabens are preservatives to guard against microbiological growth. Studies show they are safe at levels up to 25 %. In cosmetics, they are typically used at levels up to 0.3 %. Parabens do have weak estrogen like activity and for this reason a public concern has been raised. However, they are 10,000 to 100,000 less potent than natural estrogen produced in our own body. In the small quantities in which they are used, they are believed to be unlikely to contribute to any cancer risk. 

Phthalates are a group of chemicals used in many materials from floor covering to food packaging. They are also used in numerous cosmetics. Their primary use in cosmetics is in hairspray, nail polish and synthetic fragrances. They too are endocrine disruptors, meaning they interact with hormone receptors. The FDA states “ It’s not clear what effect, if any, phthalates have on human health”.They continue to follow this question, but to date “ FDA does not have evidence that phthalates used in cosmetics pose a safety risk. “ However, some people prefer to avoid phthalates until there is more proof of safety. The particular compounds to look for are dibutylphthalate (DBP), dimethylphthalate (DMP) and diethyl phthalate (DEP). DEP is the only phthalate still commonly used in cosmetics. 

Talc is a common substance which shows up in baby powder and blush. It is a mined mineral and contains magnesium and silicon. Certain talc has been known to be contaminated with asbestos, which is a known carcinogen. For this reason, since the 1970s, it is purified before use. Pure talc has not been linked conclusively to any cancer, though in the 1970s it was rumored to be linked to ovarian and breast cancer. The IARC ( International Agency for Research on Cancer), which is part of the World Health Organization, has made the following statements about talc: 

• IARC classifies talc that contains asbestos as “carcinogenic to humans.”

• Based on the lack of data from human studies and on limited data in lab animal studies, IARC classifies inhaled talc not containing asbestos as “not classifiable as to carcinogenicity in humans.” 

• Based on limited evidence from human studies of a link to ovarian cancer, IARC classifies the perineal (genital) use of talc-based body powder as “possibly carcinogenic to humans.”

Breast Cancer Fund

breastcancerfund.org

This organization takes a more conservative point of view than the FDA. They advise avoiding any substance where there is doubt, or a lack of data, and advises reducing the total number of cosmetics altogether. They also advocate for making your own products with nontoxic ingredients from your kitchen. 

Their first piece of advice is to avoid synthetic fragrance, as it often contains Phthalates. Additionally many people are sensitive to it. Several people on my staff get an instant headache when they smell strong synthetic perfume. 

They urge caution about a products with unsubstantiated claims of being natural or organic. Only a USDA organic seal guarantees 95% or more or organic ingredients. "All natural" or organic does not mean hypoallergenic and does not determine safety. Anyone can be sensitive or allergic to anything. For example, many essential oils are fine when aerosolized, but irritating when applied directly to skin. 

Breast Cancer Fund advises caution when getting the nails done. In particular they suggest steering clear of shops with use polishes with formaldehyde, toluene, and dibutylphthalate, the so called "toxic trio” . There are many brands that are now “ three free”. Ask your salon to carry these. 

I support the advice to use minimal cosmetic products. I also support the idea of making your own. I will conclude this post by sharing what I use. Bear in mind that I am 54 with dry skin and long curly dry hair. For face, I rely on what my Dermatologist has told me. I shower twice a day with plain water. I exfoliate gently with an apricot pit scrub, and in the day use a Retinol ( vitamin A based) cream with sunscreen. In the evening after I wash with water only, I use a home made mixture of a stronger Retinol cream, a richer moisturizer and a concentrated vitamin C serum. On the body I take it easy since I have sensitive skin from Lupus. I use a waterproof electric shaver in the shower, so I need no shaving cream or razors. After the shower, I use a home made 1:1 mix of cocoa butter and coconut oil, both organically produced. ( It is actually a chore to melt, blend and re-temper.) For hair, I use only conditioner, no shampoo. I use a light mineral based moisturizing foundation with sunscreen, and mascara with a brush that I clean and replace every 2 months. Finally I use Burts Bees lipgloss for face color and lips. That’s it. 

Oh yes, that photo of me was a joke but I guess it fits in here. 

Next week on Wellness Wednesday we’ll expand on this theme and go over natural home cleaning solutions. Thanks for reading. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Good Monday.

The CDC continues to study the relationship of the Zika virus to a severe brain anomaly called microcephaly. No one really doubts the association; The goal in documenting the association scientifically it to understand the mechanism of how the virus dose the damage and therefore how, ultimately to prevent or interrupt it. Similarly, new research this week provides stronger links between Zika infection and Guillaine Barre syndrome, or post viral partial paralysis. 

Zika virus has been seen as far north as Washington DC. Aedes Egyptae mosquitos have been identified there as well, and it is speculated that they survive the winter by staying indoors or in subways. Apparently the mosquito maps in the US are “not complete”. 

Preterm labor and delivery has vexed Obstetricians for decades. We have little to prevent it. We did feel were making inroads into predicting it using two specific tests: ultrasound measurement of the cervical length and a swab for a chemical called fetal fibronectin. However, according to new research these may not be as useful as previously thought. Risk factors for preterm birth are young age, low pre pregnancy maternal birthweight, smoking, short inter conceptual interval, urinary tract infections, and periodontal (gum) disease. 12% of all births in the US are preterm. Preterm delivery is the leading cause of neonatal mortality in the US. For more information, see our section HERE on preterm labor. 

A study reported in the Journal of Adolescent Health has shown that only about 42% of men have heard of emergency contraception, aka the morning after pill. This is a safe effective solution to prevent unplanned pregnancy. It is available over the counter. 

Essure is a device placed in the fallopian tubes for sterilization. It turns out to have a far higher complication rate than was previously believed or advertised. A powerful social media campaign brought this to the attention of the FDA who has now studied the matter and given its recommendations. Essure will not be pulled off the market. Instead, Bayer AG will be required to perform new studies on the implant. The FDA will also require a boxed warning and supply a checklist for physicians to review with patients. The FDA is currently seeking public input on the packaging. 

From the chickens and eggs department, a recently released study in the Journals of Gerontology showed that “ higher education, positive wellbeing, overall good health, and higher physical functioning all contribute to women maintaining good memory health after age 80.”  This data comes from a study initiated in 1991 and is a subset of the huge Women’s Health Initiative Study famous for its revelations about postmenopausal hormone replacement therapy. 

A recent study in older first time pregnant women shows that induction at or after 39 weeks is NOT associated with a bad birth experience or a higher risk of C section. This is contrary to the prevailing wisdom. 

This last week, the US Supreme Court has heard arguments over the matter of abortion facilities. At issue is whether they must meet hospital grade surgical standards. Proponents state this will make the facilities safer. Opponents say that this is a ruse, cost prohibitive and simply a legal way to close down all but a few facilities (75% of them according to ACOG, the American College of Obstetricians and Gynecologists. Medical experts say this level of facility is not medically necessary for these procedures.

Meanwhile statistics in the US now indicate an 18 % drop in unplanned pregnancies between 2008 and 2011. One third of these pregnancies were averted though legal abortion. Further south, the staunchly Catholic South American countries grapple with the devastation of Zika induced microcephaly and the question of abortion should it be identified. 

Stay tuned next week for more breaking news from the world of Obstetrics, Gynecology and Women’s Health. 

Wellness Wednesday: Menstrual Wellness

At first I thought the #freethetampon movement was a bunch of hooey. However, now I am giving it a second look. What got me thinking was a Tedx talk given by Nancy Kramer featured here on this website:

http://freethetampons.org

This site has some hard numbers about how many girls and women have to interrupt their school or work day to improvise a solution to an unanticipated period (86 % of us !) This is because restrooms the world over are stocked with toilet tissue, soap and something to dry hands, but there are scarcely ever any tampons or pads.

Granted there is an additional cost to providing these supplies, but in terms of school or professional environments, there are also benefits: less time away, less workplace stress, etc. Supporters of the #freethetampon movement advocate that tampons and pads should become freely available in every public bathroom, much like toilet tissue or soap. They view it as a public good and standard of decency in consideration for the everyday realities of normal body functions in women. Most women prepare as best they can and carry adequate menstrual supplies most of the time. But, as a Gynecologist I can assure you that irregular cycles and uncontrolled menstrual flow happen once in a while to most women. Even the best prepared among us has most likely struggled with an out of control period at one time or another.

Back to the cost of menstrual supplies. Did you know that in most places there is sales tax on tampons and other menstrual hygiene materials ? Sales tax criteria vary by state. Montana, Alaska, Oregon and New Hampshire have no sales tax on anything. Beyond that, Minnesota, Pennsylvania and Maine tax the customary items of “ tangible personal property” excluding necessities like food and medicine. Most notably these states also exclude menstrual hygiene products from sales taxation! In these states menstrual hygiene products are classified as necessities rather than “ luxury” or “ tangible personal property” items. Every other state taxes menstrual hygiene products. Every other state has what is being called the “ tampon tax.” Critics of the tampon tax say that it unfairly discriminates against women. They point out that it is a tax that women have to pay solely by virtue of being women, which is sex discrimination.

The tampon tax issue together with the #freethetampon movement has catapulted the menstrual cycle into the public limelight. For most of history however, the subject has been totally taboo. Most generally menstruation has been looked upon as an “unclean" state. In many cases menstruating women have been set apart from their family during this time. Even until recently it has been considered a topic not fit for polite conversation. And for reasons which are still not clear to me, menstruation has been a source of embarrassment or shame.

Many contemporary women are interested in removing the stigma of shame associated with this normal body function. To do so, they have taken several tacts. If you search the web on such matters, you will find all kinds of art from posters, pins and jewelry which flaunt these taboos, and demonstrate menstrual pride. There are references to “shark week”, “riding the cotton pony” and visits from “Aunt Flo”, normalizing and humorizing the subject. In one instance at one American high school

(https://en.wikipedia.org/wiki/Tri-Valley_Central_School,)

a security guard’s public search of a girl’s purse also included questions about whether she was on her period. The incident was considered intrusive. The next day, boys at the school came to class with sanitary pads taped to their shirts in a show of solidarity for the girl. Girls wore tampon necklaces. Finally, most of you have heard by now how Kiran Gandi, a Harvard business school student, ran the 26 mile London Marathon on her period, without a tampon and with visible bleeding, to “ transcend oppression” and to publicize the plight of those women who lack adequate menstrual products.

You get to decide how you feel about your period. But you should know a few things about it. No period is comfortable or convenient, but some get downright bad. If you meet certain objective criteria, you should call your doctor and get checked. Abnormal periods are not healthy, and should be treated.

Here is a section from our page on on adolescent and childhood Gynecology which describes the beginnings of periods :

The mean age of menarche (first menses) is approximately 12 1/2 years of age, with a range of about 11 to 14. Menarche typically occurs 2 to 3 years after thelarche after the breasts are fully developed. Ninety eight percent of females will have had menarche by age 15. Any adolescent girl who has not reached menarche by 15, or within 3 years of thelarche should be evaluated. Additionally, any vaginal bleeding before the age of 8 is a concern and should be evaluated by a a gynecologist.

- See more at: http://drginanelson.com/childhood-gyn-concerns#sthash.ykiQ4Hoh.dpuf

More menstrual facts you need to know:

Periods should not last longer than a week.

Period intervals ( time from day 1 of one period to day 1 of the next period ) should not be less than 21 days or greater than 35 days.

Total flow should not exceed 80 cc (1/3 cup) in one cycle.

Period flow should not make you lightheaded or anemic.

Period pain should not keep you from school, work or exercise.

You can get pregnant on your period.

If you experience any of these things, you should call your doctor. Depending on your age and medical history, an evaluation may be done. Depending on the results, a treatment can be planned.

Tips for menstrual management:

You may pick from either pads, tampons or both. You may use menstrual cups as long as you wash them as instructions indicate. None of the internal methods should be left in longer than needed, or they can foster infection. Apparently there are now unisex tampon necklaces you can wear, to use yourself or to “help a sister". There is even an app, developed by a Harvard freshman, Olenka Polak, called “ Code Red” which alerts sympathetic users in your area that you are caught in a “ periodic emergency”.

Menstrual health is a physical and psychological challenge. Don’t feel like you have to meet this challenge alone. 

Medical Monday: Breaking News form the World of Obstetrics and Gynecology

Good Monday ! We will start our news this morning with a revelation that a once deadly virus is now under firm control via the three pronged approach of surveillance, treatment and vaccination ! I speak, of course of the Human Papilloma Virus,(HPV), responsible for causing cervical dysplasia and cervical cancer.

A new CDC study published in The Journal of pediatrics reports states that" thanks to a vaccination program that began decade ago fewer US women are entering adulthood infected with” HPV. Apparently this study is the first to show falling levels of dangerous strains of the virus in women in their 20s. Human papilloma virus vaccine also known as Gardisil, has been available for use for children ages 9 through 26 for many years now. It was initially only available for girls because the studies were done first on girls but subsequently it was released also to boys. 

Zika is our newest viral threat. It has ravaged South and Central America and proceeds northward into areas where the Aedes aegypti mosquito can live. Zika is blood borne and spread by this mosquito. Male to female sexual transmission of ZIka is now also confirmed. It is also vertically transmitted, meaning from mother to unborn child, and is strongly linked to the development of microcephaly in the the growing fetus, which produces severe brain damage. Conclusive proof of the connection is likely to come in June when a large cohort of nearly 5000 women mostly in Columbia will give birth.

Zika infection is also a threat to the nonpregnant in that it is strongly associated with a much higher risk of developing post viral paralysis, Known as a Guillain-Barré syndrome. World Health Organization researchers note that there is been a spike of Guillain-Barre "everywhere that we are seeing to seek a virus".

In the good news department, breast cancer survivors are now believed to be able to safely use vaginal estrogen therapy. Vaginal estrogen therapy is used to treat vaginal atrophy, often see in menopause or after breast cancer treatments which stop a woman from producing estrogen. Vaginal atrophy is a painful condition which causes various problems and prohibits intercourse. We do not give systemic estrogen to breast cancer survivors since we are concerned it could encourage a cancer recurrence. Vaginal treatments are not believed to produce a systemic dose. 

In more good news, a cheap easy to use vaginal ring is helping to curb HIV transmission rates in Africa. The rings slowly releases an antiviral drug to combat HIV and it needs to be changed every 4 weeks. It reduces transmission by 30 %. 

In concerning news, preeclampsia in pregnancy seems to be associated with a measurable risk of cardiovascular disease later in life. The effect is so pronounced, that left ventricular functional abnormalities can be seen on imaging family soon after delivery. 

Also concerning is new research indicating that breast cancer risk may be increased in those with hyperthyroidism. 

Finally, in the news-that-sounds-like-science-fiction department, the first uterus transplant in America has been performed. The recipient is 26 years old. She will have to wait year before attempting In vitro fertilization. If she succeeds, she will be permitted to keep her uterus for one of two children and then it will be removed. 

Food Friday: Gastrointestinal Health, Bloating, IBS and FODMAPS

FODMAPS is the newest of the dietary buzzwords in the blogosphere today. If you struggle with bloating or irritable bowel symptoms, learning about FODMAPS may help.

FODMAPS stands for fermentable oligosaccharides disaccharides monosaccharides and polyols.

FODMAPS include:

Fructose – fruits honey high fructose corn syrup, Etc.

Lactose–regular dairy products

Fructans-wheat garlic onion etc.

Galactan-Legumes such as beans, lentils, and soybeans etc.

Polyols-sweeteners like mannitol, sorbitol, and xylitol; stone fruits such as avocado, cherries, apricots etc.

You will notice that a lot of the foods on this list appear to be what we normally consider to be healthy. However if eaten in excess or by those who are sensitive to this phenomenon, they can produce undesirable symptoms such as excessive gas, bloating, diarrhea, and constipation. Such a situation is uncomfortable in and of itself but may also produce a systemic increase in inflammation.

According to the Stanford FODMAPS protocol, FODMAPS eaten in excess cause problems because they pull water into the intestinal tract, may not be digested or absorbed well and therefore could be fermented by the bacteria which reside in the intestinal tract. Fermentation produces gas and other by products which irritate the lining of the gut. This can produce increased intestinal permeability, also known as leaky gut syndrome. This produces the symptoms of bloating, pain, excess gas, and inflammation.

This sort of thing can happen to anyone who eats these ingredients to excess. However, in those for whom this occurs easily and chronically, and for whom other disease is ruled out, it is called irritable bowel syndrome or IBS for short.

Click below for the Stanford FODMAPS protocol diet handout which will will elaborate on these concepts and give you a handy chart for foods to use and foods to avoid. 

Stanford FODMAPS protocol

Bear in mind that water and fiber are part of this equation. Either too much fiber or too little fiber can aggravate symptoms. You simply have to experiment to find your unique sweet spot. I think a good place to start is a small bowl of soft (not sticky) hot oat bran cereal every day. I have taken a page from the Giada DiLaurentis playbook and take my oatmeal with a little olive oil and kosher salt. This is pleasant in a popcorn kind of way and avoids the sugars that make symptoms worse.

On the other side, drinking plenty of water can fix a multitude of ills. Drinking water all through the day aids digestion, helping to avoid fermentation in the first place. It also flushes out any irritating by products of unwise dietary choices sooner rather than later. It resolves constipation and rehydrates after diarrhea. 

If you are really struggling with symptoms of bloating, abdominal pain, excess gas, diarrhea and constipation, consult your doctor. Discuss the advisability of a low FODMAP diet for you. Remember that this is cutting edge thinking, and pertains specifically to FODMAP induced symptoms. Your doctor may discern other patterns in your clinical presentation that prompt him or her to check lab studies or imaging which they believe may be pertinent to your condition. If in the end, they think this would be helpful, try it with concerted effort for about 6 weeks. After that, you may find you can “ add back" desired items one by one, in small quantity. If your intestinal tract calms down and heals well, things that irritated you before may no longer do so. 

Wellness Wednesday: Hair Care

Hair care is a case of less being more. I am of the opinion that if something is healthy, then it is beautiful. I believe this is true for hair, but also for skin and bodies in general. Here are some tips from the American Academy of Dermatologists on evidence based hair care. 

The basics: 

Oily hair and scalp require more frequent shampoo washes, perhaps even daily. Older or chemically treated hair may tolerate it less. To get the best of both worlds, massage shampoo into the scalp only. Do not scrub shampoo into your hair; let it run through the hair from the scalp. Washing too infrequently may foster the development of dandruff. 

Use conditioner after each shampoo, even is hair is oily. Concentrate it on the ends or dry parts the hair. If hair is very dry, it may need additional treatments. 

Dry hair by a loose towel wrap or air drying. Do not rub the hair with a towel. Blow drying, while popular, adds to damage. Wet hair is not unattractive. It can even be seen on the runway as a “look”. 

Sports: 

Restrain your hair without tension. Use bands covered with fabric to avoid damaging the hair. 

Wear a cap for routine swimming in pools. Rinse hair thoroughly after swimming in chlorinated or salt water. Wash with a swimmer’s shampoo and deep condition as well. 

Wear at hat to cover your hair. Your scalp with thank you. Wear a brim and your face will thank you. 

Styling: 

Go for a natural style, with a minimum of handling and products.

Keep brushing to a minimum. To minimize damage, straight hair should be brushed or combed when dry, and curly hair should be combed or brushed when wet, using conditioner to relax the curls. 

Irons should be used only on low or moderate heat, and no more than every other day. 

Minimize the use of braids, cornrows, ponytails and hair extensions, which can produce tension. Tension leads to breakage and even permanent hair loss. 

Avoid long lasting hold products, which can predispose the hair to breakage. 

Color, perm or relax as infrequently as possible. Have only one such service at a time. Choose professionals to accomplish these potentially damaging services. 

What if your hair needs a doctor?: 

If you have overall hair thinning or patchy hair loss, a visit to the Dermatologist may be in order. Treatments are available. Hair loss can be due to illness, childbirth, stress, high fevers, surgery, excess weight loss, or even stopping birth control pills. 

The best fashion is a good body.

The best makeup is healthy skin.

Likewise the best hair is hair in good condition. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Pope Francis has done something unprecedented. On Thursday the pontiff has suggested that women threatened with the Zika Virus may use contraception. This historic and, dare I say inspired move has given me great hope. The Roman Catholic church has had a longstanding ban on contraception. However, the Zika virus scourge traveling though south and central America, with its devastating effects on the unborn, has caused him to announce this exception. Pope Francis has made it clear that the exemption is “ rare and specific”. This announcement is likely to have a profound and widespread impact particularly on poor Latin American countries where the dictates of the church are absolute and where Zika virus is the most prevalent.

It is becoming better and better established that Zika, virus infection, especially early in pregnancy, is associated with the development of microcephaly. Microcephaly refers to small head, but it also entails a small dysfunctional brain. Researchers are now becoming concerned that normal appearing, non- microcephalic babies of mothers who had Zika during their pregnancies may have more cognitive and mental heath problems as they age. The potential social effects of this are enormous. 

Links between Zika infection and post infection paralysis, aka Guillaine Barre, are becoming stronger. Of course this will potentially affect men as well as women. The exact incidence of Guillane Barre after Zika infection is as yet, unknown. 

In other news, new research indicated that babies should get vitamin D supplementation whether or not they are breastfeeding and are eating solid foods. Breastfed children need 400 IU Vitamin D daily, even if they are also receiving formula. 

ACOG (American College of Obstetricians and Gynecologists) continues to push for contraception as a quality measure. This means it is a feature of medical care and insurance coverage that is routinely assessed. The ACA ( Affordable Care Act) requires all insurance plans to cover all FDA approved contraception, but this has not yet been fully implemented. 

For about 25 years “steroids” have been used in mothers under 34 weeks to accelerate the lung maturity of their growing unborn baby. This is done if an early delivery is suspected to occur. However new research in the New England Journal of Medicine indicates there may be benefit to giving steroids through 36 weeks. 

The CDC just released a report indicating that 1/3 of adults are getting insufficient sleep. Less than 7 hours of sleep is associated with increased chance of diabetes, heart disease, stroke and all- cause mortality and “ frequent mental distress”. 

So to prevent these things, I should go to sleep soon. However, I will leave you with this: My patients often bring me things from far flung places since they know I do not get out much. Tomorrow, when I sit down at my desk, I will see one gift that is more special now than it was before: a souvenir photo of Pope Francis and a miniature rosary from Rome, where one of my Catholic patients heard him speak. To this Jewish girl, Pope Francis is a hero, a real “mensch ". 

Food Friday: Protein for Healing

Most of you have been following the saga of my son’s recovery from his fractured femur. He is coming along nicely and that is due in part to his fantastic physical therapy support. They have done physical work, cognitive, and have even talked about the nutritional end of things. In particular, they have emphasized the role of protein, along with Calcium and Vitamin D. 

Protein comes from meat, seafood, poultry, and certain combinations of legumes and grains. (Legumes are foods like peas, beans and lentils.) Under normal circumstances, people need about 0.36 grams per pound of body weight of protein. This is about 50 g per day for a women and 70 g per day for a man. However, during pregnancy, athletic training, and recovery from illness, even more is needed. 

Our son’s therapists have noted that his protein requirements have increased to nearly 100 grams per day as an injured young adult male weighing about 175 #, who is trying to rebuild a femur. This is about a 40 % increase. 

Protein is composed of a string of amnio acids. All animal food are complete proteins, in that the ratio and types of amnio acids present meet human dietary needs. Plant sources of protein need to be combined to fulfill this criteria. For more on this see THIS SECTION on the website. 

In practical terms,  I had to help Vale figure out how to meet this nutritional requirement at a time when his mobility was restricted and his time for cooking was nil. Additionally, we had to take into consideration that more protein intake requires excellent hydration, since metabolism of larger amounts of protein in a dehydrated state is hard on the kideys.  We had to make sure he consumed just the right amount, and not too much since metabolism of excessively high amounts of protein can also cause the bodies calcium to be depleted- not what we want. Finally, I had to take into consideration the following: that protein is best utilized when interspersed evenly throughout the day. 

Here is how we set him up. First I made a one page schedule of meals and activities. I posted it all over his house and set up a google doc for the friends and family who would be helping. Secondly, I made a menu. There would be some constants, and some variables. The constants would be as follows: 

• Morning:16 ounces of skim milk with a protein powder
• Midmorning would be a high protein, high fiber oat cereal, and hopefully a hardboiled egg.
• Lunch would be a can of salmon made like tuna fish salad, with olive oil mayonnaise, relish, and olives. He could also have whatever else he wanted.
• Mid afternoon would be another high protein snack like a mozzarella cheese stick
• Dinner would be a traditional cooked dinner with meat chicken or fish, and salad with veggies cooked by family or friends.
• Fruit could be eaten all through the day
• A hospital pitcher would be used to measure water intake which was to exceed three liters per day, titrating to nice clear appearing urine (sorry… i’m a doctor, not a food blogger. ) 
• I had him take a gummy prenatal vitamin and two tablets of Calcium Citrate with D. 
• The items are simple, edible, and met the criteria. Of importance, I created a routine schedule that would be the same every day to foster compliance. I created checklists in different convenient locations. In other words, I have tried to engineer his nutritional success.

So far so good, as he is already crutching around to class, grateful, and enjoying being back at school. 

Wellness Wednesday: Following up on Serious Injury: the Role of Physical Therapy

When you are injured badly, you are in pain and you are shaken up, sometimes literally. You lose perspective. You may have temporary alteration of your memory mood and judgment. You need guidance on how to recover, and your instincts aren’t a good guide. That is why in good medical care environments, you have a team of people, from family and friends, to doctors and nurses who help you get better.

In the very best of medical care environments, you have those, plus the group of therapists: physical therapists, cognitive therapists, occupational therapists, and family therapists. These are the people who take you from healing and back into high functioning. We underutilize them. I write today to make you aware of all this by sharing what our experience has been thus far with my son Vale and his physical therapy.

As those of you who have been reading this blog know, our son Vale had a serious ski injury on Saturday February 6th. He sustained a comminuted (broken to pieces) fractured femur, a mild concussion, a broken rib and a mild pulmonary contusion. That evening he had a long emergency surgery requiring a great deal of internal fixation. The next day he was discharged home as per is customary. He required pain meds, and still had memory deficits, though he was basically himself. Appetite was slow to come and he was quite discouraged. 

Much to our surprise, they requested his first physical therapy visit the very next day, or post operative day two, Monday the 8th. I couldn’t imagine what they would be doing with him at that early stage, despite my familiarity with surgical recovery in general.

When we arrived, they informed us they had spoken with his surgeon and were appraised of his hospital course. They proceeded to perform consultation much like we doctors do, beginning with a history and then proceeding with a physical exam. However, this exam was precise, detailed and recorded, covering all neurological aspects, range of motion, and strength. 

I expected all this. What I didn’t expect was the best part. The facility was beautiful and open, and all the staff were fit and upbeat. There was even a freshly shampooed dog randomly going from area to area to cheer people up. The whole encounter brightened our son’s spirits, and renewed his hope. They told him all about the typical post op course with injuries like this. This showed him a light at the end of the tunnel. It gave him some tasks to do and milestones for progress, thereby dispelling feelings of powerlessness.

There were so many more things to do to help his recovery than we had anticipated. I often recommend that patients enter physical therapy. Not uncommonly they ask me, “ What could they possibly do that would help ? “ The answer is, go and see. Since Vale has entered PT, he has gotten serial cognitive testing, passive range of motion exercises, strength exercises, electrical stimulation and deep oil massage of the muscles near the fracture. Soon, when the incision is better healed, he will have water therapy. 

His sessions are not necessarily comfortable. Nonetheless he looks forward to them. He can see his own progress because it is actually measured. Thus he is consistently encouraged. They tell me this is typical. Today is post op day ten and it was his first day back to his University classes. He felt himself, and did not notice any problems in following the material or using his crutches. I credit his ongoing PT for his speedy recovery.

I encourage all of you to look into physical therapy if you have chronic pain, injury, or problems getting around. There are many other conditions which can benefit from physical therapy. Discuss this with your doctor at your next appointment to see if you might stand to benefit. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Zika virus again begins the headlines. It has now been well established that Zika virus can be sexually transmitted. The CDC ( Centers for Disease Control) has recommended that men returning from Zika affected countries take special precautions if their partners are pregnant or apt to become pregnant. They are advised to abstain or use protection through the duration of the entire pregnancy. The primary method of transmission is still believed to be through mosquitos, however, Zika has recently been isolated from both saliva and urine. 

Zika’s devastating effects on the unborn are similar to effects caused by the more well known viruses Rubella and Cytomegalovirus (CMV). Zika virus is associated with microcephaly (small underdeveloped brain and skull, with attendant developmental disabilities) and eye defects, and so are CMV and Rubella.  Researchers are turning attention back to these better understood viruses to get clues about how the ZIka virus functions. 

Additional recommendations from the CDC and ACOG ( American College of Obstetricians and Gynecologists) include testing all women living in or returning from ZIka infected countries. The US Olympic Committee has reiterated the CDC cautions, but has not issued any prohibitions against anyone going to or participating in the games. 

In the interesting and promising department, Columbia has recorded over 3000 cases of Zika infected pregnant women. To date, no cases of microcephaly have been reported there. The reasons for this are uncertain. Post Zika Guillaine Barre syndrome has been studied in Columbia as well. Guillaine Barre is a reaction to certain viral infections which produces a usually temporary paralysis. It can be life threatening since it can paralyze the respiratory muscles. Columbian officials have noticed a 66 % increase in Guillaine Barre reactions compared to baseline. 

President Obama has asked Congress for 1.8 billion dollars in funding to combat the Zika Virus. As of Friday, there are 79 cases of Zika in the United States. 

Influenza is another viral danger which continues to deserve our attention. The good news there is that we have an effective vaccine. Flu vaccine is very important to pregnant women, since pregnant women are much more vulnerable to serious disease if they contract the flu. New research indicates flu vaccine in pregnancy is most effective if given in the first trimester. 

There are other situations which can cause serious birth defects. One is exceedingly common: alcohol. Last week the CDC made news by recommending that pregnant women abstain from all alcohol. They also advised health professionals to advise women to stop using it even if they are just trying to become pregnant or, more interestingly, are simply having unprotected sex. 

Frankly, these do not see like radical recommendations to me.  They certainly do not seem mysogynist or anti-women. However, that is how some women are reacting. The blogosphere has been ablaze with what is, in my opinion, inflammatory rhetoric, saying that the government is trying to "take over women’s bodies", and other such nonsense. I wonder what these commentators think of the draconian measures recommended by South American governments to keep pregnant women from getting Zika ? Authorities have advocated that women not get pregnant for two years, and if they already are, to cover themselves and stay inside. 

Here is an issue that may have a feminist component. Consider that only women must buy feminine hygiene products. They buy them in profusion, regularly, and all throughout their reproductive life. Some people believe that women should not have to pay sales tax on such products. President Obama is in favor of ending the so called “ tampon tax”. 

Viruses and alcohol can cause serious birth defects. While smoking does not, it is strongly associated with growth restriction, low fluid, abruption, and preterm birth. CDC data indicate 8.4 percent of pregnant women smoke. 

There us no doubt that our collective concern over the exotic and seemingly uncontrollable threat of Zika virus is justified. However this threat to pregnant women and others should be blended with renewed and commensurate concern for equally serious threats which we can address: smoking and alcohol. 

Food Friday: Food for Healing

As most of you know, we spent the better part of the week nursing our 22 year old son after his ski accident. He sustained a badly fractured femur requiring a long surgery which entailed significant blood loss. He also had a mild concussion, pulmonary contusion, and a broken rib. He is stable and improving. But his course has illustrated several important things about nourishing those who are recovering from illness or injury. I thought we might take a moment and discuss them here, especially since it has been on my mind. 

When people come home from the hospital, most of time, their IV is removed. They will come home adequately hydrated. However, that can quickly change, since their capability to hold down food and drink is often limited. Your job as caregiver is to help minimize nausea which may be interfering with hydration, and to provide appropriate enticing liquids for them to sip. If your “ patient” did not come home with anti-nausea medication, and needs it, do not hesitate to call their doctor. Most of the time this can be prescribed over the phone, but sometimes, nausea heralds a concern, and the patient will be asked to come in for an evaluation. 

Another way to minimize nausea and maximize intake is to avoid overuse of narcotic pain pills. The most common are lortab and percocet, aka hydrocodone and oxycodone. These are necessary with early post ops, but they can cause nausea and constipation. Ask your doctor how they should be used if you are not sure. 

Sick or injured people do not always know what they need. It is up to the caregiver to encourage them in the right direction. In this regard, many patients will not want to drink as much as they ought. So you have to be clever. 

Hydration of the unwell is best accomplished gradually and continually. This way they are more apt to tolerate it. It is also best accomplished by fluids which contain some sugar and some electrolyte (like IV fluid!) . 

For starters, let’s do water. Some who cannot drink water can drink soda water, aka plain club soda. Even more can drink this with a splash of fruit juice or a wedge of lemon or lime. Some do well with dilute fruit juice. Decaf instant iced tea works well. Oftentimes having it quite cold will help, but this is suboptimal if your patient is chilled. Some do better with frozen cubes of the aforementioned drinks. 

On the other hand, many patients prefer hot drinks. Herbal tea is the go-to here. You can make it more appealing by adding honey or agave, and a little lemon. Decaf coffee is not a bad choice, but lots of caffeinated coffee is dehydrating. 

Some patients prefer savory or salty drinks. This is an advantage since it will better expand their intravascular volume. Here broth is the best solution, unless they can take something like Bloody Mary mix, or salted tomato juice. The best of all is a brothy chicken soup, just like tradition teaches us. Nowadays organic broth mix is widely available commercially in chicken, beef, and vegetable flavors. 

You can also hydrate your patient with watermelon if they like it. Most fruits will help, and a smoothie of fruit, ice, water, juice, and even plain yogurt can be very agreeable, even to one who is sick. 

When patients are doing well enough to take solid food, there are a few key nutritional points to bear in mind. Healing from illness and injury takes more resources than ordinary life - lots more resources. A man needing 70 g of protein a day will come to need over a hundred. He will need more nutrients too, though he may not necessarily need more calories. Therefore, everything a recovering person eats should be nutrient rich. Leave the top ramen, Pepsi, and white bread for another day - like NEVER. Present choices such as chicken, salmon and red meat, but prepare them in a way that is easy to eat. For the meat and chicken, cook it well, ground or in small pieces. For salmon, consider getting canned salmon and making it up like tuna fish salad with mayonnaise, relish and olives. But beware, if your patients are picking at their food or dairy containing drinks, the dishes cannot stay out too long, or they will spoil. The last thing you need is a recovering patient with food poisoning. With the same goal in mind, don’t put too much on a serving plate. Start with a small serving and get seconds if you need to. And, for best results, offer small quantities of food quite often. 

Caregiving is hard work. With a little forethought and a few tricks of the trade, your well hydrated, well nourished patient will have the best chance at an optimal recovery. 

Wellness Wednesday: Recovering from a Serious Injury

This last weekend my son Vale had a major skiing accident. He broke his femur, had a pulmonary contusion, a broken rib, and a mild concussion.  He had to have emergency surgery. We quickly travelled to attend him, and since then we have been making arrangements for his recovery care. 

Though he will be off school for a time he will stay at college and we will return home. Therefore, I have been working with a team of friends and relatives to accomplish his care. This will, of course, consist of a series of wound checks, physical therapy appointments and post op appointments. It will also consist of a calendar of people doing shopping, making meals and doing laundry. When he returns to school in two or three weeks, it will mean getting driven to campus and wheelchairing around. It will mean seeing how it goes.

It has also meant getting correspondence passed back and forth between the doctors, physical therapists and the university faculty. To coordinate all this, I have had to send no end of contact information. I have had to create shared calendars and documents in the cloud, and distribute them to all his friends and family who have stepped forward to help.

Vale has had to deal with pain, disappointment and disruption. It is taking all of us together to shore him up during this trying time. It is taking everything from favorite foods to ice packs, but it is worth it. Even though it has been only four days, we can see distinct and major improvements every day.

 I am in awe of his caregivers. The surgeon and anesthesiologist spent significant time on the phone with me both before and after the case. It was easy to tell they were top notch, but they were also genuinely invested in my son, and empathized with me having to be so far away during the surgery.  I will be forever grateful for the time and energy they spent. I later leaned that that they spent this kind of energy during the entire weekend, since Vale's hip fracture was one of five such cases. The winds in the mountains had been high, and had swept the ski slopes to a hard shiny gloss. It took its toll.

Vale's physical therapist was a ray of hope. She came from both academic and clinical practice backgrounds, and was deeply invested in her field. She was immediately able to put us at ease and to identify all kinds of helpful strategies. Vale felt 100 percent better after one appointment, from a combination of the physical treatments, but also the encouragement of knowing his prognosis.

All this touched me as a mother and as a physician. It sheds renewed light on what I do.

Food Friday: Setting the Table

When I was growing up, my parents had a sit down dinner since that’s how they had been raised. My mother had nice china and table linens, but we rarely saw them since she used them only for special occasions. Instead we had everyday plates and cups, often plastic. The margarine was set out in its own tub. (Remember that this was the 70s, when margarine was thought to be healthier than butter. )

My father had business contacts from all over the world and they would come to visit us. In one case, a German guest showed me a photo of his daughter. She was sitting at their table. I would never have thought to take such a picture of a person at a table since our table was nothing special to look at. But their table was beautiful even though they had already finished their meal. Each plate was white glass, and crowded round each plate were clear glasses of various deep jewel tone colors and shapes, some cylindrical and thin, some globular, and yet others like cones. A light went on in my mind, and ever since then I started to see table settings differently. I began to notice the beautiful dishes and table settings in my friends' houses. 

Fast forward to college, when freshman year and dorm food banished all thoughts of table settings. Then came second year, when I moved into a campus co-op named Synergy. The house was organic and vegetarian way back in 1981. We had a big hippie kitchen in a huge hippie house right on campus. Since we were a co-op we cooked all our own food in a big kitchen in rotating teams. There would be no chefs or housekeepers for us.

The ethic of this house also required a communal sit down dinner as a deliberate act of culture. However the table settings in Synergy were like none I had ever seen. Since we were all about conservation, with reuse happening before recycling, our cups, plates, and serving utensils were a motley collection of all that had come through the kitchen. We drank from a selection of old jars, such as those from sauces or jam. Our plates were all completely mismatched. Bowls were just old plastic containers from things like bulk peanut butter. Most wonderfully, the center of the table held as many as a dozen great steaming loaves of bread: home made whole wheat bread. It was the signature of the house. We would cut slices or tear chunks, and slather it with butter, jam, hummus, or whatever mystery stew the cooks happened to create. Kids from other dorms would come by just for the bread. There is a reason for the expression, “breaking of bread”. It seems to bring people together.

Greg and I bonded while making this bread since it literally took all four of our hands to knead it. We had met while cleaning the kitchen at Synergy. We took it upon ourselves to clean this hippie kitchen, since he and I seemed to be the only ones who noticed how dirty it was. We met over a filthy sink, and there was something about me turning on the garbage disposal at the wrong time. No one was hurt, but he did have to take a shower after the incident. 

Greg sometimes ate a couple of houses down the row where there was a clean kitchen, a chef, and of course, meat. His sister lived there and she had made friends with the chef. I think they had an arrangement since not uncommonly Greg would go there and use their massive Hobart mixer which would hold a 16 batch of his mother’s chocolate chip cookies. As you could smell the bread of Synergy wafting down the row, you could smell the chocolate chip cookies coming from the other direction. From then on, our collective memory would be infused with the aroma of bread and cookies. 

After graduation, we married and lived in a little farmhouse far away from University life. It was a bit run down, so we repaired and decorated it. Happily, among our wedding gifts were many table linens and pretty dishes, so it followed that the table got set very nicely. The cutting boards were set with bread and platters filled with cookies. When our daughter and the boys came along, they helped with all of this. Ever since then we have set the table and had a sit down dinner. 

Today I believe in the power of the sit down dinner more than ever, to promote communication, coordination and peace in the family. And for me, all my best dishware is out all the time. I think it sets a festive mood and makes people feel valued.

What would I do if I were just starting out, of modest means, and wanted to bring some inspiration to meals ? There are two possibilities. First, I could go minimalist and get all clear glass dinnerware from the dollar store. Everything would match, and design interest would come from the food itself, the table, or the table linens.

A more colorful and more ecological choice would be to thrift. I would have a fantastic set of non matching antique plates. I would shoot for a reasonably common size, and perhaps a common theme, say a color scheme or a design element like birds. A physician friend of mine did it complete with mismatched silverware, and mismatched but coordinating goblets. It was nothing short of magnificent. It was all thrifted, very inexpensive, and truly delightful.

And that is the point: to delight. Making the food and setting the table is a gift to others, and a joy for you.