Antibiotics

Just Call in My Antibiotics, Doc! I’m sick, I tell you!

Sometimes, patients and I disagree on their treatment. I feel they have a normal, regular viral illness, and they are convinced they have the plague and will die a slow and miserable death in the next hour if I don’t give them that z-pak the last doctor gave them. 

First, I’ll point out that the U.S. has had 11 cases of human plague so far in 2015 (none of which were in Hawaii) and in the previous 10 years, the number of annual cases ranged from 1-17. So, it is fortunately very unlikely you have the plague.  And even less likely that I will be a published author as a result of diagnosing you as such.  

Now, the more pressing issue: why don’t we just give you those antibiotics, you know, just in case?

There are actually several reasons doctors don’t just hand out antibiotics (well, most of us) and it’s not because we’re mean, wielding power over you or just want your copay. We are trying to protect you and your community from the harms that come from the overuse and misuse of antibiotics. 

To understand, it is important to appreciate the difference between bacteria and viruses. Bacteria are microscopic organisms that live in a number of environments, including the human body.  A virus is often considered to be a nonliving infectious agent as it only replicates inside the cells of another living being.  Antibiotics kill bacteria; antibiotics do not affect viruses.  So, those antibiotics will only help if it is a truly bacterial infection. 

Most viral upper respiratory infections will last approximately 7-10 days (not the 2-3 days that everyone thinks), although some people will have symptoms that linger longer or a post viral cough that can last for 6 annoying weeks. Remember that time you got those wonderful antibiotics, that must have cured you?  Did you happen to get those on day #4 or 5?  In other words, maybe about the time you would have started feeling better even without those antibiotics?  Common infections that are usually viral include: colds, flu, bronchitis, pharyngitis (sore throat, with the exception of strep), ear infections, sinusitis, gastroenteritis (stomach “flu”).  So the first reason, we don’t give you antibiotics is, they don’t help. 

 I know your next question: what could be the harm in a few pills for 5-10 days, just so I can feel better, doc?  Actually, there are several potential harms, ranging from self, to community, to worldwide that can result from incorrect use of antibiotics. 

Additional infections: Antibiotics kill all bacteria, not just the ones causing illness (or not causing illness in the case of a virus).  We have bacteria on and in us all the time, helping us maintain our normal life functions, like digestion.  When we take antibiotics, we kill those good bacteria as well as the harmful ones.  That can lead to other issues – including opportunistic infections, ranging from inconvenient like a vaginal yeast infection, to life threatening like C. difficile colitis.  C. difficile is an extremely nasty diarrheal illness that can lead to severe illness, require hospitalization, and in severe cases surgical removal of part of the intestine or a newer treatment option, fecal transplantation. 

Resistance: Bacteria are smart little buggers.  The weakest bacteria will die first, and the stronger ones will not only survive, they will take note of the antibiotic you took and find a way to get around it for next time.  But not just next time for you – they share that information.  So, now we have certain bacteria that are no longer sensitive to antibiotics that used to be lethal to them in the past.  MRSA, methicillin-resistant staph aureus, or just staph, is perhaps the most well-known of these sneaky bacteria.  A 2013 CDC report indicated that 2 million people get a serious infection with a resistant bacterial annually.  As more of these bacteria gain this knowledge, our development of antibiotics will be unable to keep up, and we will be thrust back in medical time to when we had no way to fight bacterial infections at all.

Side effects: Everything has a potential side effect.  Taking a medication and not taking a medication – each has its own risks and its own benefits.  There are risks for interaction with your current medications and disease process, and it’s important to have the opportunity to have these discussions with your provider. 

 

All of these thoughts go through my head when I’m trying to help you feel better. I’m not keeping a secret weapon to magically make you feel better in my pocket just to make you suffer longer.  I’m assessing you, my patient, and doing my best to make sure I’m treating your actual illness as it presents to me right now.  I’m also trying to protect you, your family and your community from future problems that can arise from the use of medications I may give you, including antibiotics.

Grief

Grief is emotional suffering or bereavement at the death of a loved one. There is no right or wrong way to grieve. There is no timetable for grieving. It is a process we navigate in our own way, at our own pace. Yes, it’s alright to cry. In fact, crying seems to release some of the heaviness of sorrow.

Grieving is an intensely personal emotion that may be colored by guilt, regret, anger, sadness. Some people withdraw, become helpless, disengage from the business of living, while others cannot sit still, and express their grief in activity.

No matter the presentation, we need patience, courage and strength, as we go through the stages of the grieving process. Elisabeth Kubler-Ross outlines 5 stages in the grieving process:

  • Denial, the initial response, is protective and serves to keep us from being overwhelmed by the loss. This stage may last a few minutes, hours, or days.
  • Anger, a tool we use to make sense of, and cope with, the reality of the loss. We may feel anger at ourselves, at God, at the deceased, at life in general for the injustice of the loss, especially if it is unexpected, as in the case of the death of one’s child.
  • Bargaining, in which we promise to do something in exchange for having the lost person returned to us: “If I devote my life to helping others, can I wake up to find this was all a bad dream?”
  • Depression, often the most painful stage, comes when we realize the finality of the loss, that there is no turning back.
  • Acceptance comes from coming to terms with the fact that our loved one has gone, and beginning to reorganize our lives around this new reality.

Others have delineated 7 stages of grief. These are shock, anger, guilt, anxiety, physical, behavioral and cognitive symptoms, suffering, and recovery.

  • Shock or numbness, the initial reaction, protects us from being overwhelmed by the loss.
  • Anger, a normal part of grieving, as explained above.
  • Guilt is a common reaction to failing to do something before the loss or perhaps doing negative things before the loss; for example, not saying “I love you,” being unkind, not apologizing for causing hurt, or any action not taken that we perceive may have prevented the loss;  
  • Anxiety, either mild insecurity or panic attacks, about our ability to take care of ourselves, and about the well-being of other loved ones;
  • Physical, behavioral and cognitive symptoms occur. We may become fatigued, may experience loss of motivation, changes in eating and sleeping patterns, may no longer enjoy activities that used to be pleasurable, may become confused, preoccupied, be unable to concentrate;
  • Suffering, often the most painful stage, is the long period of grief during which we come to terms with the loss. Suffering includes sadness (the most common aspect of grief), and may be experienced as emptiness and despair. It is expected that the physical and emotional symptoms will stabilize and diminish over time as we move through the grieving process. If they do not, professional help is recommended.
  • Recovery is the goal of grieving. True, we continue to experience feelings of loss, and the occasional wave of sorrow that hits us like a bolt out of the blue. However, as we reorganize our lives, we are better able to accept the loss, integrate it as one important aspect of life. As we do, we are enabled to resume living.

The loss of a loved one is a painful experience. It requires us to be gentle with ourselves, to accept support, and to go on sharing our lives and memories of our deceased loved ones with family and friends.

Don’t be afraid to seek support during this difficult time, whether this is through your family, friends, hospice, or a licensed therapist. We can help you through this; you don’t have to suffer alone.

 

Written by Pansy Lindo-Moulds, LMHC

Adult Pneumonia Vaccination

What is Pneumonia?

Pneumonia is an acute infection of the lungs, most often caused by a virus or bacteria.

As it turns out, breathing is not optional. And fortunately, our lungs are awesome. We are constantly bombarded with microbes that manage to get into our lungs via our upper respiratory tract. But our body’s own defense mechanisms usually fight them off and maintain the sterile environment needed in the lungs so that we can preserve air exchange. Sometimes we are not able to fight off the infection, because the microbe is too strong, because our own body has a weakened defense, because our lungs are compromised, or because the amount of exposure was particularly impressive.

Of the 4 million cases of pneumonia annually in the U.S., the most common bacterial agent is Streptococcus pneumoniae. Symptoms usually start with sudden fever, cough, shortness of breath and possibly wheezing or pain in the side or chest. Some people will also have their shortness of breath progress to a faster breathing rate and lower oxygen level. While many people have mild disease and will recover without damage to their lung function, some patients will have complications. The infection can take over an area of the lung, leading to a big ol’ ball of pus where the lung should be, or travel to the heart, brain or joints. In severe illness where the infection from the lung gets into the blood stream, the mortality rate is over 25%.

 

How can you protect yourself?

Once again, you could live in a bubble. But that could be a general solution for just about all contagious problems. Keep it in mind, as I may forget to mention it in future posts.

As always, wash your hands, don’t put things in your mouth, don’t plant a big kiss on the coughing guy on the subway (unless it is John Travolta and this may be your only chance; some things are worth risking) – common sense, people!

 

A more realistic approach is vaccination. We used to recommend a single dose of pneumonia vaccine for adults aged 65 and older. This recommendation changed in 2014, and in order to improve immunity we recommend that adults get two different pneumonia vaccines: PCV13 (pneumococcal conjugate vaccine – Prevnar ®) and PPSV23 (pneumococcal polysaccharide vaccine – Pneumovax ®). These vaccines are given one year apart. If you haven’t started the series yet, start with the PCV13, followed by the PPSV23. But if you already received the previously recommended single dose of the PPSV23 (the recommendation before 2014), we can just update you with the PCV13 one year later.

Of course there are others besides those over age 65 who are at risk for pneumonia and its complications. People with medical conditions that put them at risk may need to be vaccinated sooner than age 65. Adults with the following medical conditions should speak with their provider regarding vaccination as they are at risk due to immune suppression: cancers, any immunosuppressive medical treatments (steroids, chemotherapy), organ transplant recipients, kidney failure/disease, HIV/AIDS, loss of spleen, sickle cell, cochlear implant, cerebrospinal leaks, immunodeficiencies. You’ll need additional an additional dose of PPSV23 when you reach age 65, as long as it has been 5 years since your previous PPSV23. You may need an extra dose of PPSV23 before age 65 but after 5 years anyway, depending on your medical condition and level of immune suppression, so make sure you and your provider review the immunization schedule. It’s can be a bit complicated, so consider politely asking them to bring out their copy of the immunization schedule to show you the footnotes (they are tiny and detailed and definitely worth reviewing to protect yourself) – it is available online if your provider doesn’t have one accessible in the office (http://www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html).

Adults with the following medical conditions should consider vaccination with PPSV23 before age 65: heart disease, asthma, COPD/emphysema, diabetes, alcoholism, cirrhosis, smoking.

 

I’m always disappointed with the number of people who have declined these vaccines in the past, thinking doctors are trying to trick them into something. No trickery here – intact safety data and lives saved. I’m just trying to keep you out of the hospital. I’d much rather spend my time being healthy than being hooked up to the IVs on the medical floor at the hospital. What about you?

Influenza

“The flu” is an acute respiratory infection actually caused by the influenza virus. It is not the same as the common cold. While many of us are familiar with the symptoms of the flu, there are still too many people who confuse an actual influenza with an unfortunate viral cold.

People with the flu usually have a sudden onset of fever, headache, muscle aches and general fatigue and may also have the usual cold symptoms of cough, sore throat and runny nose. Gastrointestinal symptoms (sometimes called “stomach flu”) are actually not usually part of influenza symptoms in adults, but are more common in children.

 

How do you get influenza?

You can catch the flu from exposure to an infected person and their respiratory secretions – particles emitted when someone coughs, sneezes, etc. Ew. You can actually shed the virus for 24-48 hours before you feel sick, so if you know you’ve been exposed you’re really doing us all a kindness by being even more cautious than usual with your infectious respiratory secretions. You can actually have 1-4 days between exposure and symptoms (called the incubation period), so you can’t just blame the lady coughing next to you at church, although we’d all like to. And even after you feel better, you can still shed the virus for a total of 7-10 days in otherwise healthy adults.

 

What are the complications of influenza?

Pneumonia – You can actually have an influenza pneumonia or a secondary bacterial pneumonia infection while your immune system was distracted fighting the flu itself. The bacterial infection is often the cause of severe illness and/or death in people over age 65.  

Myositis – Inflammation of the muscles, sometimes severe enough to lead to breakdown of the muscles can be a severe but rare complication of influenza. This can lead to muscle proteins in the urine and kidney failure in severe cases.

Central nervous system involvement – Although it is unclear exactly how, the influenza virus can also attack the brain and surrounding tissues. This can lead to several severe brain pathologies, such as meningitis (inflammation of the tissue surrounding the brain), encephalitis (inflammation of the brain), or transverse myelitis (inflammation of the spinal cord). The actual influenza infection has also been associated with Guillain-Barre syndrome, in which the peripheral nervous system shuts down, likely due to the body’s own immune system getting confused and attacking it. In Guillain-Barre syndrome, people first notice weakness of their legs, which then spreads upward, hopefully stopping before it reaches muscles that control breathing. Guillain-Barre syndrome is always listed as a potential consequence of the flu vaccine, but it can be a result of getting the natural virus as well.

Cardiac – Several studies have linked influenza infection and hospitalization for poor blood flow to the heart and heart attack.  

Death – In the U.S, there’s around (an average) of 30,000 deaths annually, with influenza as a contributing factor.

 

High risk persons

People who have medical conditions that affect their lungs or immune systems put them at increased risk for the flu: diabetes, asthma, pregnancy, HIV/AIDS, cancer. In addition, children less than 5 years old, and adults greater than 65 years old are also at greater risk.

 

How can you prevent influenza?

Clearly, getting the flu sucks. Well, getting a cold sucks; getting the flu really sucks. There are several ways to prevent catching the flu.

Move to Alaska to live in a bubble – It’s happened before (http://www.amazon.com/Northern-Exposure-The-Complete-Series/dp/B000V6LSO0).

Good hygiene – Wash your hands often and definitely before you touch your face, eyes, mouth or nose. You can’t make others cover their mouths and nose when they cough or sneeze (so gross!), but you can make sure you do cover your own. Always cough or sneeze into your elbow so you don’t get germs on your hands and mush them around all over the place.

Encourage sick family/friends to stay home – Sick contacts in public spread germs. We all know you’re tough; I’ll even write it on a prescription pad for you to show all your friends. Even if you’re the toughest one around, please stay home when you are sick so your whole office doesn’t get sick too. Your boss won’t be happy about you missing some work days, but will be even less happy about the entire office being out for a week because you sneezed.

Clean surfaces – Clean areas that are highly trafficked by dirty hands, such as doorknobs, light switches, keyboards, phones, desks, water faucet handles. Don’t let germs move in without paying rent.

Vaccine – The flu vaccine reduces both your risk of catching the flu and having complications if you do catch the flu. Studies show a reduction in hospitalizations of infants when pregnant women are given the vaccine (92% reduction!), of diabetics given the vaccine (79% reduction!), and of patients with chronic lung disease given the vaccine (52% reduction).

The vaccine causes your body to develop its own antibody response in the event you are exposed to the flu in the future. Because your body is mounting an immune response and generating antibodies, you can have those unpleasant side effects of mild fever, body aches or fatigue. Fortunately, it is not the flu itself and is much less severe than the actual flu. Think you don’t like feeling like that? Try getting an influenza infection. Most of the vaccines are injected via needle, but there is even a nasal spray available for you needle-phobic people out there (ages 2-50 only). The nasal spray does contain a live virus, and is not appropriate for people with poor immune systems or people who will be around those with poor immune systems. The standard flu vaccine is manufactured via virus grown in eggs, which can be a problem for people with an allergy to eggs. There is an egg-free vaccine approved for adults, so if you have an egg allergy, discuss this option with your provider.

 

Flu season is here. You have tools to keep yourself and those around you healthy. Set up an appointment with your provider to get your vaccine today!

Stress

I believe that the most important word in the phrase “mental health” is “health.” There was a time when people felt a stigma associated with seeing a psychologist, psychiatrist, or counselor. Admittedly, until recent years, mental health was not always portrayed in a positive light in the media or in our communities. If someone had not experienced positive interactions with a mental health provider either directly or through family members, then there may have been a reluctance to try the unknown.

The concept of health is really a mind and body comprehensive approach. The reality is that our mind is a part of our body, and impacts our physical and emotional well being. Think about the concept of stress. Let’s take a tangible object like a paper towel. Stretch it out and keep pulling. The stress from pulling it, even gently, will begin to tear the paper towel. Add something else from the environment such as water to the paper towel and it will fall apart more quickly. Add something heavy on top of it, and we are certain to see it fall apart.

Now, let’s take the physical body. Add some stress. Pull at it with the loss of a loved one, sudden illness or injury, change of life, coping with chronic illness, work-related stress, financial stress, relationship stress, time management of life with many responsibilities, etc….. During those times, we often hear of people experiencing sore shoulders, headaches, stomach aches and digestive problems, weight gain or loss, increased blood pressure, insomnia, anxiety, and depression. What came first? Truthfully, it could be either. Sometimes physical problems contribute to emotional distress and sometimes the emotional distress can lead to physical problems.

Certainly, there are a variety of avenues of support for well-being, to include self-help books, community support groups, exercise, healthy diet, and social activities to name a few.

Why see a mental health professional? If you are struggling with managing symptoms and overall health, the question really is, why not? Regardless of which came first, quality, competent mental health treatment may alleviate or reduce both psychological and physical symptoms. A mental health provider can provide skills, support, and collaboration with your medical or psychiatric health care provider to provide a comprehensive approach to your overall health and well-being.

 

Written by Michelle Zalenski, PsyD

Sun Protection

 

Beach attire, indeed!

Beach attire, indeed!

The sun is wonderful – it promotes life, improves our mood and allows us to make vitamin D. But this comes at a cost. Sunlight contains ultraviolet radiation, which results in damage to the skin and DNA leading to burns, color changes and cancer.

There are two types of UV radiation from the sun – UVA and UVB. Nearly 95% of the radiation reaching the earth is UVA (UVA1 + UVA2), which causes increased pigmentation (sun spots) and aging (wrinkles) in skin as well as may be involved in the processes leading to skin cancers. UVB radiation, while less of the overall radiation, has been found to be responsible for burning, inflammation and cancers of the skin.

Protecting your skin from sun now can prevent cancerous changes in the future. In addition, you can keep your skin smoother and reduce sun-related dark spots by being diligent with the protection now.

Fortunately, you don’t have to cover up every bit of skin to protect it from the sun.

Fortunately, you don’t have to cover up every bit of skin to protect it from the sun.

Sunblock

SPF (Sun Protection Factor) – This measures the sunblock’s effectiveness in protection against UVB only when compared to not wearing sunblock. Theoretically, the SPF is a measure of how much longer you can stay in the sun before burning. But, people in real life don’t apply the sunblock in the same way it was applied in the actual studies – real people actually use approximately 1/3 the amount expected. Also, real people sweat, and go in the ocean / pool or wipe the water off their face taking some of the sunblock with it. And, remember the SPF only measures the protection against UVB.

So, while the SPF does matter, it also is important to pick out the right sunblock and apply it correctly. An SPF of 15 will protect against 93% of UVB radiation, SPF of 30 against 97%, SPF of 50 against 98%. So that SPF of 100, which sticks to your skin for days is not really getting you any more protection than the SPF 50, and providing much more irritation to your skin than likely necessary.

Spectrum – This tells whether the sunblock protects against UVA and/or UVB radiation. Remember that the SPF already tells you that there is UVB protection. Now, you need to make sure there is UVA protection as well. Only three ingredients will protect against UVA1: avobenzone, zinc oxide, titanium dioxide. Avobenzo will come combined with other ingredients to ensure entire UV spectrum protection, as it does not provide full coverage alone. Zinc and titanium are mineral compounds that reflect a wide range of UV wavelengths and are considered broad spectrum independently, however they are often combined with other ingredients, both for efficacy and cosmetic reasons (remember the lifeguards with white noses?). But if you tend to sensitive skin, limiting the chemical components can be helpful and a sunblock containing just zinc oxide or titanium dioxide would be a good choice for broad spectrum coverage with a single ingredient.

Form – If you wear it, it will work. It doesn’t work sitting in your beach bag. Spray, cream, lotion, stick, whatever. Put it on.

Application – Apply 20 minutes prior to the sun exposure and every two hours thereafter. Also reapply if you’ve been in water or wiped off water or sweat. The SPF is tested at 2 mg/sq cm, but no reasonable person knows how much that is when applying sunblock.   An adult should use approximately a fully a shot glass full to cover his/her body (more relatable?).

Water-resistant – In order to be labeled as “water-resistant” the sunblock has to stay strong for 40 minutes in the water. That’s it. How many of you go to the beach and spend 40 minutes in the water? Make sure you reapply! The “very water-resistant” sunblock gets 80 minutes.

 

Is sunblock safe?

Sunblocks have an excellent safety profile. Most of the issues related to sunblock are skin irritation and / or allergic reactions. Fortunately, since there are so many formulations available, a person with sensitive skin can find a manufacturer they can handle.

More recent concerns have been raised with the use of titanium dioxide and zinc oxide nanoparticles (for cosmetic reasons) in sunblock and the possible absorption through the skin.   Studies show that use of these components do not cause toxicity and the nanoparticles do not penetrate the outer layer of skin, which is composed of dead cells.

With sunblock use, your body will be unable to synthesize its own vitamin D. Fortunately, vitamin D is readily available as a supplement at your local pharmacy, grocery store, big box store and likely gas station these days.

 

Other measures

Protective clothing

Ultraviolet protection factor (UPF) – This is an international classification system to identify how well a fabric blocks out ultraviolet radiation.   The UPF depends on several factors: type of material, tightness of weave (most important), color, stretch, moisture, conditions, additional treatments. Garments marked with UPF have built in photo-protection.

Laundry additive – Make your own UPF clothing by adding a package of sun blocking agent such as “SunGuard®” to your washer. 

The Skin Cancer Foundation has a seal of recommendation on products they have reviewed and tested for sun protection. http://www.skincancer.org/prevention/seal-of-recommendation

Shade – Shade is better than direct sunlight, but remember that UV radiation can reach the skin indirectly as well. UV radiation can scatter and bounce through clouds, off sand, off concrete, etc.

Hats – Stylish and protective.

Sunglasses – Don’t forget sun can damage your eyes too.

 

We live on a beautiful island. With occasional beautiful weather. Enjoy the sun safely now and avoid skin biopsies later!

 

Screening for Cervical Cancer

The cervix is the lowest part of the uterus, opening into the vagina. Fortunately, cervical cancer incidence has decreased by 75% in the last 50 year in developed countries due to screening programs and HPV vaccination. Of women diagnosed with cervical cancer, more than half have not had appropriate pap smear screening, including 25% who never had a pap and 10% who didn’t have a pap in the last 5 years. Cervical cancer usually doesn’t have any symptoms and early cancers definitely don’t have any symptoms, leaving screening to be an important factor in preventing this type of cancer from progressing.

A pap– Papanicolaou (pap is way easier to say) – smear is when the doctor takes a small scraping of the cervix to test for cancerous or precancerous cells. Most people use the term pap smear to include the whole exam, which is often called a “well woman exam” or previously an “annual exam.” This includes a reproductive history, breast exam, pap smear and internal vaginal exam.

Every woman should start getting pap smears at age 21. Most women should have a pap smear every 3 years. This has changed from what many women were used to having as an annual exam, but who can object to spacing these out! Some insurances have started to pay for human papillomavirus (HPV) cotesting with the pap smear in women over age 30, which extends the need for a pap smear to every 5 years. Not all insurers are paying for this yet, and some insurers are actually requiring pap smears for screening more frequently than that, so don’t be surprised if your physician asks you to come in for your screening.

We don’t routinely test for HPV in women under age 30 because there are a higher number of HPV infections in this age group that the body can clear on its own, and testing can lead to unnecessary cervical biopsies. However, if a pap smear comes back abnormal, an HPV test is also run. We just don’t test for HPV independent of an abnormal pap smear.

If a pap smear comes back abnormal, you may require additional testing with colposcopy. Some primary care physicians do this procedure, but not all and a referral to a gynecologist may be required. A colposcope is used to magnify the cervix to look for abnormal areas and biopsies are taken of any concerning spots. In addition, the inside of the cervix, the endocervical canal, is usually scraped to obtain samples to test for abnormal cells as well.

Pap smears have greatly reduced mortality from cervical cancer and can detect early changes before they turn into cancer. This ten minute exam could save your life. You can spare 10 minutes every 3 years. Make sure your pap smear is up to date.  

Group Therapy

Group therapy is a powerful tool. Effective group therapy provides psycho-education, gives members permission to talk about their fears, and to receive feedback and support from others who are in the same boat, so to speak!  As early as 1895, the French social psychologist, Gustav LeBon referred to the “group mind.” At about the time, William MacDougall, an Englishman, also saw that groups can affect individual behavior.

Effective group therapy takes place when an environment of trust has been established, which facilitates group members’ ability to share issues of concern in the here-and-now, and to be supported. That is, to allow people who are struggling with the same or a similar issue talk about how they manage symptoms on a day-to-day basis, about the tools they find effective in coping with such feelings (anger, guilt, helplessness, hopelessness, or other issues), and that help to improve their quality of life. The role of the therapist is to facilitate the process and to encourage members to apply lessons learned in group to everyday living.

As with any organism, the group goes through a developmental process:      

1) Form, at the beginning                                                                                

2) Storm, when members vie for power and control                                          

3) Norm, when members develop group rules or norms, leadership becomes shared by group participants, and the facilitator can assume more of a peripheral and less active role.                                                                       

4) Perform, when differentiation of members is respected, open feedback is expressed and shared, and members work together.                                      

5) Adjourn, when the group terminates.

As a prerequisite, group members are required to sign an Informed Consent for Group Therapy. While confidentiality cannot be guaranteed, it is understood that whatever happens in the group stays in the group so that participants will feel safe enough to talk about what they perceive as their most uncomfortable issues, and to respectfully challenge any therapeutic intervention that does not resonate with them. In the same way, the therapist does not take personally members’ disagreements, but welcomes questions and perspectives as valuable resources for promoting group cohesiveness and social learning.

 Seven qualities of successful group therapy have been identified (Yalom, I & Leszcz, M. (2005). The theory and practice of group psychotherapy. New York: Basic Books):

1) Installation of hope – if group members expect help, a positive therapy outcome is more likely.

2) Universality – hearing others’ stories and sharing their own promotes group members’ understanding that they are part of a community with the same or similar issues, so that members don’t feel so alone.

3) Imparting information – the therapist gives factual information on issues of concern, and members share advice in an environment of mutual support and respect.

4) Altruism – a “must have” component: giving and receiving help is intrinsic to the healing process: people need to feel they are needed.

5) Corrective Recapitulation of Primary Family Group – the therapist and group members help participants become unstuck from early traumas, and assist them to reframe early family conflicts correctively. For example, the member is helped to process, from an adult perspective, childhood or other trauma that disrupted the developmental process, and to adaptively realign the process.

6) Development of Socializing Techniques – group members learn basic social skills, and gain an understanding of the vast difference between their intentions and their actual impact on others.

7) Imitative Behavior – group members imitate and learn from each other, identify with more senior members of the group or with the therapist, find out what they are not, and also what they are.

Participating in group therapy can appear intimidating, but the group can be a wonderful support network as well as resource for ideas for dealing with a particular life situation or challenge.

Group therapy is, indeed, a powerful healing tool which all participants can access, and influence, and in which all participants are equal stakeholders!

 

Written by Pansy Lindo-Moulds, LMHC

Screening for colorectal cancer

Colorectal cancer is the third most common type of cancer in the U.S. It is the second leading cause of cancer related deaths within the U.S and the world.

Colon cancer is rare before age 40 and 90% of cases occur after age 50, which is why we start recommending screening for all adults at age 50. Your doctor may recommend earlier screening if you have significant risk factors, so always review your medical and family history with your doctor.

Risks for developing colon cancer include a family history, prior colon cancer, prior colon polyps, inflammatory bowel disease (not irritable bowel disease), high fat and low fiber diet, lack of physical activity, smoking, diabetes, radiation exposure, certain genetic syndromes.

Now that you’ve been appropriately warned or perhaps worried, let’s talk about ways of detecting colorectal cancer early, when it is easiest to treat.

Fecal Occult Blood Test (FOBT)
This test requires you to collect 3 separate small poop samples at home and provide them to the lab on a card, which the lab will then test for blood. This test will not be able to see the inside of your colon or detect any polyps unless they are bleeding. Because this test detects a component of blood, you do need to avoid certain foods, such as red meat prior to collecting the samples. This routine screening test is valid for 1 year only and any findings of blood will require a colonoscopy.

Colonoscopy
A colonoscopy is a medical procedure done by a trained doctor who specializes in the colon. He inserts a colonoscope, which is a long thin tube with a camera on the end, into the rectum and through the colon to visualize the tissue of your colon. Calm down, you get some medication to help you relax for this procedure and you definitely need a chauffeur as a result. Fortunately, during this procedure, if there are any polyps or areas of concern, the gastroenterologist can remove the polyp or take a biopsy immediately. Unfortunately, in order for the gastroenterologist to have a good look around, we need to give you diarrhea the day before the procedure. While it is unlikely, colonoscopy does have the risk of perforation and bleeding (when they remove the polyp).
Interestingly, the biggest complaint I get isn’t about the procedure, or even the diarrhea – it’s that the liquid to induce diarrhea tastes pretty darn icky. Even with today’s technology, the best we can do is watered down Crystal Light apparently. Sorry. For most people, this routine screening test is valid for 10 years.

Flexible Sigmoidoscopy
A flexible sigmoidoscopy is an outpatient procedure similar to a colonoscopy that can be done by a trained doctor who doesn’t have to specialize in gastroenterology, which can increase its availability. You will still need to have bowel prep with diarrhea the day prior to get a good exam. The sigmoidoscopy does not usually use sedation and it doesn’t reach as far within the colon as the colonoscopy, which are the main differences between the two exams. A normal routine screening is valid for 5 years. If there are concerning findings on this exam, a colonoscopy will need to be completed.

Here are some possible other methods that may available, depending on your location, medical needs or the timing of your reading of this.

Double Contrast Barium Enema
A barium enema also requires the bowel prep with diarrhea. You are given a dose of barium solution rectally to outline the colon during a radiologic exam. It is less sensitive than a colonoscopy for smaller polyps and cancers. A normal routine screening is valid for 5 years. If there are concerning findings on this exam, a colonoscopy will need to be completed. We don’t usually recommend this as a routine screening for colorectal cancer.

CT Colonography
This is a CT scan that visualizes your colon in order to look for abnormal findings. A CT scan also requires the bowel prep with diarrhea, so you still haven’t found a way to avoid that portion of the pain and suffering of maintaining your health. This screening does expose you to radiation, and the accumulation of repeated radiation may increase cancer risk in the future. A normal routine screening is valid for 5 years. If there are concerning findings on this exam, a colonoscopy will need to be completed. So far studies haven’t been conclusive on whether this screening reduces the deaths from cancer, so many insurance companies will not pay for the procedure and the USPSTF does not recommend this as a routine screening for colorectal cancer.

Immunochemical-based Fecal Occult Blood Test (iFOBT or FIT)
This newer test is more expensive than the regular FOBT. This routine screening test is valid for 1 year only and any abnormal findings will require a colonoscopy. This test is not considered effective if it is completed one time only. I haven’t known our local insurers to cover this testing, so if you find out differently, let me know.

Cologuard
This is a poop test which can detect both blood and DNA biomarkers that have been linked with cancerous growths. It is more expensive and new to the market so not quite ready for prime time yet. Stay tuned for more information on when this one may be incorporated into the guidelines.

The incidence of colorectal cancer in Hawaii is 43-49/100,000.
This incidence of colorectal cancer death in Hawaii is 11-14/100,000.
(source: CDC)
http://www.cdc.gov/cancer/colorectal/statistics/state.htm

Let’s lower these numbers!

Fluoride

Fluoride is a naturally occurring mineral that protects the teeth from decay. It stops the demineralization of the good enamel and helps enhance the remineralization of bad enamel on the teeth.

It seems that there is a complex relationship between systemic (body concentration) and topical (on the surface of the teeth) fluoride, as the concentration of fluoride in the enamel does not completely explain how we achieved such a marked reduction in cavities by adding fluoride to water. There seems to be at least some level of topical protection from the systemic fluoride from salivary secretion of fluoride as well. And, who’s to say that some of the topically applied fluoride doesn’t get into our system as we swallow a small amount?

Here in Hawaii, we do not add fluoride to the water. So, the fluoride needs to come from either your doctor or your dentist. According to the American Academy of Pediatric Dentistry 2014 update, there are three recommended ways to provide fluoride to your child:
1. Oral supplementation – This dose is based on the age (and on the amount of fluoride in your water) and can be combined with a multiple vitamin. I’ve been advised by several experts in the area (taste-testers under the age of 6) that the fluoride only is palatable, but the multiple vitamin combination is quite “icky.”
2. Professionally applied treatments – These are usually done by a dentist in his office every 3-6 months.
3. Fluoridated toothpaste – This is my least favorite of the options as a stand-alone source of fluoride. It is the most cumbersome for parents as it does require ensuring the correct amount of fluoride – in the toothpaste, the amount of toothpaste used, the frequency of the brushing, and avoiding rinsing after brushing. And all of these factors need to change with age.

As with everything, there is always a risk. Excessive fluoride can cause dental fluorosis, which can cause irregular coloration of the teeth. This usually presents as white lacey spots on the surface of the tooth, but a stronger form can appear as an opaque white area. A very severe, very rare form can cause some brownish discoloration or pitting of the teeth. This is why it is important to get the correct dosing; as the severe form usually occurs when the community has water fluoride levels greater than 2 mg/L (current recommendations are 0.7 mg/L).

Babies will get some fluoride via breast milk if mom is drinking fluorinated water. Bottle fed babies will get fluoride from two separate sources – a small amount from the formula and from the water used for preparing a concentrate. Most of the fluoride found in infant formula will come from the water, as the amount in the formula itself is quite small. To avoid giving the baby too much fluoride, a low-fluoride bottled water can be used to mix the formula; these are labeled as purified or demineralized and can be purchased at most stores.

I like my teeth. I like my teeth intact. I have paid extra, even when I was living on noodles and butter in medical school, just to have a cavity filled with tooth-colored filling instead of the silver. My waistline may have paid the ultimate price, but I’d be certain my smile wouldn’t.
We’ve seen more studies linking periodontal disease and systemic diseases (cardiovascular, infection, diabetic, etc). Perhaps we’ll see studies linking fluoride into the picture as our knowledge continues to grow. For now, I’ll continue to request tooth-colored fillings on the rare occasion they are needed. But I’ll do everything in my power to prevent cavities from appearing in the first place, for both me and your child.