Health

Walking for a five-minute duration every 30 minutes can reduce the risk of diabetes. Stock photo
Screening guidelines still miss 15 to 20 percent of cases

By David Dunaief, M.D.

Dr. David Dunaief

Finally, there is good news on the diabetes front. According to the Centers for Disease Control and Prevention, the incidence, or the rate of increase in new cases, has begun to slow for the first time in 25 years (1). There was a 20 percent reduction in the rate of new cases in the six-year period ending in 2014. This should help to brighten your day. However, your optimism should be cautious; it does not mean the disease has stopped growing. It means it has potentially turned a corner in terms of the growth rate, or at least we hope. This may relate in part to the fact that we have reduced our consumption of sugary drinks like soda and orange juice.

Get up, stand up!

It may be easier than you think to reduce the risk of developing diabetes. Standing and walking may be equivalent in certain circumstances for diabetes prevention. In a small, randomized control trial, the gold standard of studies, results showed that when sitting, those who either stood or walked for a five-minute duration every 30 minutes, had a substantial reduction in the risk of diabetes, compared to those who sat for long uninterrupted periods (2).

There was a postprandial, or postmeal, reduction in the rise of glucose of 34 percent in those who stood and 28 percent reduction in those who walked, both compared to those who sat for long periods continuously in the first day. The effects remained significant on the second day. A controlled diet was given to the patients. In this study, the difference in results for the standers and walkers was not statistically significant.

The participants were overweight, postmenopausal women who had prediabetes, HbA1C between 5.7 and 6.4 percent. The HbA1C gives an average glucose or sugar reading over three months. The researchers hypothesize that this effect of standing or walking may have to do with favorably changing the muscle physiology. So, in other words, a large effect can come from a very small but conscientious effort. This is a preliminary study, but the results are impressive.

Do prediabetes and diabetes have similar complications?

Diabetes is much more significant than prediabetes, or is it? It turns out that both stages of the disease can have substantial complications. In a study of those presenting in the emergency room with acute coronary syndrome (ACS), those who have either prediabetes or diabetes have a much poorer outcome. ACS is defined as a sudden reduction in blood flow to the heart, resulting in potentially severe events, such as heart attack or unstable angina (chest pain).

In the patients with diabetes or prediabetes, there was an increased risk of death with ACS as compared to those with normal sugars. The diabetes patients experienced an increased risk of greater than 100 percent, while those who had prediabetes had an almost 50 percent increased risk of mortality over and above the general population with ACS. Thus, both diabetes and prediabetes need to be taken seriously. Sadly, most diabetes drugs do not reduce the risk of cardiac events. And bariatric surgery, which may reduce or put diabetes in remission for five years, did not have an impact on increasing survival (3).

What do the prevention guidelines tell us?

The United States Preventive Services Task Force (USPSTF) renders recommendations on screening for diseases. In 2015, the committee drafted new guidelines suggesting that everyone more than 45 years old should be screened, but the final guidelines settled on screening a target population of those between the ages of 40 and 70 who are overweight or obese (4). They recommend that those with abnormal glucose levels pursue intensive lifestyle modification as a first step.

This is a great improvement, as most diabetes patients are overweight or obese; however, 15 to 20 percent of diabetes patients are within the normal range for body mass index (5). So, this screening still misses a significant number of people.

Potassium’s effect

When we think of potassium, the first things that comes to mind is bananas, which do contain a significant amount of potassium, as do other plant-based foods. Those with rich amounts of potassium include dark green, leafy vegetables; almonds; avocado; beans; and raisins. We know potassium is critical for blood pressure control, but why is this important to diabetes?

In an observational study, results showed that the greater the exertion of potassium through the kidneys, the lower the risk of cardiovascular disease and kidney dysfunction in those with diabetes (6). There were 623 Japanese participants with normal kidney function at the start of the trial. The duration was substantial, with a mean of 11 years of follow-up. Those who had the highest quartile of urinary potassium excretion were 67 percent less likely to experience a cardiovascular event or kidney event than those in the lowest quartile. The researchers suggested that higher urinary excretion of potassium is associated with higher intake of foods rich in potassium.

Where does this leave us for the prevention of diabetes and its complications? You guessed it: lifestyle modifications, the tried and true! Lifestyle should be the cornerstone, including diet and at least mild to moderate physical activity.

References:

(1) cdc.gov. (2) Diabetes Care. online Dec. 1, 2015. (3) JAMA Surg. online Sept. 16, 2015. (4) Ann Intern Med. 2015;163(11):861-868. (5) JAMA. 2012;308(6):581-590. (6) Clin J Am Soc Nephrol. online Nov 12, 2015.

Students from Northport, Huntington and Southampton high schools, as well as from Tug Valley High School in West Virginia, are working together to curb the opioid crisis. Photo from Northport-East Northport Union Free School District

Students from Northport, Huntington and Southampton high schools, along with the hard-hit Tug Valley High School in Kermit, West Virginia, have been working together to address the opioid crisis through a unique exchange program. Northport students, who are a part of the Students for 60,000 Club, visited West Virginia earlier this year on a service trip and were deeply affected by the magnitude of the crisis. 

Club advisers Darryl St. George and Kim Braha coordinated a “student exchange” in which the students from West Virginia came to visit Long Island to discuss realistic steps to solving the crisis. 

During the week of July 7, the students met in a variety of forums to learn from each other and discuss ways to address and solve the crisis. Students met with U.S. Rep. Thomas Suozzi (D-Glen Cove) and Suffolk County Executive Steve Bellone (D) in Huntington to engage in discussion and also visited Southampton High School to hear from local Southampton representatives. Students asked questions, shared personal experiences and offered their thoughts on curtailing opioid use. 

Ideas included creating more mental health programs in schools and providing a greater sense of purpose for students. 

At the end of the week, students spent some time volunteering at the Northport VA. 

“The most inspiring part of this week long student exchange experience included seeing how empowered our Northport students were working with Southampton, Huntington and West Virginia students,” said Braha, “and the incredible opportunities to have conversations about how we can all work together to improve our communities.

Belly fat can play a critical role in increased risk of pancreatitis. Stock photo
Central obesity is more important than body mass index

By David Dunaief, M.D.

Dr. David Dunaief

Pancreatitis is among the top gastrointestinal reasons for patients to be admitted to a hospital, and its incidence has been growing steadily (1). Typically it’s severe abdominal pain that drives patients to the emergency room, but diagnosis is more complex.

First, let’s define pancreatitis. A rudimentary definition is an inflammation of the pancreas. There are both acute and chronic forms. We are going to address the acute — abrupt and of short duration — form. There are three acute types: mild, moderate and severe. Those with the mild type don’t have organ failure, whereas those with moderate acute pancreatitis experience short-term or transient (less than 48 hours) organ failure. Those with the severe type have persistent organ failure. One in five patients presents with moderate or severe levels (2).

What are the symptoms?

To diagnosis this disease, the American College of Gastroenterology guidelines suggest that two of three symptoms be present. The three symptoms include severe abdominal pain; enzymes (amylase or lipase) that are at least three times greater than normal; and radiologic imaging that shows characteristic disease findings (3). Most of the time, the abdominal pain is in the central upper abdomen near the stomach, and it may also present with pain in the right upper quadrant of the abdomen (4). Approximately 90 percent of patients also experience nausea and vomiting (5). In half of patients, there is also pain that radiates to the back.

What are the risk factors?

Acute pancreatitis risk factors include gallstones, alcohol, obesity and, to a much lesser degree, drugs. Gallstones and alcohol may cause up to 75 percent of the cases (2). Many other cases of acute pancreatitis are considered idiopathic (of unknown cause). Although medications are potentially responsible for between 1.4 and 5.3 percent of cases, making it rare, the number of medications implicated is diverse (6, 7). These include certain classes of diabetes therapies, some antibiotics — metronidazole (Flagyl) and tetracycline — and immunosuppressive drugs used to treat ailments like autoimmune diseases. Even calcium may potentially increase risk.

Obesity effects

In a study using the Swedish Mammography Cohort and the Cohort of Swedish Men, results showed that central obesity is an important risk factor, not body mass index or obesity overall (8). In other words, it is the fat in the belly that is very important, since this may increase risk more than twofold for the occurrence of a first-time acute pancreatitis episode. Those who had a waist circumference of greater than 105 cm (41 inches) experienced this significantly increased risk compared to those who had a waist circumference of 75 to 85 cm (29.5 to 33.5 inches). The association between central obesity and acute pancreatitis occurred in both gallbladder-induced and non-gallbladder-induced disease. There were 68,158 patients involved in the study, which had a median duration of 12 years. Remember that waistline is measured from the navel, not from the hips.

Mortality risks

What makes acute pancreatitis so potentially dangerous is the surprisingly high rate of organ failure and mortality. A prospective (forward-looking) observational trial involving 1,005 patients found that the risk of mortality was 5 percent overall. This statistic broke out into a smaller percentage for mild acute pancreatitis and a greater percentage for severe acute pancreatitis, 1.5 and 17 percent, respectively (9). However, in another study, when patients were hospitalized, the mortality rate was higher, at 10 percent overall (10).

Diabetes risks

The pancreas is a critical organ for balancing glucose (sugar) in the body. In a meta-analysis (24 observational trials), results showed that more than one-third of patients diagnosed with acute pancreatitis went on to develop prediabetes or diabetes (11). Within the first year, 15 percent of patients were newly diagnosed with diabetes. After five years, the risk of diabetes increased 2.7-fold. By reducing the risk of pancreatitis, we may also help reduce the risk of diabetes.

Surgical treatments

Gallstones and gallbladder sludge are major risk factors, accounting for 35 to 40 percent of acute pancreatitis incidences (12). Gallstones are thought to cause pancreatitis by temporarily blocking the duct shared by the pancreas and gallbladder that leads into the small intestine. When the liver enzyme ALT is elevated threefold (measured through a simple blood test), it has a positive predictive value of 95 percent that it is indeed gallstone-induced pancreatitis (13). 

If it is gallstone-induced, surgery plays an important role in helping to resolve pancreatitis and prevent recurrence. In a retrospective study with 102 patients, results showed that surgery to remove the gallbladder was better than medical treatment when comparing hospitalized patients with this disease (14). Surgery trumped medical treatment in terms of outcomes, complication rates, length of stay in the hospital and overall cost for patients with mild acute pancreatitis.

Can diet have an impact?

The short answer is: Yes. What foods specifically? In a large, prospective observational study, results showed that there was a direct linear relationship between those who consumed vegetables and a decreased risk of non-gallstone acute pancreatitis (15). For every two servings of vegetables, there was 17 percent drop in the risk of pancreatitis. Those who consumed the most vegetables — the highest quintile (4.6 servings per day) — had a 44 percent reduction in disease risk, compared to those who were in the lowest quintile (0.8 servings per day). There were 80,000 participants involved in the study with an 11-year follow-up. The authors surmise that the reason for this effect with vegetables may have to do with their antioxidant properties, since acute pancreatitis increases oxidative stress on the pancreas.

References:

(1) Gastroenterology. 2012;143:1179-1187. (2) www.uptodate.com. (3) Am J Gastroenterol. 2013;108:1400-1415. (4) JAMA. 2004;291:2865-2868. (5) Am J Gastroenterol. 2006;101:2379-2400. (6) Gut. 1995;37:565-567. (7) Dig Dis Sci. 2010;55:2977-2981. (8) Am J Gastroenterol. 2013;108:133-139. (9) Dig Liver Dis. 2004;36:205-211. (10) Dig Dis Sci. 1985;30:573-574. (11) Gut. 2014;63:818-831. (12) Gastroenterology. 2007;132:2022-2044. (13) Am J Gastroenterol. 1994;89:1863-1866. (14) Am J Surg online. 2014 Sept. 20. (15) Gut. 2013;62:1187-1192.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.  

From left to right: Daniel Lozeau, Galo Del Heirro, Alexander Dagum, Marissa Ayasse, Richard J Scriven. Photo from SBU

By David Luces

For one Ecuadorian native, attending a lecture by Stony Brook Medicine doctors changed his life.

Galo Del Hierro, 44, who works for the Charles Darwin Foundation in the Galapagos, was attending a lecture given by the Stony Brook Medicine team about skin cancer screenings and prevention in the archipelago. After the lecture, Del Hierro approached Alexander Dagum, a reconstructive plastic surgeon at Stony Brook, and showed him a lesion he had on his right eyelid that was not going away and had grown bigger in the last couple of years.

“He came up to me and said, ‘I’ve had this spot that has gotten larger for some time,’” Dagum said. “I looked at it and thought it was pretty suspicious and told him he should see one of our dermatologists.”

The team’s trip in March was part of a mission through Blanca’s House, a Long Island non-profit organization that works to bring much-needed, quality medical care to countries and communities throughout Latin America. The seven-person team from Stony Brook planned on providing screenings and other care for the local community. As they further examined Del Hierro, they realized they might have to bring him 3,051 miles away to Stony Brook for care.

Dr. Daniel Lozeau, a dermatologist and clinical assistant professor at Stony Brook Medicine, took a look at Del Hierro’s lesion and determined that they needed to do a biopsy. After testing was done, Del Hierro was diagnosed with a malignant melanoma.

Lozeau said given the location of the melanoma it would make it difficult to remove.

“On the eyelid you have less room to work with,” he said. “It not like when it’s on someone’s back, where we have a lot more real estate [to work with].”

Dagum said if people in the Galapagos had anything serious, they would have to go over to the mainland in Ecuador, which is quite far. Initially, he tried to find a doctor on the mainland to perform the surgery for Del Hierro instead of bringing him to Stony Brook as it was more convenient for Del Hierro, but he couldn’t find anyone that could do it.

Lozeau said the cancer Del Hierro had is aggressive, and he could have lost his eye and his life.

Dagum then got clearance to perform the surgery as a teaching case at Stony Brook Medicine and with help from the Darwin Foundation and Blanca’s House, Del Hierro was able to come to Stony Brook for the surgery in May.

The Stony Brook plastic surgeon said the procedure takes several days and requires using skin grafts to reconstruct and support the lower eyelid.

“It was important they we got [the melanoma] out as quickly as possible,” Dagum said.

Dagum and colleagues removed the lesion in full around his eyelids, and reconstructed skin around the eyelid so Del Hierro could see properly and blink normally. He had a second procedure to adjust the eyelid.

The Ecuadorian native said through a translator that he was grateful and impressed with the care he received at Stony Brook.

Del Hierro said that he had first noticed the spot on his eyelid when he was 18 years old.

“It was a tiny little dot, and I didn’t really think much of it, I thought it was just a mole,” he said.

He admitted when he first got his diagnosis, he was worried for himself and his family, but trusted Dagum and the team.

With the procedures complete, Dagum said they are waiting for the swelling to go down and everything should settle in and heal up in the next couple of months.

Dagum expects Del Hierro to live normally; however, he recommends he should continue to get screened and have the eyelid area examined periodically.

Del Hierro’s case and the team’s experiences bring to light the importance of skin cancer screening and skin protection, especially during the summer season.

Lozeau said the Academy of Dermatology recommends sunscreen of SPF 30 or higher.

“Most important thing is to constantly re-apply frequently every couple of hours,” he said. “Hats are good to wear and make sure you have eye protection.”

The dermatologist said when it comes to skin cancer, if one notices a spot that hasn’t gone away or has grown in size, he or she should get it checked out. Also, he mentioned spots that constantly bleed or scab over.

“Galo was really fortunate. He was at the right place at the right time,” Lozeau said.

Gluten is found mainly in wheat, rye and barley. Stock photo
Antibiotics may contribute to celiac disease

By David Dunaief, M.D.

Dr. David Dunaief

Gluten-free diets are a hot topic. When we hear someone mention a gluten-free diet, we may automatically think that this is a healthy diet. However, gluten-free is not necessarily synonymous with healthy. There are many beneficial products containing gluten.

Still, we keep hearing how more people feel better without gluten. Could this be a placebo effect? What is myth and what is reality in terms of gluten? In this article I will try to distill what we know about gluten and gluten-free diets, who may benefit and who may not.

But first, what is gluten? Gluten is a plant protein found mainly in wheat, rye and barley.

While more popular recently, going gluten-free is not a fad, since we know that patients who suffer from celiac disease, an autoimmune disease, benefit tremendously when gluten is removed (1). In fact, it is the main treatment.

But what about people who don’t have celiac disease? There seems to be a spectrum of physiological reaction to gluten, from intolerance to gluten (sensitivity) to gluten tolerance (insensitivity). Obviously, celiac disease is the extreme of intolerance, but even these patients may be asymptomatic. Then, there is nonceliac gluten sensitivity (NCGS), referring to those in the middle portion of the spectrum (2). The prevalence of NCGS is half that of celiac disease, according to the NHANES data from 2009-2010 (3). However, many disagree with this assessment, indicating that it is much more prevalent and that its incidence is likely to rise (4). The term was not even coined until 2011.

What is the difference between full-blown celiac disease and gluten sensitivity? They both may present with intestinal symptoms, such as bloating, gas, cramping and diarrhea, as well as extraintestinal (outside the gut) symptoms, including gait ataxia (gait disturbance), malaise, fatigue and attention deficit disorder (5). Surprisingly, they both may have the same results with serological (blood) tests, which may be positive or negative. The first line of testing includes anti-gliadin antibodies and tissue transglutaminase. These measure a reaction to gluten; however, they don’t have to be positive for there to be a reaction to gluten. HLA–DQ phenotype testing is the second line of testing and tends to be more specific for celiac disease.

What is unique to celiac disease is a histological change in the small intestine, with atrophy of the villi (small fingerlike projections) contributing to gut permeability, what might be called “leaky gut.” Biopsy of the small intestine is the most definitive way to diagnose celiac disease. Though the research has mainly focused on celiac disease, there is some evidence that shows NCGS has potential validity, especially in irritable bowel syndrome.

Before we look at the studies, what does it mean when a food says it’s “gluten-free”? Well, the FDA has weighed in by passing regulation that requires all gluten-free foods to have no more than 20 parts per million of gluten (6).

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a nebulous disease diagnosed through exclusion, and the treatments are not obvious. That is why the results from a 34-patient, randomized controlled trial, the gold standard of studies, showing that a gluten-free diet significantly improved symptoms in IBS patients, is so important (7). Patients were given a muffin and bread on a daily basis.

Of course, one group was given gluten-free products and the other given products with gluten, though the texture and taste were identical. In six weeks, many of those who were gluten-free saw the pain associated with bloating and gas mostly resolve; significant improvement in stool composition, such that they were not suffering from diarrhea; and their fatigue diminished. In fact, in one week, those in the gluten group were in substantially more discomfort than those in the gluten-free group.

As part of a well-written March 4, 2013 editorial in Medscape by David Johnson, M.D., a professor of gastroenterology, questions whether this beneficial effect from the IBS trial was due to gluten withdrawal or to withdrawal of fermentable sugars because of the elimination of some grains themselves (8). In other words, gluten may be just one part of the picture. He believes that nonceliac gluten sensitivity is a valid concern.

Antibiotics

The microbiome in the gut may play a pivotal role as to whether a person develops celiac disease. In an observational study using data from the Swedish Prescribed Drug Register, results indicate that those who were given antibiotics within the last year had a 40 percent greater chance of developing celiac disease and a 90 percent greater risk of developing inflammation in the gut (9). The researchers believe that this has to do with dysbiosis, a misbalance in the microbiota, or flora, of the gastrointestinal tract. It is interesting that celiac disease may be propagated by change in bacteria in the gut from the use of antibiotics.

Not everyone will benefit from a gluten-free diet. In fact, most of us will not. Ultimately, people who may benefit from this type of diet are those patients who have celiac disease and those who have symptomatic gluten sensitivity. Also, patients who have positive serological tests, including tissue transglutaminase or anti-gliadin antibodies, are good candidates for gluten-free diets.

There is a downside to a gluten-free diet: potential development of macronutrient and micronutrient deficiencies. Therefore, it would be wise to ask your doctor before starting gluten withdrawal. The research in patients with gluten sensitivity is relatively recent, and most gluten research has to do with celiac disease. Hopefully, we will see intriguing studies in the near future.

References:

(1) Am J Gastroenterol. 2013;108:656-676. (2) Gut 2013;62:43–52. (3) Scand J Gastroenterol. (4) Neurogastroenterol Motil. 2013 Nov;25(11):864-871. (5) medscape.com. (6) fda.gov. (7) Am J Gastroenterol. 2011; 106(3):508-514. (8) medscape.com. (9) BMC Gastroenterol. 2013:13(109).

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

By Donna Deedy

donna@tbrnewsmedia.com

“It’s more than a pretty garden,” said Chris Clapp, a marine scientist for The Nature Conservancy. “It’s a biological process that relies on plants, wood chips and microbes to remove nitrogen in wastewater before it flows back into the environment.”

On June 24, County Executive Steve Bellone (D) joined Clapp with a conglomerate of representatives from both government and the private sector at The Nature Conservancy’s Upland Farms Sanctuary in Cold Spring Harbor to unveil a state-of-the-art method for reducing and eliminating nitrogen from wastewater. 

The county expects the new system to be a replacement for cesspools and septic systems, which are blamed for the seeping of nitrogen into Long Island waterways, causing red tides, dead zones and closed beaches.

County Executive Steve Bellone and Nancy Kelley of The Nature Conservancy plant the new garden at Upland Farms.

The issue is a serious concern, Bellone said, as he introduced the county’s Deputy Executive Peter Scully, who is spearheading the county’s Reclaim Our Water Initiative and serves as the Suffolk’s water czar. “Anytime a government appoints a water czar, you know you have problems to address.”

Scully, formerly the director for the Long Island region of the New York State Department of Environmental Conservation, said six other septic alternatives are currently approved.    

Long Island is reportedly one of the most densely populated locations in the country without adequate wastewater treatment. Currently, there are 360,000 antiquated cesspools and septic systems. The county expects to set nitrogen reduction targets for watershed areas where replacement holds the most benefit. 

The technique, called a vegetated circulating gravel system, is composed of an underground network that essentially connects the drains and toilets of a home or office to plant life and microbial action. It works in two stages to denitrify the wastewater. The first phase discharges wastewater into an underground gravel bed covered with a surprisingly small garden of native plants that takes up nitrogen through its roots. The water is then circulated into an underground box of wood chips that convert the remaining nitrogen into gas, before it’s circulated back to the gravel bed. Once the water is denitrified, it’s dispersed through a buried leaching field. 

The county partnered with the Nature Conservancy to develop and implement the system for its Upland Farms Sanctuary. The sanctuary is located a half-mile from Cold Spring Harbor, where water quality has worsened during the last 12 years to the point where the state is officially proposing to designate it an impaired water body. 

“The Conservancy is proud to stand alongside the county and our partners to celebrate this exciting new system that taps into the power of nature to combat the nitrogen crisis, putting us on a path to cleaner water,” said Nancy Kelley, Long Island chapter director for The Nature Conservancy.  

During the experimental phase the system reduced by half the amount of nitrogen discharged from wastewater. A similar technique has been effective at removing up to 90% in other parts of the country. The system’s designers at Stony Brook University’s Center for Clean Water Technology aim to completely remove nitrogen from discharges.  The Upland Farms offices and meeting hall system, which encompasses 156 square feet,  serves the equivalent of two to three homes. 

Suffolk County Legislator William “Doc” Spencer (D-Centerport) said that denitrification efforts work. The Centerport Yacht Club’s beach was closed for seven years due to water quality issues and reopened in 2015 after the Northport sewer plant upgraded to a denitrification system. Improvements to the harbor storm drain discharges, and a public lawn care campaign about curbing the use of fertilizers, also reportedly helped. 

The county has reached a critical juncture and beginning July 1, its new sanitary code for septic systems takes effect, which permits only denitrifying technology.

Justin Jobin, who works on environmental projects with the Suffolk County Department of Health Services, said that he expects to gain approval for a pilot program to accelerate the vegetated circulating gravel system’s public introduction, which could be approved as soon as this summer.  The design can be modified, its developers said, to serve single homes or large businesses. In addition to removing nitrogen, the system can also naturally filter out pharmaceuticals and personal care products.  Its impacts on 1,4-dioxane are being studied. 

Visit www.ReclaimOurWater.info for additional information. 

Photos by Donna Deedy

Lyme disease starts with a circular rash where the ticks bite. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

Ah, summer is upon us. Unfortunately, this means that tick season is getting into full swing.Thus, it is good timing to talk about Borrelia burgdorferi, better known as the bacterium that causes Lyme disease. This bacterium is from the spirochete class and is typically found in the deer tick, also known as the blacklegged tick.

What do deer ticks look like? They are small and can be as tiny as a pencil tip or the size of a period at the end of a sentence. The CDC.gov site is a great resource for tick images and other information related to Lyme disease.

If you have been bitten by a tick, the first thing you should do is remove it with forceps, tweezers or protected fingers (paper) as close to the skin as possible and pull slow and steady straight up. Do not crush or squeeze the tick, for doing so may spread infectious disease (1). In a study, petroleum jelly, fingernail polish, a hot kitchen match and 70 percent isopropyl alcohol all failed to properly remove a tick. The National Institutes of Health recommend not removing a tick with oil (2).

When a tick is removed within 36 to 48 hours, the risk of infection is quite low (3). However, a patient can be given a prophylactic dose of the antibiotic doxycycline, one dose of 200 mg, if the erythema migrans, or bulls-eye rash — a red outer ring and red spot in the center — has not occurred, and it is within 72 hours of tick removal (4). Those who took doxycycline had significantly lower risk of developing the bulls-eye rash and thus Lyme disease; however, treatment with doxycycline did have higher incidence of nausea and vomiting than placebo.

What are the signs and symptoms of Lyme disease? There are three stages of Lyme disease: early stage, where the bacteria are localized; early disseminated disease, where the bacteria have spread throughout the body; and late stage disseminated disease. Symptoms for early localized stage and early disseminated disease include the bulls-eye rash, which occurs in about 80 percent of patients, with or without systemic symptoms of fatigue (54 percent), muscle pain and joint pain (44 percent), headache (42 percent), neck stiffness (35 percent), swollen glands (23 percent) and fever (16 percent) (5).

Early disseminated disease may cause neurological symptoms such as meningitis, cranial neuropathy (Bell’s palsy) and motor or sensory radiculoneuropathy (nerve roots of spinal cord). Late disseminated disease can cause Lyme arthritis (inflammation in the joints), heart problems, facial paralysis, impaired memory, numbness, pain and decreased concentration (2).

How do we prevent Lyme? According to the Centers for Disease Control and Prevention, we should wear protective clothing, spray ourselves with insect repellent that includes at least 20 percent DEET and treat our yards (3). Always check your skin and hair for ticks after walking through a woody or tall grassy area. Many of us on Long Island have ticks in the yard, so remember to check your pets; even if treated, they can carry ticks into the house.

Diagnosis of Lyme disease

Many times Lyme disease can be diagnosed within the clinical setting. When it comes to serologic or blood tests, the CDC recommends an ELISA test followed by a confirmatory Western blot test (3). However, testing immediately after being bitten by a tick is not useful, since the test will tend to be negative, regardless of infection or not (4). It takes about one to two weeks for IgM antibodies to appear and two to six weeks for IgG antibodies (5). These antibodies sometimes remain elevated even after successful treatment with antibiotics.

The cardiac impact

Lyme carditis is a rare complication affecting 1.1 percent of those with disseminated disease, but it can result in sudden cardiac death due to second- or third-degree atrioventricular (AV) node conduction (electrical) block. Among the 1.1 percent who had Lyme carditis, there were five sudden deaths (6). If there are symptoms of chest pain, palpitations, light-headedness, shortness of breath or fainting, then clinicians should suspect Lyme carditis.

Does chronic Lyme disease exist?

There has been a debate about whether there is something called “chronic Lyme” disease. The research, unfortunately, has not shown consistent results that indicate that it exists. In one analysis, the authors note that the definition of chronic Lyme disease is obfuscated and that extended durations of antibiotics do not prevent or alleviate post-Lyme syndromes, according to several prospective trials (7). The authors do admit that there are prolonged neurologic symptoms in a subset population that may be debilitating even after the treatment of Lyme disease. These authors also suggest that there may be post-Lyme disease syndromes with joint pain, muscle pain, neck and back pain, fatigue and cognitive impairment.

Ultimately, it comes down to the IDSA (Infectious Diseases Society of America) arguing against chronic Lyme but in favor of post-Lyme disease syndromes, while the ILADS (International Lyme and Associated Diseases Society) believes chronic Lyme exists.

Regardless, the lingering effects of Lyme can be debilitating. This may be as a result of systemic inflammation (8). Systemic inflammation and its symptoms can be improved significantly with dietary and other lifestyle modifications.

But to throw one more wrench in the mix, the CDC recommends that physicians look beyond Lyme for other possible diagnoses before diagnosing someone with chronic Lyme disease (9).

Prevention is key to helping stem Lyme disease. If this is not possible, treating prophylactically when pulling off a tick is an important step. Contact your physician as soon as you notice a tick. If you have a bulls-eye rash and it is early, then treatment for two to three weeks needs to be started right away. If it is prolonged and disseminated, then treatment should be for approximately three to four weeks with antibiotics. If it has affected the central nervous system, then IV antibiotics could be needed.

References:

(1) Pediatrics. 1985;75(6):997. (2) nlm.nih.gov. (3) cdc.gov. (4) Clin Infect Dis. 2008;47(2):188. (5) uptodate.com. (6) MMWR. 2014;63(43):982-983. (7) Expert Rev Anti Infect Ther. 2011;9(7):787-797. (8) J Infect Dis. 2009;199(9:1379-1388). (9) JAMA Intern Med. online Nov. 3, 2014.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.  

Stock photo
Toenail fungus can have medical implications

By David Dunaief, M.D.

Dr. David Dunaief

Summer is almost here, and millions of Americans are beginning to expose their toes. Some are more self-conscious about it because of a disease called onychomycosis, better known as nail fungus.

Nail fungus usually affects toenails but can also affect fingernails. It turns the nails yellow, makes them potentially brittle, creates growth underneath the nail (thickening of the nails) and may cause pain.

Many consider getting treatment for cosmetic reasons, but there are also medical reasons to treat, including the chronic or acute pain caused by nail cutting or pressure from bedsheets and footwear. There is also an increased potential risk for infections, such as cellulitis, in those with compromised immune systems (1).

Onychomycosis is not easy to treat, although it affects approximately 8 percent of the population (2). The risk factors are unclear but may relate to family history, tinea pedis (athlete’s foot), older age, swimming, diabetes, psoriasis, suppression of the immune system and/or living with someone affected (3).

Many organisms can affect the nail. The most common class is dermatophytes, but others are yeast (Candida) and nondermatophytes. A KOH (potassium hydroxide) preparation can be used to differentiate them. This is important since some medications work better on one type than another. Also, yellow nails alone may not be caused by onychomycosis; they can be a sign of psoriasis.

When considering treatment, there are several important criteria, including effectiveness, length of treatment and potential adverse effects. The bad news is that none of the treatments are foolproof, and the highest “cure” rate is around two-thirds. Oral medications tend to be the most efficacious, but they also have the most side effects. The treatments can take from around three months to one year. Unfortunately, the recurrence rate of fungal infection is thought to be approximately 20 to 50 percent with patients who have experienced “cure” (4).

Oral antifungals

There are several oral antifungal options, including terbinafine (Lamisil), fluconazole (Diflucan) and itraconazole. These tend to have the greatest success rate, but the disadvantages are their side effects. In a small but randomized controlled trial (RCT), terbinafine was shown to work better in a head-to-head trial than fluconazole (5). Of those treated, 67 percent of patients experienced a clearing of toenail fungus with terbinafine, compared to 21 and 32 percent with fluconazole, depending on duration. Patients in the terbinafine group were treated with 250 mg of the drug for 12 weeks. Those in the fluconazole group were treated with 150 mg of the drug for either 12 or 24 weeks, with the 24-week group experiencing better results.

The disadvantage of terbinafine is the risk of potential hepatic (liver) damage and failure, though it’s an uncommon occurrence. Liver enzymes need to be checked while using terbinafine.

Another approach to reducing side effects is to give oral antifungals in a pulsed fashion. In an RCT, fluconazole 150 or 300 mg was shown to have significant benefit compared to the control arm when given on a weekly basis (6). However, efficacy was not as great as with terbinafine or itraconazole (7).

Topical medication

A commonly used topical medication is ciclopirox (Penlac). The advantage of this lacquer is that there are minor potential side effects. However, it takes approximately a year of daily use, and its efficacy is not as great as oral antifungals. In two randomized controlled trials, the use of ciclopirox showed a 7 percent “cure” rate in patients, compared to 0.4 percent in the placebo groups (8). There is also a significant rate of fungus recurrence. In one trial, ciclopirox had to be applied daily for 48 weeks in patients with mild to moderate levels of fungus.

Laser therapy

Of the treatments, laser therapy would seem to be the least innocuous. However, there are very few trials showing significant benefit with this approach. A study with one type of laser treatment (Nd:YAG 1064-nm laser) did not show a significant difference after five sessions (9). This was only one type of laser treatment, but it does not bode well. The advantage of laser treatment is the mild side effects. The disadvantages are the questionable efficacy and the cost. We need more research to determine if they are effective.

Alternative therapy

Vicks VapoRub may have a place in the treatment of onychomycosis. In a very small pilot trial with 18 patients, 27.8 percent or 5 of the patients experienced complete “cure” of their nail fungus (10). Partial improvement occurred in the toenails of 10 patients. The gel was applied daily for 48 weeks. The advantages are low risk of side effects and low cost. The disadvantages are a lack of larger studies for efficacy, the duration of use and a lower efficacy when compared to oral antifungals.

None of the treatments are perfect. Oral medications tend to be the most efficacious but also have the most side effects. If treatment is for medical reasons, then oral may be the way to go. If you have diabetes, then treatment may be of the utmost importance.

If you decide on this approach, discuss it with your doctor; and do appropriate precautionary tests on a regular basis, such as liver enzyme monitoring with terbinafine. However, if treatment is for cosmetic reasons, then topical medications or alternative approaches may be the better choice. No matter what, have patience. The process may take a while; nails, especially in toes, grow very slowly.

References:

(1) J Am Acad Dermatol. 1999 Aug.;41:189–196; Dermatology. 2004;209:301–307. (2) J Am Acad Dermatol. 2000;43:244–248. (3) J Eur Acad Dermatol Venereol. 2004;18:48–51. (4) Dermatology. 1998;197:162–166; uptodate.com. (5) Pharmacoeconomics. 2002;20:319–324. (6) J Am Acad Dermatol. 1998;38:S77. (7) Br J Dermatol. 2000;142:97–102; Pharmacoeconomics. 1998;13:243–256. (8) J Am Acad Dermatol. 2000;43(4 Suppl.):S70-S80. (9) J Am Acad Dermatol. 2013 Oct.;69:578–582. (10) J Am Board Fam Med. 2011;24:69–74.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.       

Being active is the magic pill for a healthy life. Stock photo
Inactivity may increase mortality and disease risk

By David Dunaief, M.D.

Dr. David Dunaief

With the advent of summer weather, with its heat and humidity, who wants to think about exercise? Instead, it’s tempting to lounge by the pool or even inside with air conditioning.

First, let me delineate between exercise and inactivity; they are not complete opposites. When we consider exercise, studies tend to focus on moderate to intense activity. However, light activity and being sedentary, or inactive, tend to get clumped together. But there are differences between light activity and inactivity.

Light activity may involve cooking, writing and strolling (1). Inactivity involves sitting, as in watching TV or in front of a computer screen. Inactivity utilizes between 1 and 1.5 metabolic equivalent units — better known as METS — a way of measuring energy. Light activity, however, requires greater than 1.5 METS. Thus, in order to avoid inactivity, we don’t have to exercise in the dreaded heat. We need to increase our movement.

What are the potential costs of inactivity? According to the World Health Organization, over 3 million people die annually from inactivity. This ranks inactivity in the top five of potential underlying mortality causes (2).

How much time do we spend inactive? In an observational study of over 7,000 women with a mean age of 71 years old, 9.7 waking hours were spent inactive or sedentary. These women wore an accelerometer to measure movements. Interestingly, as body mass index and age increased, the amount of time spent sedentary also increased (3).

Inactivity may increase the risk of mortality and plays a role in increasing risks for diseases such as heart disease, diabetes and fibromyalgia. It can also increase the risk of disability in older adults.

Surprisingly, inactivity may be worse for us than smoking and obesity. For example, there can be a doubling of the risk for diabetes in those who sit for long periods of time, compared to those who sit the least (4).

Let’s look at the evidence.

Does exercise overcome inactivity?

We tend to think that exercise trumps all; if you exercise, you can eat what you want and, by definition, you’re not sedentary. Right? Not exactly. Diet is important, and you can still be sedentary, even if you exercise. In a meta-analysis — a group of 47 studies — results show that there is an increased risk of all-cause mortality with inactivity, even in those who exercised (5). In other words, even if you exercise, you can’t sit for the rest of the day. The risk for all-cause mortality was 24 percent overall.

However, those who exercised saw a blunted effect with all-cause mortality, making it significantly lower than those who were inactive and did very little exercise: 16 percent versus 46 percent increased risk of all-cause mortality. So, it isn’t that exercise is not important, it just may not be enough to reduce the risk of all-cause mortality if you are inactive for a significant part of the rest of the day.

Worse than obesity?

Obesity is a massive problem in this country; it has been declared a disease, itself, and it also contributes to other chronic diseases. But would you believe that inactivity has more of an impact than even obesity? In an observational study, using data from the EPIC trial, inactivity might be responsible for two times as many premature deaths as obesity (6). This was a study involving 330,000 men and women.

Interestingly, the researchers created an index that combined occupational activity with recreational activity. They found that the greatest reduction in premature deaths (in the range of 16 to 30 percent) was between two groups, the normal weight and moderately inactive group versus the normal weight and completely inactive group. The latter was defined as those having a desk job with no additional physical activity. To go from the completely inactive to moderately inactive, all it took, according to the study, was 20 minutes of brisk walking on a daily basis.

So what have we learned about inactivity? If you are inactive, increasing your activity to be moderately inactive by briskly walking for 20 minutes a day may reduce your risk of premature death significantly. Even if you exercise the recommended 150 minutes a week, but are inactive the rest of the day, you may still be at risk for cardiovascular disease. You can potentially further reduce your risk of cardiovascular disease by increasing your activity with small additions throughout the day.

The underlying message is that we need to consciously move throughout the day, whether at work with a walk during lunch or at home with recreational activity. Those with desk jobs need to be most attuned to opportunities to increase activity. Simply setting a timer and standing or walking every 30 to 45 minutes may increase your activity levels and possibly reduce your risk.

References:

(1) Exerc Sport Sci Rev. 2008;36(4):173-178. (2) WHO report: http://bit.ly/1z7TBAF. (3) JAMA. 2013;310(23):2562-2563. (4) Diabetologia 2012; 55:2895-2905. (5) Ann Intern Med. 2015;162:123-132, 146-147. (6) Am J Clin Nutr. online Jan. 24, 2015.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.   

Photo from Stony Brook Medicine
Dr. Kenneth Kaushansky

When choosing a hospital, whether for yourself or a loved one, it pays to have the peace of mind in knowing that you or your loved one will receive the highest quality of care. One way to help ensure that peace of mind is to do your homework.

We recently received news that will give the residents of Suffolk County and beyond one more reason to feel confident about choosing Stony Brook University Hospital for their health care needs. Our hospital has been named one of America’s 100 Best Hospitals™ for 2019 by Healthgrades, the first organization in the country to rate hospitals entirely on the basis of the quality of clinical outcomes.

Recipients of the America’s 100 Best Hospitals Award are recognized for overall clinical excellence based on quality outcomes for 34 conditions and procedures for 4,500 hospitals nationwide. Healthgrades reviews three years of Medicare and other inpatient data, comparing actual to predicted performance for specific and common patient conditions. 

This impressive distinction was achieved by the entire Stony Brook University Hospital team working together to achieve one goal — to deliver on a commitment to provide every patient with exceptional care. We continuously put patient safety and quality of care first, while bringing cutting-edge services and evidence-based medicine to our community. 

As one of America’s 100 Best Hospitals, Stony Brook University Hospital is in the top 2 percent of hospitals nationwide and one of only four hospitals in New York State exhibiting exemplary clinical excellence over the most recent three-year evaluation.

Stony Brook was also named one of America’s 100 Best Hospitals for cardiac care, coronary intervention and stroke care. I’m proud to report that our hospital is the only one in the entire U.S. Northeast region, and one of only two hospitals in the nation, to achieve America’s 100 Best Hospitals in all four of these categories.

With so many choices, it helps to understand that the quality of care you receive varies from hospital to hospital. Whether you are planning an elective surgery or you are admitted to our hospital unexpectedly, it’s important to know that at Stony Brook University Hospital, you’ll be at one of the nation’s best.

Dr. Kenneth Kaushansky is senior vice president, Health Sciences, and dean, Renaissance School of Medicine at Stony Brook University.