Internal Medicine Blog
- 31 May 2016
- Internal Medicine Blog
Hives are raised, red, itchy patches of skin (also called Urticaria, welts, or wheals) that can be frustrating to experience. Hives are commonly caused by a number of triggers, and figuring out the cause is sometimes challenging. Hives can be the result of allergies to medicines like penicillin, or to foods like nut, soy, or shellfish. They can be caused by viral, bacterial, or parasitic infections (especially in children), by physical contact with substances like plants (such as poison ivy or poison oak) or latex, and by insect bites or stings. Some people can even develop hives in response to less obvious triggers, such as exposure to temperature changes, or pressure on the skin. Regardless of the cause, treatment ofhives is usually initiated with medications called antihistamines (Loratadine, Cetirizine, Benadryl); in more resistant or diffuse cases, a short course of oral steroids may be used to reduce the swelling, itching and inflammation.
Occasionally, hives are accompanied by a more serious type of allergic reaction called Angioedema. Angioedema causes swelling of the face, eye area, hands feet or genitals. This can be treated with the same medications as hives, but angioedema should always be evaluated by a health care professional to make sure it does not progress to a more serious type of allergic reaction. Other complications of hives that require emergent attention include hives that are accompanied by throat closing or breathing difficulty; nausea, vomiting or abdominal pain; or passing out--these symptoms will not respond to regular antihistamines alone.
Although typically hives will be a self-limited affliction, with lesions coming and going in minutes to hours, and episodes lasting for a few days, in some cases, they can last for weeks. If hives last for six weeks or more, they are called chronic hives. This type of hives is more difficult to manage, and often, a cause if not found. Symptoms will usually resolve over several months, however. Generally, hives can be successfully managed by avoidance of triggers and prompt treatment of outbreaks. For more information about this and other skin issues, ask you health care provider.
- 31 May 2016
- Internal Medicine Blog
Nutrient Intravenous Infusion is a concept pioneered in the 1970s by John Myers, MD, a physician from Baltimore, Maryland. These infusions are a great means to provide essential nutrients and vitamins to patients who cannot absorb them naturally or to obtain higher concentrations than could be achieved by oral means alone. A good example of this is Vitamin C which may have antiviral and antibacterial properties at concentrations higher than would be expected with regular meals. Over the past 50 years nutrient intravenous infusions have been developed to treat a variety of clinical conditions. Millions of these infusions have been used to treat patients worldwide.
Myers’ original solution has now been modified to treat symptoms related to asthma, migraines, fatigue, fibromyalgia, acute muscle spasm, upper respiratory tract infections, sinusitis, seasonal allergic rhinitis and fluid dehydration. For chronic problems, patients may receive a number of treatments until their condition improves. It is important to note that although intravenous nutrient therapy is not meant to ‘cure’ any illnesses, it can give patients an extra boost to help fight infections, relieve pain or give you the feeling of a little additional energy to continue to recover. We all know how important it is to ‘feel’ better when we are ill, even if this does not mean we are recovered. The way we feel helps give us the strength to continue!
Under the direction of physicians, intravenous infusions are currently offered in a safe manner in an outpatient setting. Each infusion can be individualized for a specific patient’s needs. Following insertion of a small IV, the infusion takes only 30-45 minutes. We will be offering a wide range of formulations for our patients to take advantage of including hangover recovery, jet lag, fatigue and stress relief, dehydration treatment, migraine relief, cold and flu remedy, vitamin boost and hydration, a beauty enhancement formula, and a treatment to maximize athletic performance. If you’re feeling under the weather or need an extra boost, IV Nutrient Therapy may be just the thing for you! Call our office to schedule today! Services are available on Sundays from 8am till 2pm.
- 28 March 2016
- Internal Medicine Blog
April is Sexual Assault Awareness month, so we wanted to take the time to go over this tough issue that far too many women encounter. Many people think of sexual assault as “rape,” but what most people think of as rape is only just one form of sexual assault. Sexual assault comprises of sexual acts performed by one person on another without consent through intimidation or force. This can happen when someone is cognizant, or if the victim is passed out, drunk, or on drugs and not able to make decisions for herself. People can be sexually assaulted by strangers or people they know, such as family members.
Sexual assault is very common. In the United States, one in three women will be a victim of sexual assault during her lifetime and only 10 to 15 percent of sexual assaults are reported to the police. The number of cases that are reported decreases when the woman knows their assailant.
Sexual assault can be traumatizing and debilitating, but with the appropriate resources, it does not have to be overwhelming. The first thing you should do after a sexual assault is find a safe place away from the person who attacked you, then:
- Call a close friend or family member. Choose someone who will give you support no matter what.
- Call 911, go to the emergency room, or call a provider here. In the emergency room, a doctor or nurse can do an exam and make sure you are OK. They can take samples of cells or fluid from your body and clothes. These samples can show who your attacker was and what he or she did. You do not have to let the doctor or nurse do anything you do not want. We do not have the test kits available in our office to get DNA samples, so we would make sure to refer you to the appropriate center to have that done. Either way, either a provider here or at the emergency room will be able to offer you medicines that can reduce your chances of getting pregnant or an infection. Emergency contraception can work 5 days after being raped, but it works better the sooner you take it, so don’t wait. If you are older than 17, you can get some forms of emergency contraception without a prescription.
- Do NOT try to clean up before you see a doctor or nurse. If you clean up, you might wash away proof of what happened. This includes:
- do not change clothes
- do not take a shower or bathe
- do not brush your teeth
- do not wash the inside of your vagina or rectum (in other words, do not douche)
- If you can wait, try not to go to the bathroom or to eat anything until after you have seen a doctor or nurse
- Seek emotional support- someone you can talk to about what happened. We have therapists at our practice who are good resources to talk to after any traumatic event. Other options include your primary care provider, a crisis counselor, a social worker, or a sexual assault nurse examiner.
- Talk to your provider or counselor about filing a police report. If you do not want to report the assault, you do not have to, but people often change their mind later. Either way, it could be helpful to talk to one of the providers here or a counselor. Evidence is most useful when it is collected right after the assault.
- Return to our office 1 to 2 weeks. This will give us a chance to do any follow up lab work that is needed and to make sure you are doing Ok.
- Protect others if you might have an infection For at least 3 months after being raped, if you have sex with someone, use a condom every time. This will reduce the chance that you will spread any infections you might have caught. Also, wait at least 3 months before trying to get pregnant. That way, you can find out before you get pregnant if you have an infection that could hurt the baby.
- If it has been awhile since you have been attacked, please schedule an appointment with us anyway. It doesn’t matter if we cannot collect proof of the attack. We will be able to test and treat you for infection or pregnancy, and help you recover from the event. We can also provide you with resources to help you if you decide you would like to report the event.
Additional resources available in the event of any sexual assault are:
- The Sexual Assault Hotline 1-800-656-4673
- Women Organized Against Rape: Philadelphia’s Rape Crisis Center 215-985-3333
- Pennsylvania Victims Compensation Assistance Program (VCAP) to receive compensation for expenses incurred as a result of a crime www.pccd.pa.gov/Victim-Services or 1-800-233-2339
- 29 February 2016
- Internal Medicine Blog
By: Maria Mazzotti, D.O.
Lead poisoning presents with very non-specific symptoms such as abdominal pain, constipation, irritability, anemia, difficulty concentrating and especially in children, developmental delays, learning difficulties and vomiting. Although it seems to be more prominent in children than in adults, repeated slow exposure in adults can also be very critical. Lead exposure in adults can lead to increased risk of hypertension, renal damage and cognitive decline if gone undetected.
Children are more likely to get it by inhaling or swallowing lead in dust. It may also be in paint chips in houses built before 1978. We have also learned that certain toys that are manufactured outside of the US contain lead. Finally, we were recently reminded that water that travels through lead piping could also carry dangerous amount of lead particles.
Interestingly, in adults it seems to be more likely to occur in men than women, due to occupational exposure such as in the manufacturing of batteries, cable wires, car radiators and batteries, cosmetics, tin cans, glazes, paints and ceramic ware. Obviously, if you are remodeling an older home you should be wearing a mask. It is important to tell your physician if you work in any of these environments.
It is even more important if you are pregnant or breastfeeding. If there is concern, the blood from the baby’s umbilical cord should be tested at birth or the baby’s blood at 2 weeks. Since lead poisoning can also be transmitted through breast milk, and if there is concern, it is recommended that mom and baby be tested.
Lead poisoning can be prevented. Obviously, if you are aware of lead in your house, there are lead abatement professionals that can come into the house to eliminate the lead. Nutritionally speaking, you can have a diet rich in calcium, vitamin D and iron to prevent lead poisoning. Children especially should take a multivitamin with iron on a daily basis.
When your lead levels are high enough, you will need to undergo a treatment called Chelation. Chelation involves taking a medication that helps the elimination of lead from your body. It is important to keep in mind that since Chelation does not reverse the long-term effects of lead on learning and intelligence, patients should only be treated if they are no longer exposed to the lead environment.
- 29 February 2016
- Internal Medicine Blog
Philadelphia’s drinking water is sourced from the Delaware and Schuylkill rivers. It is monitored and regularly tested throughout the treatment process before it reaches your faucet. This includes a corrosion control treatment to help reduce the amount of lead leached from pipes and testing for more than 100 contaminants, including lead. The Philadelphia Water Department also does lead-specific tests in more than 50 “vulnerable” homes that may have lead exposure or lead pipes. The results help to determine if the corrosion control treatment technique is successful and verify that there is a minimal amount of lead leaching from the plumbing. Current tests shows these levels are minimal and that Philadelphia’s water quality continues to meet all State and Federal standards.
However, there is some skepticism with the way the Water Department tests for lead, saying that current testing may mask the problems. This controversy states that the testing of water differs from the way residents use tap water, and true levels are not represented in results. The removal of the aerator, a small filter, and “pre-flushing” running cold water to clean out the system prior to testing, alter results and make levels seem safer than they are. The Philadelphia Water Department has responded saying flushed samples are not what is tested. Guidelines state residents in high-risk homes to flush their faucets in an effort to clean their pipes of the chemical, not as a method to rid potential samples of it. Increased interest in Flint and questions about Philadelphia’s water quality has led Councilwoman Helen Gym to hold future hearings to discuss prevention of a Flint level catastrophe happening here. Gym says, "I don't think Philadelphia is Flint, but, we need to be vigilant."
There are many ways to reduce you and your family's risk of lead contamination. If you’d like to get your water tested, at-home tests are available from home improvement stores, but may not be accurate. The EPA recommends using a certified laboratory for testing. Lists of approved labs in the Philadelphia area are available from the Pennsylvania Department of Environmental Protection. Call 717-346-7200 to find a lab close to your home. Most labs will either send out a testing kit or schedule a test at your home. The PWD can also send someone to test your home.
Warm water increases the chances of leaching from your pipes, so before use, run the faucet on cold for a few minutes to flush any lead and bring fresh water into your pipes. When using tap water for drinking and cooking use cold water as well. You could also filter your water, unfortunately, commonly used filtered water pitchers may not do much to remove lead. A reverse osmosis filter is recommended if you suspect you may have lead contamination. Remember, even if you have lead plumbing it does not mean you have high levels of lead in your water, due to the city’s methods of preventing lead corrosion.
If you’d like to help the residents of Flint, Michigan, there is a multiple ways to do so. There are a number of established organizations bringing aid to those residents that are accepting donations, including The Flint Water Fund by United Way of Genesee County, The Flint Child Health & Development Fund of The Community Foundation, Catholic Charities of Shiawassee and Genesee Counties, and other organizations like Water We Fighting For. You could also support the research team, Flint Water Study, aiming to keep the residents informed about what is really happening with their water. Last but not least, you could sign the petition asking Gov. Rick Snyder to stop making Flint residents pay for poisoned water!
- 26 January 2016
- Internal Medicine Blog
We have all seen the commercials. A patient in obvious pain is shown with a terrible looking rash over a significant portion of his or her body. They are asking questions such as “why me?” and “what could I have done to prevent this?”. These patients have been diagnosed with shingles, and the suffering pictured can be accurate. Here’s what you needs to know about this disease and how to prevent a severe outbreak.
Shingles, also know as Herpes Zoster, is caused by the Varicella Zoster Virus (VZV). This is the same virus that causes chicken pox (varicella). After a patient has had the chicken pox or received the varicella vaccine, the VZV continues to reside in the nerve roots indefinitely. The VZV can then be reactivated, leading to a case of shingles. Any patient who has had the chicken pox or the Varicella vaccine is therefore at risk for shingles.
While most severe cases are seen in patients over the age of 60, shingles can occur at any age. Generally, individuals will only have one case of shingles in a lifetime, but recurrent cases are possible. Those who are immunocompromised are at higher risk of recurrence.
The hallmark symptoms of shingles are pain and rash. Approximately 75% of patients have pain prior to the rash developing. This pain is usually described as burning, throbbing or stabbing and can occur days to weeks prior to skin lesions.
The shingles rash starts as red papules (bumps) and evolves into grouped vesicles or blisters. After about 3-4 days the lesions may become pustular and will crust over at 7-10 days. Once these lesions are dry and crusted, the patient is no longer contagious. Because the virus resides in the nerve roots, the rash tends to involve a limited area on only one side of the body. The most dreaded shingles infection involves the trigeminal nerve located in the head. Infection here can lead to Herpes Zoster Opthalmicus, which can be sight-threatening. An individual with this manifestation will have lesions around one eye and the tip of the nose.
The most common complications of shingles include: post-herpetic neuralgia and bacterial superinfection of the skin lesions. Post-herpetic neuralgia is pain that persists at the sight of the rash for months to years following infection. It occurs in 5-20% of those with shingles and is more common in patients over the age of 60.
When discussing shingles with patients, the most common questions I hear relate to transmission and contagiousness of this disease. Let me try to break it down simply for you. You cannot give someone else a case of shingles. The VZV can be passed from contact with the skin lesions and is generally not airborne in an individual with shingles. Only people who have not had chicken pox or the varicella vaccine, or are immunocompromised are at risk when in contact with a shingles patient. If one of these individuals comes in contact with the active shingles lesions, they could go on to develop chicken pox, but NOT shingles. I am often asked about pregnant women and exposure to shingles. If the pregnant woman has had chicken pox or the vaccine in the past, there is very little risk present. That being said, I would recommend that a patient with an active shingles infection avoid infants, pregnant women and the immunocompromised until lesions have crusted over. It is advised to keep the rash covered and wash hands frequently to prevent transmission.
For older patients, there is a vaccine available to help prevent shingles. Though this vaccine will not prevent 100% of cases, it has the potential to reduce the severity of an infection and prevent the dreaded post-herpetic neuralgia. This vaccine is recommended in patients 60 and over (though it is FDA approved for those over 50). It can and should be given even if a patient has had a history of shingles. Talk with your doctor to see if the shingles vaccine is right for you.
In summary, the vast majority of the population is at risk for shingles. It is most common in older patients and those with weakened immune systems. The VZV responsible for this disease can be transmitted through contact with the skin lesions, but only those who have not had chicken pox or the varicella vaccine or the immunocompromised are at risk. If you are older than 50 talk with your doctor about getting the shingles vaccine.
- 26 January 2016
- Internal Medicine Blog
Whether you just get a pimple or two the day before your period or have a constant struggle, acne is a frustration that can cause embarrassment and anxiety for many women. Acne can be triggered by excess oil production, which can clog pores and promote bacteria growth. Many treatments exist, both topical and oral, that target different portions of the process leading to acne. One very effective treatment is birth control pills. Combined birth control pills (those containing both estrogen and progesterone) have been shown in many studies to cause decreased acne flare-ups, fewer pimples, less inflammation and less severe acne.
HOW IT WORKS
Birth control pills work to improve acne mainly by reducing the amount of androgens (male-type hormones, including testosterone) in your bloodstream. This occurs as a result of your liver increasing its production of a protein called sex hormone-binding globulin, which binds androgens making them inactive. This is beneficial, as oil-producing glands in the skin are stimulated by androgens. For some, the pill will also decrease the amount of androgens made by the ovary, additionally decreasing oil production in the skin. It can take a few months on the pill to maximize these effects.
WHICH PILL IS RIGHT FOR ME?
There has been an explosion in the number of new birth control pills in the past decade and few have been directly studied for their effect on acne. Currently, only 3 types have been FDA approved for treating acne: Ortho Tri-Cyclen, Estrostep and Yaz. However, all combined pills will likely have some effect. The degree of improvement can depend on the type of progesterone in the pill, since some types directly cause more androgen-like effects than others.
While birth control pills are a safe and effective way to decrease acne (and prevent pregnancy) for many women, there are some side effects and risks of this hormonal treatment. Some women experience headaches, nausea, breast tenderness and mood changes, which may improve or resolve with switching to a pill with a different dose or type of progesterone. All combined birth control pills can mildly increase the risk of blood clots, such as a deep vein thrombosis or stroke. This increase is small overall, but may be of concern if you have another risk factor for clots such as smoking, obesity or a significant family history of clots. Recent studies also indicate that some types of progesterone may have a higher risk of clotting than others, although these differences are likely very small.
OTHER BENEFITS OF THE PILL
Birth control pills have other benefits, such as decreasing amount of menstrual bleeding, cramping and premenstrual symptoms, and have also been shown to cut the risk of ovarian cancer in half if taken for >5 years. If you are interested in learning more or think birth control pills might be a good option for you, come in for a discussion with your doctor or nurse practitioner.
- 27 November 2015
- Internal Medicine Blog
I’d like to address some common misconceptions about daily medications used to treat depression and anxiety. These medications are classified as antidepressants or antianxiety medications, and work by affecting the neurotransmitters in the brain, chemicals that help transmit signals. One person can have mostly depressive symptoms and benefit from the same medication as a person who has crippling anxiety but doesn't feel a bit depressed. Though lifestyle changes and seeing a therapist can help many with mild symptoms, if your depression or anxiety persists despite this (or it prevents you from being able to take these steps) it does not mean that you failed or that you just didn't try hard enough. Sometimes you need some additional help for a time and that is okay.
Like most medications antidepressants or anti-anxieties come with a long list of potential side effects, but the doctor will review the most serious and most common ones with you before prescribing. Everyone is different - you may experience a lot, some, or none of the side effects. These medications are not “happy pills,” nor are they intended to make you feel numb or like a zombie; if you are feeling this way then it may be a sign that it is not the correct medication or dose for you. The goal is to make you feel more like yourself!
Often I will hear people say that they don’t want to use these medications because they see them as a crutch. I like to think of them more like a cast; they help hold everything in place while you do the work of healing. Then you take them off.
Many people worry if they start taking a pill then they will be on it their entire life. Though there are people who continue to take daily medication for decades, a vast majority will be on it for a much shorter time. Part of the process is a regular and ongoing reassessment. When a medication is first started, your doctor will have you come back in about six to eight weeks to see how it is working. Once they have found a medication and a dose that works for you we generally have you follow up every six months or so thereafter to see how you are doing. Timing, of course, varies from case to case. If things are going well then you may feel like it is a good time to stop the medication. If things are still not that great then you should continue the medication and check back in in a few months. These are not medications you want to stop abruptly; they can have some pretty unpleasant withdrawal symptoms, so your doctor will wean you off of them by incrementally decreasing the dose over a period of time.
Medications are not for everyone but having correct information is a great first step in determining if something is right for you. If you would like to learn more about treatments or talk over how you have been feeling please come in, the doctors at Rittenhouse Women’s Wellness Center are always here to talk and to listen.
- 02 November 2015
- Internal Medicine Blog
Contraceptive care is an integral part of women’s health and family planning. The choice to plan to bear children or not is an important decision, and the outcome can have life changing effects. According to the National Conference of State Legislature, almost half of pregnancies in the U.S. are unintended. Most women nowadays graduate college and are career driven. They would prefer to plan their pregnancies – and this is possible through the use of contraceptives. It is critical to understand your insurance coverage under changes in health care laws, which have pushed to expand women’s’ health care since January 2013 by requiring coverage of certain preventative health services and screenings, including contraception. Despite comprehensive coverage required by law, some employers have the ability to not offer contraceptives.
Required contraceptive care can be bypassed by employer’s plans that have been “grandfathered” in as well as those who opt out due to religious beliefs. Churches and other houses of worship are not required to include birth control coverage to their employees. Non-profit organizations that object to offering birth control because of religious reason may also do so, but women may still have access directly from their insurance company. You may remember the Hobby Lobby controversy, in which the for-profit “family-owned” corporation was able to refuse birth control coverage. In this case the Supreme Court decided that certain “closely-held” for-profit corporations can deny coverage on religious grounds. Figure out what your employer’s insurance plan allows and if it is in accordance with the law.
As mentioned earlier, most insurance plans now allow women to select an option to include contraceptive benefits at no additional cost. If you are sexually active and not looking to have children at this point in your life, (and your employer does not offer this benefit) you may want to talk to you Human Resources Director to see if this benefit can be added for you. Once you are ready to have children, you may talk to your health care provider about discontinuing your contraceptive care.
The bottom line: When you visit your health care provider regarding birth control, be sure you have contraceptive coverage and you should not have to pay a co-pay for your oral contraceptive.
- 02 November 2015
- Internal Medicine Blog
Hormonal or Non-Hormonal?
There are several non-hormonal methods to prevent pregnancy. Natural family planning or fertility awareness method is a method in which a couple opts to avoid sexual intercourse or use a barrier method during times of ovulation. This requires careful planning and discipline; a woman must have regular menstrual cycles and understand when she is likely to ovulate to be successful in pregnancy prevention. There are various apps for smart phone users that can keep track of cycles and peak ovulatory days. The efficacy of this method largely depends on consistency and vigilance of the couple; it is unclear but suspected that as many as 25% of women experience unintended pregnancy within the first year of typical use of this method.
Other non-hormonal methods work by either creating a physical barrier preventing sperm from reaching the egg (inhibiting fertilization) or killing sperm altogether. In general, non-hormonal methods tend to be less effective than hormonal methods, with the exception of the Copper-T IUD. Male and female condoms are the only methods that can decrease the risk of transmission of sexual transmitted infections (STI/STD). Examples of non-hormonal methods include:
· Male or female condom
· Cervical cap (FemCap)
· Copper – T IUD (Paragard®)
Hormonal birth control alters the hormone fluctuations in a woman’s body, thereby inhibiting ovulation, thinning the uterine lining, and/or thickening the cervical mucus. Hormonal birth control not only prevents pregnancy but it is also used to control heavy menstrual cycles, improve menstrual cramps, stop PMS, and even treat acne and unwanted hair growth. Studies also prove that prolonged use can decrease the risk of endometrial and ovarian cancer. But hormonal birth control does not come without risks and side effects. Some women may experience side effects including headaches, bloating, and mood changes. Also hormonal birth control may increase blood pressure, lead to migraines with visual disturbances, and carry a slight increased risk for stroke and blood clots, especially in certain health populations. It is also important to note that hormonal birth control does not prevent the transmission of STI’s. If used correctly hormonal methods tend to be more effective than non-hormonal methods. Examples of hormonal birth control include
Oral contraceptives (“birth control pill”) – a pill taken at the same time every day to prevent pregnancy. There are both estrogen/progestin preparations and progestin-only preparations. It is the most commonly used hormonal method. Side effects may include nausea, bloating, and breast tenderness.
Ortho Evra® (“The Patch”) – estrogen/progestin containing patch placed on the skin (usually abdomen or buttocks) that is worn for 3 weeks and removed for 1 week to induce a cycle. Side effects are similar to the birth control pill.
NuvaRing® – estrogen/progestin vaginal ring placed for 3 weeks and removed for 1 week to induce a cycle. Side effects are similar to the birth control pill.
Depo Provera® (“The Shot”) – progestin-only injection given in office every 3 months. The shot may cause irregular bleeding and weight gain.
Nexplanon® (“The Implant”)– small, progestin-only rod placed in the upper arm in a quick office procedure. It is effective for 3 years. Most common side effect is irregular bleeding
Levonorgestrel Intrauterine Device (Mirena®, Skyla®, Liletta®) – progestin-only T-shaped device placed in the uterus at a quick office procedure. Approved for use for 3 or 5 years use. Most common side effect is irregular bleeding.
Which Method is Right for Me?
When choosing a birth control method several factors should be considered. Do you plan to have children soon or many years in the future? Does cost matter? How effective is each birth control method? How will a particular method impact my health? There is no perfect form of birth control that fits the needs of every woman, so approach your birth control choice with personal reflection. Speaking with a healthcare provider about what your needs is the best way to start the conversation. We offer various options of birth control at Rittenhouse Women’s Wellness Center. Please contact the office at 215-735-7992 to schedule your appointment and start the path towards taking charge of your reproductive health; your future depends on it.
Rittenhouse Internal Medicine™ has received the highest recognition from the National Center for Quality Assurance (NCQA). What this means for our patients