Month: May 2015

Dr. Swiner’s Medical Note of the Month-June 2010-Dog ticks, and deer ticks, and mites..oh my! by Nicole Price Swiner on Friday,

Tick season seemed to start earlier this year than usual. One of my partners in our practice in March said she awoke one morning with a deer tick, and we knew the season was here.

the interesting things I’ve learned about since practicing in N.C., as these illnesses are more common in the Southeast. But apparently they are an issue all over the U.S. during this time.

The illnesses include the above-mentioned RMSF, Ehrlichiosis, Tularemia and Lyme disease. Lyme disease is actually very rare in N.C., because the tick that carries the disease is rarely found here.

The usual season for ticks is during the spring and summer months. The different types of ticks vary from dog ticks to deer ticks to Lone Star ticks. The American dog tick is generally a reddish-brown color and becomes large and red after it’s attached itself and fed. Deer ticks are usually smaller and darker than dog ticks. The Lone Star tick is also small and reddish-brown in color but usually has a white spot on the back. Clear as mud? If confused like I was, you can go to the Center for Disease Control and Prevention website to see pictures.

I also have a hard time identifying which is which, so I’ve posted a picture of types in my examination rooms for patients to point them out. Lone Star ticks are probably the most common type in this area, and they cause symptoms like fever, headaches, body aches and possibly a round “bulls-eye” rash where they have bitten. This is the classic rash called erythema migrans, and it’s very helpful to see when trying to diagnose the illness. Not all tick bites will cause the symptoms if caught early enough.

The best way to remove them is with tweezers and picking the whole body off, but most importantly the head. If you don’t know whether you’ve removed the entire body, don’t play around with it, have you doctor look at it and remove the rest as quickly as you see it. Don’t use matches or ointments, because they don’t work well all the time.

Once symptoms have been identified, your doctor may go ahead and start treatment or do blood work. Labs that are affected by tick-borne illnesses include white blood cell count, platelet count, liver labs and sodium. There are also antibody tests for RMSF, Erhlichiosis and Lyme disease. Once I generally have a good idea that a person has been affected, I usually will start treatment with Doxycycline, which is the most common antibiotic that treats all the common types of tick-borne illnesses. The medicine is prescribed either for one or two weeks depending on the severity of symptoms.

Now, to say a word about Lyme disease in N.C. – it is present but not very common. In 2008, the CDC reported 16 cases in the state versus 2,000 to 3,000 cases in the upper north states of Connecticut and Minnesota. Because of its long-term effects and consequences – arthritis and neurologic effects – Lyme disease is taken seriously. But the other types of tick-borne illnesses are far more common here in N.C. Be careful this summer!

* Reference: www.aafp.org (American Family Physician), www.cdc.gov (Center for Disease Control and Prevention)

  1. Nicole Price Swiner, MD, works for the Durham Family Practice in Durham. Contact her at 220-9800.
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Dr. Swiner’s Medical Note of the Month-June 2010-‘Tis the “allergy” season……

‘Tis the season for pollen, mold and trees. Recently at the clinic, I think half of my 20 visits involved complaints of “I think I have a sinus infection.” The response to my “Why?” included many common truths and misconceptions, ranging from “because I’ve been congested for a week” and “because I have green and yellow mucus” to “because this happens every year to me.” 

The truth is all of these signs of symptoms may be present, but I’d bet money that patients are correct less than 30 percent of the time when trying to self-diagnose themselves with infection versus inflammation. Would you know the difference?

Let’s first review the common cold, which I’ve talked about many times before. A cold is a viral infection, which means there’s no great cure. There are ways we can shorten the duration of symptoms, but if I had the cure to a cold, I’d be a retired millionaire.

If you read a medical textbook, it would say symptoms of a cold include headache, muscle aches, low-grade fever, runny nose and cough, which can last for about a week. By day seven, symptoms generally begin to dissipate. Because it’s a viral infection, antibiotics are not the treatment.

Let me repeat myself: Antibiotics do not treat colds.

I can imagine what the next question might be, and the answer is you’re right. Doctors do and might prescribe an antibiotic when you present with a cold. However, this is incorrect and should not be done. This helps to produce super-bacteria that are resistant to the drugs we currently have and create monsters such as MRSA or methicillin-resistant Staph aureus and other resistant bugs.

This means it will be harder to treat you if and when you do have a bacterial infection in the future. I hear the mumblings of the next question: Then, why do antibiotics seem to work when taken for a “cold”? I put cold in quotes on purpose, because what patients often think is a cold isn’t really one. It may be a bacterial sinus infection, walking pneumonia or Strep throat. Or, what I believe is the most common reason, the cold was going away on its own, and it was coincidental that you were taking the antibiotic at the same time.

What does help and what has been proven in studies to help includes taking Zinc (such as Zicam) or eating chicken noodle soup at the first start of symptoms to cut your sick time by two days. Notice I didn’t say cure but shorten the amount of time you’re sick. After trying to shorten the duration of the cold, we treat the individual symptoms with antihistamines, cough medicine, menthol, tea and salt water gargling.

During the allergy season, it becomes even harder to differentiate because symptoms are similar. Classic allergy symptoms include sneezing; runny nose; itchy, red eyes; congestion and headache. Allergies don’t occur with fever and are treated with antihistamines like Zyrtec or Claritin. Other important treatments include steam, nasal saline and washes, and cleaning one’s filters in the house and car. A chronic cough can be caused by allergies.

Another million-dollar question is: “Does green mucus mean I have an infection?” Yes and no. It could mean an infection, but it doesn’t mean it’s bacterial. It is a sign of white blood cells fighting something, and that something could be an allergy or a virus. A bacterial sinus infection is when one-sided facial pain, runny nose, fatigue, congestion, tooth pain and sneezing begin, and is prolonged. Talk to your doctor about concerning symptoms.

C. Nicole Price Swiner, MD, works for the Durham Family Practice in Durham. Contact her at 220-9800.

Dr. Swiner’s Medical Note of the Month-May 2010-Updates on birth control

In a recent “Ask Dr. Swiner” segment on my Facebook page, I had a number of interesting questions about what’s new in birth control. I deal with this issue frequently in my practice, and even I have to make sure I’m up-to-date with the information that comes out.

f levels of estrogen and progesterone that balance one another and allow a woman to have monthly, regular menstrual cycles. Some pills, if taken without taking the placebo pill (the ones at the end of the pack that are usually a different color), allow a woman to have only three menses a year.

We’ve had the patch, the ring, the shot, the implant and the pill for a number of years. Most recently, IUDs have become all the rage. Intrauterine devices such as the Mirena and the Paragard are one of the “hands-off” methods, in that the woman doesn’t have to do anything except wear a condom to prevent STDs, of course.

A doctor places the plastic device into the uterus during an office visit, and that’s it essentially. When the woman is ready to have it removed at five years (Mirena) or 10 years (Paragard), the doctor takes it out. Recently, the complaint I’ve heard from women about the IUD is that it appeared to thin their hair, which might, theoretically, occur with any hormonal option or for other reasons if they’re postpartum.

What can be unpredictable about Mirena IUDs is the way a woman’s cycle might change once it’s placed. Because it’s made primarily of progesterone and does not have estrogen – like most pills – to balance it out, it can change the timing of menstrual cycles. What I tell most women is the rule of thirds: approximately one-third of women with the IUD may have their normal, monthly cycles; one-third may have no cycles, which is usually what the majority of women hope for; and one-third may have variable, unpredictable cycles. We don’t know which group you’ll end up in until we place the device. In most cases, however, women are pleased with this method of birth control.

Norplant was put out a couple of years ago, and it is known as the implant that is placed under the skin of the arm and lasts for up to five years. It was a five-rod method made primarily of a progesterone-related hormone like the IUD, meaning it may have the same effect on bleeding.

It was taken off the market about four years ago, and now we have Implanon, the “new and improved” version. This one lasts for up to three years and has to be removed after this point. Instead of five rods, Implanon only has one and appears to have less bleeding variability, less bone loss concern and less weight gain than some of its counterparts. I was recently trained to place this method, and it seems to be a good alternative to the Depo-Provera injection for women who may want to try something different.

The newest contraception I’ve heard about is Essure. Instead of going into an operating room and having a bilateral tubal ligation, or getting your tubes tied, this is an outpatient version of the procedure. It involves the release of small metal coils into the fallopian tubes to block fertilization. It is irreversible. The usual surgery that is done to have a tubal ligation is now possibly reversible, depending on how the surgery was done and who performed it. And finally, there is another type of outpatient surgery; one that doesn’t involve any female anatomy, and that’s a vasectomy.

  1. Nicole Price Swiner, M.D., works for the Durham Family Practice in Durham. Contact her at 220-9800.

Dr. Swiner’s Medical Note of the Month-April 2010-Teens, adolescents deserve special treatment

I work with a large population of teenagers and adolescents in my practice, mostly during times of sports and school physicals, but also during illness, birth control, or STD testing and treatments. With this comes great responsibility and challenges because of this age group (11-20.)

group and should be regarded as such. Teens and adolescents are not simply “small adults,” nor are they older children; they’re in their own group.

gone are the days of checking their blood pressure and pulse, heart and lungs, vision and hearing, giving shots and sending them out the door with a signed school form. Nowadays, due to the increase of medical, social and emotional problems of this age group, medical professionals – and, more importantly, parents – must spend more time talking. I choose to add more time to my usual 20-minute visit with my teen and adolescent patients for counseling for many reasons, and this is why.

You might have heard me on the radio or read other articles here discussing my concern for teens and adolescents, particularly in the Triangle and specifically in Durham. Medical issues for teens and adolescents in the area have been a surprise for me as I’ve tried to treat them. These issues include rising rates of Chlamydia, gonorrhea, HIV and depression.

Statistics in 2007 for our state note that 70 percent of kids have had sex by the 12th-grade. This is an unfortunate case despite sex education in high schools. Another unfortunate issue is the sex is often unprotected, meaning without a condom. Teen pregnancy continues to be an issue that I deal with in practice despite my repetition of “Abstinence is best but use a condom if having sex.” I say this over and over and over again, but it’s still not enough.

Other statistics in N.C. report that 11 percent to 15 percent of teens and adolescents say they have attempted suicide one or more times by 11th-grade; 30 percent have smoked tobacco by 12th-grade; almost 45 percent by 12th-grade have had alcohol; and the state is ranked ninth in the country for AIDS in all age groups.

The sad conclusion is the ball is being dropped somewhere. I try to yell from the rooftops for young adults to take care of themselves, protect themselves and not form harmful habits, but it’s not enough. It has to be reiterated at school, at home and in the media. The only statistic that has improved somewhat is smoking. With efforts, and likely media such as the Truth commercial campaign, we have been able to decrease the use of tobacco in N.C. The same needs to occur for STDs, violence and mental health.

Speak openly and freely with your young people at home so they feel they have a voice to ask questions, and you can educate them appropriately. Instead of just talking, I got involved.

TeenFest is a group that involves positive teens and adolescents that mentor one another, and share information on preventing violence and encouraging good health practices. They are based mostly in Raleigh and Wake County. Another group to note in Durham is the Adolescent Health Initiative that is dedicated to enhancing the health of adolescents in Durham. There is room for interested adult advocates, parents and teens to become involved. Check them out at teenfest.org anddurhamahi.org, or on Facebook.

References:• 2007 Youth Risk Behavior Surveillance Survey• Portrait of Adolescent Health, NC Metamorphosis Project

  1. Nicole Price Swiner, MD, works for the Durham Family Practice in Durham. Contact her at (919) 220-9800.

Dr. Swiner’s Medical Note for the Month-March 2010-“Ask Dr. Swiner!”

ole_swiner@med.unc.edu. Enjoy………

Question 1:I have a question about a “bruise” on my right breast. I don’t remember running into anything but I’m clumsy so anything is possible. The bruise looks like a black and blue mark but it hasn’t gone away in a month!! I asked my gyno what it could be but he seemed unconcerned and called it a bruise. It’s not raised in anyway and feels no different than my skin. It’s not on the areola or nipple, just on the part of my breast kind of close to my underarm (actually, when I wear a bra, the strap pretty much goes right across the bruise).I also have a non-raised mole near the bruise but I’ve had that forever and it hasn’t changed in appearance. My question is what kind of doc should I see to check it out? A derm? My gyno again??

M.L. (black female, age late 20s)

Dear M.L.,Do you have a general/family/internal medicine doctor? If so, he or she might be the best one to ask. It’s not painful, right? I would examine it to see if I could feel any lumpiness underneath it. Even if you did have a lump, it’s still probably benign and will go away on its own. It’s probably nothing, but if it hasn’t changed in a month, I’d probably ultrasound it. Hope this helps.

Question 2:…I’ve been having a real concern for females as of late. I work on a college campus and am finding out that they are believing themselves to be virgins if they do any and everything with the exception of penis to vagina contact. I’d heard some of this when I was in college (was that 10 years ago or better, yikes!) but what is blowing my mind is that the young ladies in our African American communities are also thinking likewise. This means that parents are not having the appropriate conversations. What can we do?

T.C. (black female, early 30s)

Dear T.C.,You make great points, ones that I didn’t even realize. Clearly, any penile to orifice contact is dangerous and can lead to viral infections and sexually transmitted diseases, such has herpes, HIV, and HPV (human papilloma virus). All of us–parents, doctors, and mentors–need to be more clear when discussing this issue with teenagers nowadays and cover all types of intercourse. In all cases, use condoms. No excuses! Be more open and comfortable to talk to them. If you’re not comfortable, find someone who is.

Question 3:What are some signs and symptoms of teen depression?

J.S. (44 year old mother of 2 teenagers)

Dear J.S.,Teens with depression may have the classic signs of depression that you’d might expect an adult to have, such as decreased mood, disruptions to sleep cycles, or changes in eating habits or weight. However, they more commonly become irritable and have mood swings, withdrawn and are less social, and may become hyperactive. It can be difficult to determine this from the usual fluctuations of attitude and mood of a “normal teenager”. However, if he or she appears to be constantly disengaged, withdrawn, or has decreased concentration and focus, see a doctor.

Dr. Swiner’s Medical Note–Necessary vs. unnecessary medical care

I asked some friends what they wanted my next article to be about and, interestingly, I received two requests – almost the opposite of the other. One friend asked about the importance of regular exams. The other wanted to discuss how NOT important some exams were.

cal exams because of how “healthy” a person can appear on the exterior yet have many silent and deadly disease occurring internally. The second friend commented on how many tests and studies were being discussed as “must-haves,” appearing to be unnecessary on the back end.

I refer back to a November article I wrote on the controversial change in recommendations on mammograms. It centered around the fact of decreasing how many mammograms a women gets and increasing the age at which she starts getting one depending on her history and family history.

Some people thought this was a conspiracy for insurance companies and the government to save and make money. Others were pleased that finally someone agreed that some of these tests are at times unnecessary.

Whichever way you go about it, my main point is always to have an educated conversation with your primary clinician about the pros and cons of any procedure. This includes annual physical exams and tests. My belief is, regardless of one’s health, it is always a reasonable idea to have a yearly checkup as we often find those signs and symptoms of silent killers like high blood pressure, diabetes or heart disease. Other conditions found that may not present with any symptoms are cervical disorders and sexually transmitted diseases.

The flip side of the coin is this: Has it been proven that doing annual physical exams actually help to prevent disease? Some research has shown that doctors are not as great with catching diseases when someone does not have symptoms. The U.S. Preventive Services Task Force is the organization that recommends how helpful screening tests and studies are, and how frequently we should have them done. You may have heard this name recently in the mammogram discussion and the change of recommendations with this study. To reduce unnecessary costs, stress and decrease false positives – meaning something looking falsely abnormal that is not really abnormal – yearly tests on some diseases might not be needed. These would include – for healthy patients with normal results in the past – pap smears, mammograms and cholesterol screening. The recommendation for mammograms was changed to say we only need them every two to three years after the age of 50, except under special circumstances, like family history of cancer.

How about tests like CAT scans, MRIs and such? Are they really necessary all the time? Certainly not. There could be a more efficient, cost-effective and less invasive test or study to do in many cases. However, there’s only one that we know of in the medical world to suffice.

Take the Pap smear for instance. As of right now, we do not have a better alternative to screening for cervical cancer in women. However, that doesn’t mean every woman has to have one every single year. I begin doing pap smears for women either two or three years after first sexual intercourse or age 21, whichever comes first. After a woman has at least two normal pap smears in a row and is sexually monogamous with one partner, I think it’s reasonable to start skipping years.

After a hysterectomy – unless done for a cancerous reason – or age 65, she can stop having paps altogether. But you wouldn’t know that unless you asked your doctor, which one should always do. It all depends on the situation and each individual patient’s risk factors.

Even if you’re not having any tests done, nothing takes the place of yearly checking in with your clinician or doctor to have him listen and feel your organs.

Dr. Swiner is accepting new patients at Durham Family Practice at 220-9800. She is also available for speaking engagements.

Dr. Swiner’s Medical Note of the Month-Jan. 2010-Stress induced disorders

This month makes a year that I’ve been writing articles for medical education. My first article centered on the issue of depression and being self-aware of the warning signs.

ical and physical complaints that we have or have to discuss can in some way or another be due to or can be worsened by stress. Let’s review some of those that have evidence behind them.

  1. Depression and anxiety/panic disorders. This is pretty easy to understand. The more stress a person has, the worse underlying mental health disorders can become. The stress of loss of a loved one, loss of a job or threat of losing your job, or a strained relationship can lead to overwhelming sadness or symptoms of panic. Insomnia and sleep disturbances can occur as racing thoughts and worry increase at night. Alcohol and tobacco abuse can also occur concurrently as ways to self-medicate in the absence of correct ways of treatment such as prayer, counseling, therapy or prescribed medication.
  2. Hypertension and heart disease. Otherwise known as high blood pressure, stress can cause an increase in constriction of blood vessels. Stress has not been proven as a direct cause of high blood pressure, but it can have an overall effect on the release of hormones from the nervous system and circulatory systems, which makes it harder for the heart to pump blood to our vital organs. If blood pressure is chronically high and blood vessels have enough damage or cholesterol buildup, heart disease can be the result. Some chest pain can even be linked to stress.
  3. GERD (acid reflux) and stomach ulcers. Emotional stress can lead to an increased production of acid from proton pumps and H2 receptors in our stomachs. If acidity is prominent, a burning sensation can be felt and pain can extend from the stomach (in the center and to the left of the middle of the stomach) all the way up to the esophagus and throat. Foods that we eat, including caffeinated beverages, spicy ingredients and citrus can make this worse. If left for too long, ulcers, or an eating away of the lining of the stomach, can develop and even worsen to the point of bleeding.
  4. Obesity. Stress can cause an increase of the hormone cortisol to be released from the adrenal glands. Cortisol is linked to increased glucose (blood sugar) and weight gain. Also, while some of us eat less with stress, many of us eat more “comfort foods,” which are generally more sweet and fatty, and have more calories.
  5. Headaches. Migraines are thought to be the most common type of headache, but tension is probably higher on the list of causes of headache. Both types can increase with stress. With tension headaches, a tense pressure or squeeze can be felt in any part of the head, usually with muscle tension and soreness of the neck and even shoulders. Migraines are thought to be associated with signals from the nervous system that relax blood vessels. When vessels relax, blood rushes to them and cause dilation. If too dilated, this can cause pain.
  6. Abnormal menstrual cycles. Skipping a period can be very distressing for a woman, especially if unexplained. Although we don’t know what the certain cause is, it is thought that emotional stress affects release of certain pituitary hormones that can cause irregular periods. If weight is lost or gained due to stress, estrogen or a lack thereof, it can also cause irregular periods.
  7. Viral infections. When we’re stressed or fatigued, our immune system doesn’t work as well to prevent us from infection. We all have antibodies from vaccines or from previous infections that have built up in memory cells and are programmed to increase when we are exposed to infections. Stress reduces this response. Colds can occur more frequently and, even worse, viruses such as herpes and HPV (human papilloma virus can show themselves during these “down” times.
  8. Cancers. This one is controversial, as some studies say one thing and some say another. The conflicting data questions whether stress can be a direct cause of some cancers. In 2002, a study was done on patients who had breast cancer that was treated. The question was asked if stress could be linked to the cancer coming back. The study could not prove it to be true. However, in animal studies, an increase of stress hormones was linked directly to growth of some tumors. Long story short, the evidence is inconsistent, but there may be truth to the claim that stress can lead to certain cancers.

All in all, be self-aware of the signs. If you’re feeling overwhelmed, as we all at some point do, be pro-active by exercising, drinking plenty of water, getting good restful sleep and doing those things that you enjoy doing with those you love. If it still feels like life is crashing down on you or your body is breaking down, please see your doctor.

  1. Nicole Price Swiner, MD, works for the Durham Family Practice in Durham. Contact her at 220-9800.