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Author: Stephen J. Klemawesch, MD

Sensitive – but timely and critical conversation for families to have

Sensitive – but timely and critical conversation for families to have

 Death. Unfortunately, in my line of work, it’s part of my daily life. If you’ve had an appointment with my dad anytime in the past year, you know that I recently shifted gears from an Emergency residency to a Critical Care fellowship. Having spent the last several years in the Emergency Department (ED), I’d forgotten what a different beast death is in the Intensive Care Unit (ICU). In the ED, death is swift, often unexpected and sometimes merciful. ICU deaths however, are frequently prolonged, often excruciatingly so – and in my experience, much more slow, painful experiences for everyone involved.

In the ICU, I often feel like I’m prolonging death and suffering rather than restoring life and vitality. My patients often have more organ systems that have failed than ones still functioning; death is being kept at bay by multiple forms or life support; ventilators, vasopressors, dialysis, ECMO (a form of partial cardiopulmonary bypass), etc. Very rarely is the person who emerges from that cloud of clinical contrivances the same that went into it. More commonly, they are frail shells of their former selves, often without all their faculties, and now condemned to the all-too-common narrative of discharge to rehab facility, where they will continue to linger until they incur one in a long line of complications and end up back in the hospital, often to do the whole thing all over again.

Now, you may say this is a very bleak representative of what the ICU is. Certainly, there are success stories, and not everyone is condemned to this fate. While that is true, those cases are not the impetus behind my writing this column. One of the reasons even frankly futile cases end up languishing on life support for days or months on end is their family’s inability to make complex medical decisions for the patient, which is why Advanced Directives (ADRs) are so important.

While it can be an uncomfortable or awkward discussion for many people to have, it is absolutely imperative that you think about and discuss your goals and wishes before you or your loved one end up in an unfortunate, unforeseen situation. Unless you’ve had a sick family member, or happen to work in health care, you likely have never heard of ADRs. Even those who have may not know everything that can go into them.

And while deciding if you want a breathing tube or CPR are certainly key decisions (described in the “DNR/DNI” portion of an ADR), advanced directives can go way beyond just that. You can make yours as personal and intricate as you want; e.g., blood transfusions, dialysis, feeding methods, surgeries, etc., etc. Or you can stick to the very basic DNR decision. There is a lot to think about and the time to do it is now. Making these choices by no means locks you into anything; you can change, update or rescind any decision at any time.

But where do you even start? Your primary care doctor is a good first stop. He/she likely has a social worker or specialized nurse who can help you through the steps or provide you with worksheets or information pamphlets. Or this person may refer you to a Palliative Care colleague. Family lawyers can be good non-medical resources to assist you through the process as well. Or you can do some research on your own—www.caringinfo.org and theconversationproject.org are both excellent resources.

Q – Tips: Dogs and allergies

Q – Tips: Dogs and allergies

 The University of Chicago just finished a research study showing the benefit of dog ownership in reducing the likelihood of allergies in children born into a pet-owning household. Children born to allergic parents reduced their risk for developing allergies by 33% if born into a household with dogs.

Pepper trees also get a bad rap

Pepper trees also get a bad rap

The Brazilian Pepper tree – also known as the Florida Holly – is an invasive species from South America that has spread throughout Florida and the Southeastern U.S. Many Floridians hate it because it is a common source of contact dermatitis similar in nature to poison ivy.

Despite this mischievous aspect of the plant, immunologists have discovered it has incredible antibiotic properties. Amazonian native healers have used the plant for hundreds of years for its medicinal value. Now modern science is jumping on board.

It turns out the berries and leaves contain a variety of flavonoids and terpenoids — especially thymol, carvacrol and myrcenol – which have proven effective against “super germs,” namely E. coli and the dreaded multi-drug-resistant Staph aureus (MRSA).

The plant enzymes work by several mechanisms, one of which is to destabilize the germ’s plasma membrane, causing it to rupture. Two others work through gene repression in the bacteria. Specifically, the Brazilian Pepper represses the gene that transfers antibiotic resistance, and the one that controls the production of bacterial toxins, thus lessening the virulence of the germ.

Veterinarians have started to use the plant extract to treat certain infections in dogs.

These ulcers probably not caused by allergy

These ulcers probably not caused by allergy

Dear Dr. K:  Dear Dr. K: I get recurrent aphthous ulcers in my mouth and on my tongue. Is this an allergic problem?

Known by various names, including canker sores, this condition of recurrent aphthous stomatitis (RAS) can be due to allergy, but that is one of the least frequent causes. Several systemic illnesses have RAS as part of their disease complex, including Behcet’s disease with RAS, genital ulcers, eye disease and neurologic symptoms; MAGIC syndrome with RAS, genital ulcers and inflamed cartilage; PFAPA syndrome with RAS, periodic fever and swollen lymph nodes; SWEET syndrome with RAS, periodic fever and significant skin rash, and Cyclic neutropenia with RAS, fever every 15 to 24 days and a low white blood count.

In terms of allergy, RAS is very rarely seen as a response to food allergy, but more commonly as an allergy to tooth paste – especially kinds that contain sodium lauryl sulfate. Very rarely it occurs from chewing gums that contain balsam of Peru.

Factors that predispose to, but don’t cause RAS are mouth trauma, tobacco, alcohol and poor nutrition. Occasionally RAS is seen from vitamin deficiencies including B1, B2, B6 and B12, folic acid and zinc. Another uncommon cause is Herpes virus that causes internal sores instead of the usual external fever blisters.

Some medicines can also cause RAS: Beta-blockers, ACE-inhibitors, antibiotics, some anti-arrhythmic drugs, NSAIDs and nicorandil. And there’s more: although uncommon, RAS can be a manifestation of celiac disease (gluten sensitivity). Whew! Pesky ulcers can have many causes!

Therapies vary depending on the cause and severity of the condition. Deficiencies in zinc, folic acid, iron and vitamins can be treated with replacement supplements. Avoiding foods that are irritating, such as alcohol, carbonated drinks, spicy foods and acidic foods can help keep the mucous membranes healthy.

Topical steroids in an oral base can be applied to the ulcers, and mouth rinses with the antibiotic tetracycline help some patients. Application of silver nitrate can cauterize and heal resistant ulcers. Medicated tooth pastes also can help healing.

Q – Tips: ionizers and ozone

Q – Tips: ionizers and ozone

Several local businesses recently have advertised installation of ionizers to central air-conditioning systems to improve air quality and reduce infections. The CDC (Centers for Disease Control and Prevention), however, recommends that ionizers only be used temporarily to clear contaminated air, but not on a permanent basis because they produce ozone.

Don’t blame the goldenrod — blame prolific ragweed

Don’t blame the goldenrod — blame prolific ragweed

When allergic people hear the word goldenrod, it makes them want to sneeze. But if truth be told, these plants have been victims of a bad rap.

Goldenrod blooms at the same time (late summer and fall) as ragweed, and because of its bright yellow flowers, it has been blamed for fall allergy symptoms.

But this plant produces a very heavy and sticky pollen that relies on insect transfer for pollination. It’s too heavy to fly in the wind. Ragweed pollen, on the other hand, is tiny and light, plus a single plant can release as many as a million pollen grains.

And goldenrod is not only friendly to humans, but also to insects. There are more than 100 species of goldenrod native to North America and their pollen feeds countless bees, butterflies and hummingbirds.

Take a much-deserved bow, noble goldenrod.

Not just face lifts with Botox

Not just face lifts with Botox

By Sasha Klemawesch, M.D.

When a patient recently told me that she was getting Botox for her depression, not for cosmetics, my initial reaction was: “Sure, and your rhinoplasty was for a deviated septum.” But is turns out the joke was on me.

Botox has been explored as an alternate therapy (to drugs) for clinical depression. Charles Darwin was one of the earliest with the theory that facial expressions are not only manifestations of emotions, but also have a direct impact on them. This “Facial Feedback Hypothesis” is now widely established by modern psychiatry.

As it turns out, the part of the brain responsible for fear, anger, sadness and other negative difficult emotions is part of a feedback loop that includes facial muscles – especially the glabella (spot between your eyebrows that scrunches up when you frown.) Using Botox in this area has led to 60 percent of patients in a clinical trial having marked reduction in depression after a single treatment. Of note, the benefit from a single treatment lasted three to six months, independent of the cosmetic benefits.

The trial included a number of severely depressed individuals who seemed resistant to various medications. New trials are underway addressing depression, plus expanding to social anxiety and bipolar disorders.

Child’s fear of choking again can lead to weight loss and eating issues

Child’s fear of choking again can lead to weight loss and eating issues

Some children who have endured a scary choking incident may suffer from what’s called Avoidant-Restrictive Food Intake Disorder. The disorder was recently reviewed in The New England Journal of Medicine and presents as a condition associated with weight loss due to eating difficulties following a choking incident.

The child basically fears having another choking episode. This leads to avoiding solid food, preferring or demanding only soft food or liquids such as milkshakes, puddings and oatmeal. Weight loss follows because the child also restricts the quantity consumed and receives inadequate calories.

This is a different condition than anorexia because its cause is the antecedent choking, but the result can be the same.

It seems that children who were “picky eaters” as toddlers are more prone to this condition if they choke. The condition is most commonly seen between the ages of 4 and 16.