Shingles: Why the Fuss, and What to Do About It

Update Spring 2018 Shingles: Why the Fuss, and What to Do About it Many of us hear about the medical condition The treatment for shingles is one of several antiviral medications, which shingles from friends or relatives who have are most effective if started as early as possible in the course of the illness. had this unpleasant illness. In recent years, This can be difficult, since the rash often develops only after the pain is media advertising has brought this to the present for days, and may not look very dramatic in some cases. We often public’s attention. So, what is shingles, how do give cortisone-type medication along with the antiviral, in an attempt to you treat it, and is there a way to prevent it? lessen the inflammation and damage to the involved nerve. There are also several types of medications that are usually helpful for the pain. Anyone who had chickenpox at some point in his or her life is at risk for shingles. Many The older the age of the individual, the greater his or her likelihood of more baby boomers remember this viral illness severe and more prolonged pain. That is why the population over age 60 is seen as a critical target to recognize and treat shingles early in the course Peter Stack, MD, FACP as a child, characterized by an itching rash that can leave a few scars. In fact, research and to offer preventative measures. studies have confirmed that virtually all Americans over age 40 have had In 2012 the Zostavax® shingles vaccine was approved by the FDA. It contains chickenpox, though some either had no appreciable rash or no memory of a live but weakened chickenpox virus. This stimulates the immune system it. We see many fewer cases nowadays, since the widespread use of the to regain strength against the virus, so as to keep it in check along the chickenpox vaccine has protected more recent generations. spinal nerve endings. It has been modestly effective in preventing shingles When you resolve the chickenpox illness, the majority of the virus particles and in decreasing the severity of those cases that do develop. However, the ® are killed off. However some virus remains in your body, and goes into a FDA recently approved a newer vaccine, Shingrix , which should be widely ® dormant state within the nerve endings adjacent to the spinal cord. Years available within the next several months. Shingrix is far more effective later, when your immune system memory of the illness declines, the virus can in preventing shingles in older people, and should rapidly become the vaccination of choice. It does not contain live virus. As a result, it should be proliferate and grow along one of those nerves. There are separate sets of much safer to take compared with Zostavax® if you have a condition that may spinal nerves for each side of the body, so one of the hallmarks of shingles impair your immune system or are taking medication that can suppress your is that it always affects only one side of the body and virtually never involves immune function. This is another significant advantage over Zostavax®. both sides. The symptoms that develop with shingles include a blistering rash that is in some ways similar to chickenpox, but occurs in a localized Both of these vaccines are expensive, in the range of several hundred distribution. Some people experience low grade fever and may feel mildly ill. dollars. Shingrix® is a two shot series that has a low incidence of side The rash can be present in any region of the body, from the scalp to the toes, effects. The cost for both vaccines is often covered by private insurance, since the location depends upon which spinal nerve is affected. but may not be covered by Medicare. Both are approved for people over 50. However, we usually recommend waiting until age 60, since shingles The shingles rash is usually associated with varying degrees of pain and is often a milder condition prior to that age. The risk for a more severe or itching. In milder cases, it may be minimally uncomfortable, but some prolonged episode of shingles is significantly greater after age 60. people suffer more severe and intense pain. The rash itself is self-limited, in that it will resolve without any treatment. However, because shingles We are seeing more shingles cases as the number of elderly Americans is is actually a viral infection of a nerve, the pain can persist for months or increasing, particularly those “oldest old”, age 85 and older. Vaccination for longer until the nerve finally heals the damage. In the unlucky few, the prevention and early treatment are important measures to keep shingles nerve is permanently damaged, and can be a source of lifelong pain. from tarnishing their “golden years”.

In this issue:

2 A Review of the New Blood Pressure 3 Making Healthy Habits Stick 5 “Care team” – what is that? Guidelines and the Hypotensive Effects of Exercise 4 Measles Outbreak 8 Two new Baylor Scott & White Lunch & Learn Signature Medicine Practices “Care team” – what is that?

Paul D. Wade, MD

As I was going through one of the many items listed in the patient’s electronic record, I came to an entry entitled “care team”. The patient saw this and asked me “Am I so sick that I need a team? I thought you said that I was in pretty good shape.” I assured the patient that she was in good general health, but as we age, we usually start seeing specialists for certain specific issues. Some examples would be the physician you saw for your colonoscopy, the ophthalmologist you saw for your eye exam and the dermatologist you see periodically for your skin exam. Almost all patients over the age of 50, even those in good health, will see some, if not all of the specialists I just mentioned. Above and beyond that, if the patient has a significant heart or other organ problem, she most likely will also be seeing a cardiologist or another specialist, as appropriate to her condition.

All of these people comprise the care team. One of the most important functions for your internist (or other primary care physician) to do is to make sure you’re up-to-date with all the physicians whom you see and that your care is “coordinated” as much as possible. This involves open communication and sharing of information between the doctors, which generally results in better overall quality of care at a lower cost. One example of this is by reducing redundancies in the healthcare system, such as sharing lab and x-ray reports between members of the team. As time goes by, new problems may well develop which perhaps may require adding another specialist to the team. Generally, your primary care physician will coordinate this function, usually by adding a new specialist with whom he or she has worked in the past. This usually provides a smooth and cooperative effort between the primary care physician, the new specialist and the patient.

Also, the care team may also include social workers as well as home health care professionals (nurses, coordinators and various therapists- speech, occupational and physical- to name a few) who become involved in the patient’s care during and after hospitalization. These professionals strive to ensure a smooth transition between being hospitalized and going home or, perhaps, to a transitional situation such as a rehabilitation facility. They also function to maintain open lines of communication between the primary care physician and the other physicians involved and to provide Thus the goal of the entire care team is to attempt to provide seamless the patient the appropriate follow-up care needed after a hospitalization care for the patient, no matter what new circumstances come into play. has occurred. This is a very important time in the continuation of care. The team is just that-a group of health care professionals who strive to If this transition is not handled appropriately, re-hospitalization or other provide continuous care for the patient at all times and in all situations. adverse situations may arise which could affect the patient’s care.

The information provided is for general information and patients should not rely on the information as medical advice. 5 A Review of the New Blood Pressure Guidelines and the Hypotensive Effects of Exercise Madison Ryals, M. Ed., ACSM-CPT

As a new calendar year is underway, a majority of the population is on a beneficial. Exercises that can also help lower blood pressure include aerobics, mission, working towards making themselves better. For the first time in swimming, biking, and jogging1. There is a need for more research, however, over a decade, there have been changes published, by the American Heart resistance training has even shown evidence to lower blood pressure Association and the American College of Cardiology, to high blood pressure immediately, as well as over time if consistency is kept. Especially when guidelines. Blood pressure ranges in the new guidelines are as follows: training with large muscle groups2. The important thing to remember here is that you do not have to “get in shape” in order to gain blood pressure • Normal: Less than 120/80 mm Hg benefits from exercise. This is because blood pressure lowers immediately • Elevated: Systolic pressure (top number) between 120-129 and diastolic after a single session of exercise for up to 24 hours. This could mean that (bottom number) less than 80 30 minutes of exercise a day could keep the medicines away6. The habit of improving vascular health begins a domino effect of positive benefits on • Stage 1: Systolic between 130-139 or diastolic between 80-89 mm Hg blood pressure. Exercise-induced stress provides a physiological stimulus • Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg that requires adaptations in blood vessel function and vascular remodeling. • Hypertensive crisis: Systolic pressure over 180 and/or bottom number This phenomenon suggests that arterial stiffness, that leads to hypertension over 120, prompt changes in medications if no other problems are and possible, eventual cardiac events, can be slowed and or reversed with 4 evident, or immediate hospitalization if there are signs of organ damage3. consistent physical activity and exercise . Needless to say, there are a few things to expect to occur with the New guidelines, in any realm, typically have some resistance being publishing of these new guidelines. The elimination of the category of accepted to a certain degree. The high blood pressure campaign that has prehypertension is projected to lead to about a 14% increase (from 32% stemmed from the new guidelines can be viewed as an extreme measure to 46%) of people diagnosed with high blood pressure. Although, it is in order to get the population on board with blood pressure maintenance, anticipated that there will only be a small increase in the amount of people and high blood pressure prevention. With lack of educating the audience who receive prescription blood pressure medications. The “silent killer,” on treatment options and the risk reduction that follows treatment, the high blood pressure, is the second leading cause of preventable heart campaign may look a lot like a scare tactic to get patients into clinics. disease and stroke deaths, second only to smoking. High blood pressure The best advice for those who are unsure or possibly at risk of high blood 5 is known for coming with few symptoms, thus, many men and women are pressure is to simply talk to your doctor and express your concern . unaware that they have it1. It is because of the prevalence of high blood pressure related complications that the new guidelines are aimed to be 1. American College of Sports Medicine. (2011). Exercising Your Way to Lower Blood Pressure [Brochure]. Hagberg, J. a preventative measure put into place. “These guidelines are designed to 3 2. Casonatto, J., Goessler, K., Cornelissen, V., Cardoso, J., & Polito, M. (2016). The blood pressure- help people address the potentially deadly condition much earlier” . lowering effect of a single bout of resistance exercise: A systemic review and meta-analysis of randomised controlled trials. European Journal of Preventative Cardiology, 23(16), 1700-1714. Those who fall into the categories of elevated, Stage 1, or Stage 2 of the doi:10.1177/2047487316664147 new guidelines are not doomed to a cardiac event. In fact, there are steps 3. High blood pressure redefined for first time in 14 years: 130 is the new high. (2017, November you can take and lifestyle changes that can be made to reduce your risks 13). Retrieved January 31, 2018, from http://newsroom.heart.org/news/high-blood-pressure- redefined-for-first-time-in-14-years-130-is-the-new-high?utm_campaign=sciencenews17- before prescription medication is ever needed. Increasing the frequency of 18&utm_source=community-htn&utm_medium=phd-link&utm_content=phd11-13-17_htn-gl exercise and physical activity is one of the most common ways to avoid high 4. Kokkinos, P. (2014). Cardiorespiratory Fitness, Exercise, and Blood Pressure. Journal of the blood pressure. “Exercise generally decreases both the systolic and diastolic American Heart Association, 1160-1164. doi:10.1161/HYPERTENSIONAHA.114.03616 value by 5 to 7 mm Hg, and the decrease can occur as early as three to 5. Lomangino, K. (2018, January 26). New Blood Pressure Guidelines Are Promoted with Scars and 1 Scare Tactics. Retrieved February 01, 2018, from http://news.doximity.com/entries/10983005?aut four weeks after increasing your activity level” . There are no specific forms henticated=false of physical activity or exercise designed to lower blood pressure. Every day 6. Pescatello, L., & Thompson, P. (2017, December 01). What’s Changed: New High Blood Pressure activities such as brisk walking, moderate to vigorous yardwork, moderate Guidelines . Retrieved January 23, 2018, from http://www.acsm.org/public-information/ to vigorous housework, and taking the stairs rather than the elevator are acsm-blog/2017/12/01/new-high-blood-pressure-guidelines

The information provided is for general information and patients should not rely on the information as medical advice. 2 Making Healthy Habits Stick: Tips from the book, “Switch: How to Change Things When Change is Hard” by Chip Heath and Dan Heath

Lisa Marsh, MS, RD, LD, CNSC

In the midst of a new year many people are motivated to make positive The book describes three key components to change. They are, 1. Directing changes in their life and set goals. A variety of aspects are focused the rider, 2. Motivating the elephant, and 3. Shaping the path. To illustrate upon such as financial planning, career development, and health-related how to apply these principles, consider the goal to exercise more. ambitions. Losing weight is often one of the biggest goals for the year. Bill is a successful business owner and spends most of his work week at Instead of following a fad diet or giving a list of “bad foods” to avoid it can the office managing his team and overseeing projects. He has not been be more effective to pinpoint key behaviors that drive weight problems. consistent with an exercise regimen since a few years ago. To direct the Habits such as not exercising enough, mindless eating or snacking, or rider means Bill will have to consider a time when he is able to exercise eating too much sugar are common unhealthy habits that lead to weight regularly during the week. What did that look like? What was different then gain. For most people changing these behaviors is not as simple as, “Start compared to now? a running program”, “Stop snacking at night”, or “Limit desserts to every now and then”. Even the best intentions fail without investigating how the It turns out Bill used to schedule his exercise into his work calendar by environment could be influencing habits and what emotions are driving the reviewing the week ahead of time and finding times to fit it in. This was a desire or lack thereof to change. Often one must look beyond the bad habit weekly strategic effort that allowed him to plan ahead and set in place a to develop solutions that are practical, realistic and effective. plan he could follow. Bill decided to set a reminder and block 20 minutes in his calendar every Friday morning for “plan workouts” for the week to The book, “Switch: How to Change Things When Change is Hard” by Chip come. Discovering tactics that worked before and initiating them again into Heath and Dan Heath, points out how people often successfully embrace a system feasible for today provided Bill with clear and specific actions he a lot of big changes in life; such as having children, getting married, can take to change his behavior. and taking on a new job, etc., while other smaller changes like quitting smoking, taking supplements regularly, or losing weight seem impossible. But, Bill also needs to motivate the elephant so as to foster enough energy to set the new habit in place. How would Bill’s life be different if he did The reason for this is that the mind has two independent systems working exercise regularly? How did having the healthy habit before make him at all times and which often live in conflict, described by the authors as an feel physically, mentally, and emotionally? Bill recalled how exercising elephant and a rider. The rider is the rational self and the elephant is the really energized him and helped him decompress from the stress of the emotional self. The rider will analyze, deliberate, and look into the future, day. He often came home in a good mood and felt ready and refreshed while the elephant is more instinctive, feeling its way through life, driven by to interact with his family. Not exercising tended to cause him to be pain and pleasure. There is an inherent tension between the two. overwhelmed when he got home and still keyed up from the day. He also For example, the rider will want to avoid eating the chocolate chip cookie recalled how feeling stronger physically and being leaner made him more so he can lose weight. But the elephant really wants to enjoy the cookie confident which enhanced his interactions with his employees. Engaging because it tastes so good. The rider usually overthinks and overanalyzes the emotional side and finding the feelings that gets one excited about the things, making it difficult to make decisions in the moment. But the change will help put intentions into action. Without the emotion the change elephant operates out of emotions such as love, compassion, loyalty, and can become just an idea. sympathy. The rider provides the plan and direction while the elephant Finally, the book describes how one must shape the path towards change. provides the passion and energy to implement the change. In order for This includes controlling the environment and sometimes changing the change to occur successfully, one must utilize both systems. situation. When Bill thought more about how he used to exercise regularly Understanding this tension and learning how to enlist both systems to he remembered keeping sets of workout clothes at the gym so he always make positive change is the focus of the book. So, how does one get both had something to exercise in when he got there. By not having to do this systems to work together so change can actually occur? every night at home avoided giving up due to fatigue at the end of a busy day. He recalled how he often struggled with fatigue in the afternoon which

The information provided is for general information and patients should not rely on the information as medical advice. 3 Measles Outbreak

Chad Coleman, MD

Recently an outbreak of measles in Ellis County has 2 weeks, but can range from 7-21 days. People are usually contagious sparked concern. As of January 25, 2018, there have from about 4 days before the rash occurs to 4 days or so after the rash goes away. been six confirmed cases of measles in Ellis County, all of which have been in unvaccinated individuals. For If you have these symptoms, even if you have had an MMR vaccine, you should call your doctor. He/She will want to see you in the office and can comparison there was only one case of measles reported do testing to determine if you have the measles. While the vaccine is very in the state of Texas in all of 2017. effective in preventing measles, you should still call your doctor if you have these symptoms. Symptoms of measles usually include fever (typically >101), a rash that appears over most of your body and a cough with runny nose and While there is no medication that can treat measles, it is important to congestion. There is also typically redness to your eyes and often bluish- talk to your doctor. Your doctor may decide a measles vaccine (if given white specks or a reddish type area of spots inside the mouth. Patients within 72 hours of exposure) or immune globulin (another type of measles with measles will typically have all of these symptoms, not just one or two. injection) may be helpful. Catching this early can prevent spread to those that are at the highest risk. Measles is very contagious and is transmitted by respiratory droplets (coughing and sneezing). The incubation period (the time it takes from Again, make sure you are fully vaccinated, this is the best way to prevent being exposed to the time you first start seeing symptoms) is typically getting and spreading measles.

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made it harder to exercise. So, he made a note to bring in a box of energy bars, nuts, and fruit into the office Monday so he has a fresh Lunch & Learn supply of snacks for the week. Designing an environment that makes “Making Healthy Habits Stick”. Having a hard time sticking it easier to change is an important part of creating new habits. to your New Year’s resolutions? Changing our behavior can be challenging but not impossible. Please join us for our next Lunch Changing behaviors can be challenging but entirely possible. By and Learn, “Making Healthy Habits Stick”, presented by our understanding and honing in on the desire for change (motivate dietitian Lisa Marsh, MS RD LD CNSC. She will provide helpful tips elephant) while strategically setting goals (direct the rider) and from the book, “Switch: How to Change Things When Change is controlling the environment (shape the path) one can make change Hard” by Chip Heath and Dan Heath. easier. The approaches outlined in this book can be used for any Day/Time: Friday, April 27 at noon personal, family, or work related goal. Location: Gaston Medical Office Building As always, a registered and licensed dietitian is available for any 3417 Gaston Avenue, Dallas, TX 75246 weight or nutrition-related goal for Signature Medicine patients. 9th floor Conference Room Lunch will be provided. Free parking. Heath, Chip, and Dan Heath. Switch: How to Change Things When Change is Hard. Random House US, 2010. Please RSVP to Lisa at [email protected] Heath, Chip and Dan, et al. “Switch!” Experience Life, 2010, experiencelife.com/article/switch/. by April 23.

The information provided is for general information and patients should not rely on the information as medical advice. 4 9101 North Central Expy., Suite 440 / Dallas, TX 75231 3417 Gaston Ave., Suite 600 / Dallas, TX 75246 1441 S. Midlothian Pkwy., Suite 110 / Midlothian, TX 76065 4716 Alliance Blvd., Suite 310 / Plano, TX 75093

Two new Baylor Scott & White Signature Medicine Practices PLANO: Peter Stack, MD, FACP MIDLOTHIAN: Chad Coleman, MD Matthew Moreland, DO, MPH Check out SignatureMedicineTexas.com for more information about our practices.