Everything you need to know about acute flaccid myelitis

This rare but very serious condition can cause paralysis in children

Dr. Crutchfield, I saw on the news that many Minnesota children are developing polio-like symptoms. What is this about?

The condition is called acute flaccid myelitis (AFM). It is a rare, but very serious condition that affects a person’s nervous system via the spinal cord. The results are a weakening of one or more of the arms or legs or other muscles of the body. The weakening of the legs can cause extreme difficulty walking and even paralysis. As a result, the condition is very similar, clinically, to polio.

Some patients make a rapid recovery and others may have a lengthy, perhaps even permanent paralysis. The prognosis can vary depending on the patient. If a person does have AFM, it is essential to use all treatment and rehabilitation options available.

We currently are uncertain of what causes AFM. There may be one singular cause, or the condition may be a result of many causes that can produce the same effects. Scientists postulate that it could be a yet-to-be-identified virus or even environmental toxin. I would also submit for consideration infectious proteins called “prions” that can cause disease. Additionally, doctors are not sure of any factors that would increase one’s risk of developing AFM.

What we do know

  • The condition is very rare, affecting less than one in a million persons in the United States.
  • There have been six documented cases of AFM in Minnesota, with over 20 suspected cases.
  • From August 2014 through September 2018, there have been about 390 reported cases of AFM in the United States. (Reporting is voluntary, so this number is probably lower than the actual number of cases that have actually occurred.)
  • Most cases are of children. The average age is four, and 90 percent of cases occur in those younger than 18.
  • In no cases have doctors discovered a causative agent, including the polio virus.

Symptoms

  • Sudden weakness in the arms or legs
  • Facial droop
  • Facial weakness
  • Slurred speech
  • Drooping eyelids
  • Difficulty moving the eyes
  • Difficulty swallowing
  • Difficulty breathing. This is the most severe complication of AFM because a weakening of the muscle that controls breathing is a medical emergency that, without immediate support, can lead to death.

What the Centers for Disease Control (CDC) is doing

The CDC is actively investigating all reported cases of AFM and working closely with doctors and other healthcare providers and health departments to increase awareness of AFM.

CDC activities include:

  • Encouraging healthcare providers to be watchful and report suspected cases of AFM
  • Actively looking for risk factors for developing AFM
  • Testing specimens, including stool, blood, and cerebrospinal fluid, from alleged AFM cases
  • Working with researchers across the country and world to determine the cause of AFM
  • Disseminating all new information on AFM to doctors, healthcare providers, and health departments as it becomes available

What you can do

Because the condition mimics the result of a viral infection, it is essential to:

  • Practice good hand-washing techniques
  • Use appropriate mosquito repellants and protection
  • Ensure all vaccinations are up to date

If your child develops weakness of any limb, especially if they have cold-like symptoms or other viral symptoms, take them to the doctor immediately. The prognosis now depends on getting prompt medical care as soon as possible.

Eventually, we will understand the cause of AFM. Until then, these action steps are our best hope for prevention and a good recovery.

50 Over 50

Charles E. Crutchfield III, M.D.

Busy Healer

Skin is the body’s largest organ—and Dr. Charles E. Crutchfield III, owner of Crutchfield Dermatology, works tirelessly to keep skin of all shades healthy. And “tireless” is perhaps an understatement. The 57-year-old Eagan resident sees patients five days a week, manages a staff of 40, and serves as a clinical professor at the University of Minnesota Medical School, where he’s earned three distinguished teaching awards. Dr. Crutchfield also serves as team dermatologist for the Timberwolves, Twins, Vikings, and Wild; and publishes a dermatology “case-of-the-month” that’s delivered to over 50,000 physicians worldwide. He also writes a highly regarded column on skin care for the Minneapolis Spokesman-Recorder, and has penned over 200 scientific and educational publications, plus several books, including one for children. He’s a founding member of a nonprofit dedicated to improving the safety and ethics of cosmetic skin care for people of all ethnicities, and he sponsors a lecture series on the topic. So, it’s no surprise that Dr. Crutchfield has received virtually every prestigious professional recognition, including the Karis Humanitarian Award from the Mayo Clinic.

Success in business is sometimes measured with simple arithmetic, but many in business see true success as finding ways to sustain both themselves as well as the environments in which they exist. That’s the common bond between these 10 business leaders. Whether they’ve made a name for themselves in banking, financial planning, life planning, marketing, media or medicine, they all apply their effort and know-how to invest in their neighbors and communities. They’re living proof that these unique combinations of skills and values don’t depreciate past age 50.

Cutting one’s skin is a cry for attention and help

Many things happen behind closed doors and in private, sometimes going completely unnoticed or unimaginable. One of those things is self-harm, such as cutting, which occurs much more often than people would expect.

Every year, one in five females and one in seven males engage in self-injurious behavior. About 90 percent of those who participate in self-harm began during their pre-teen or teenage years.

Approximately two million cases are reported annually in the U.S. Imagine how many cases there actually are, since a majority of the cases go unreported.

When cutting occurs, it usually manifests as horizontal scars across the lower arms (as in the picture) and upper thighs. These are both areas that can easily be covered with clothing.

Cutting isn’t the only form of self-harm that can be done. Other types of harm that can be self-inflicted and warning signs to look out for include:

  • Burning
  • Picking at or reopening wounds
  • Punching or hitting oneself
  • Inserting objects into the skin
  • Purposely bruising or breaking one’s bones
  • Pulling out one’s hair

There are several myths about cutting and other forms of self-harm, which are important to recognize, understand, and even debunk.

First, cutting isn’t considered an attempt at suicide. According to the Diagnostic Manual of Mental Disorders (DSM-5), the authoritative guide for doctors, cutting is considered a non-suicidal self-injury disorder.

Second, it is not a mental illness. Cutting is a behavior indicating a lack of coping skills for emotional pain, intense anger and frustration. Even though self-injury brings a brief feeling of calm, it is usually followed by guilt, shame, and the return of painful emotions. This destructive cycle can become addictive to the point that it becomes a compulsive behavior and difficult to stop.

There are a great many reasons why people engage in cutting. It can be triggered by someone’s social environment. An overwhelming amount of stress can lead someone to feel like there’s no way out or to feel so empty that the only emotional release is through inflicting pain.

What you can do:

In order to help prevent someone from harming themselves, it helps to understand the risk factors and to be aware of red flags of secretive behavior. Risk factors include, but are not limited to:

  • Age (teenagers and young adults most common, although it can happen at any age)
  • Having friends who self-injure
  • Abuse (sexual, physical or emotional)
  • Social isolation/ loneliness
  • Mental health issues (i.e., borderline personality disorder, eating disorders, depression, anxiety disorders, substance abuse, conduct, and oppositional defiant disorders)

Common signs and symptoms might include:

  • Parallel linear scars on the arms
  • Fresh cuts, scratches, bruises or other wounds
  • Possession of sharp objects, like a razor
  • Difficulties with relationships
  • Persistent questions about personal identity, such as “Who am I?” and “What am I doing here?”
  • Emotional and behavioral instability, impulsivity and unpredictability
  • Statements of helplessness, hopelessness or worthlessness

Each of us has a responsibility to look out for friends, family and acquaintances for any signs or suspicions of self-harm and to offer help and support during whatever is compelling someone to hurt themselves. If you have a friend, loved one or acquaintance who is self-injuring or has revealed thoughts about self- harm, you must take it seriously.

You may feel shocked, scared, or even feel you’re betraying their privacy. However, this is too big of a problem to ignore, and their safety and well-being are the most important considerations.

If you know anyone injuring themselves, suggest they reach out to someone they trust, such as their parents, friends, teachers, a counselor, a physician or spiritual leader. Furthermore, always keep the suicide hotline number close by: 1-800-273-TALK (1-800-273-8255). If you find yourself in an emergency situation, this requires a quicker but, most importantly, calm response by calling 911 or other local emergency numbers.

Do not condemn or criticize anyone who has cut themselves for their behavior. What they need most is support and healthy coping skills rather than added negativity.

Preventing self-harm should be the utmost goal. There’s no fool-proof way to do so, but there are various avenues that can be taken to curtail it, including many seemingly small things anybody can do to look out for others and make a real difference.

Help is available

If you have ever harmed or currently harm yourself in any way, or if you’ve had suicidal thoughts, remember one thing: You can overcome almost any challenge. If you have injured yourself and believe your injury is life-threatening in any way, immediately call 911 or the suicide hotline.

Most importantly, reach out to somebody, anybody. If you can’t talk to your family members, talk to your doctor. If the doctor is not available, there is always help available at the hospital’s emergency room. Be it family, friend, minister or doctor, there is always someone there to help you. Please reach out.

Five principles for closing the learning gap in babies

When it comes to improving learning and increasing brain development in children, the earlier we involve infants, the better.

Sociologists are talking a lot about something called “the learning gap.” This is a gap in knowledge and ability seen between different groups of children. These groups can vary based on race or socioeconomic status.

The key is identifying ways to close, or even eliminate, this learning gap in children. Closing the learning gap is a passion for Harvard professor Dr. Ron Ferguson. He was stunned to be able to identify a learning gap in children as early as age two. As he has stated, “Kids aren’t halfway to kindergarten, and they’re already well behind their peers.”

Brain development techniques can be implemented by caregivers well before any formal learning programs, like preschool, begin. Even more encouraging is that these techniques are mainly low cost or free.

In a recent interview with NPR, Dr. Ferguson said, “Things that we need to do with infants and toddlers are not things that cost a lot of money. It’s really about interacting with them, being responsive to them.”

So he developed a plan to help eliminate the learning gap in kids. It is a series of five principles that all caregivers can implement to increase early childhood development significantly. He calls these principles “The Boston Five.”

His goal is to introduce “the Five” to the Boston area and then across the country. According to a recent report on NPR.com, the “Boston Five” principles are:

  1. Maximize love, manage stress. Babies pick up on stress, which means moms and dads have to take care of themselves, too. It’s also not possible to over-love or be too affectionate with young children. Research shows feeling safe can have a lasting influence on development.
  2. Talk, sing and point. “When you point at something, that helps the baby start to associate words with objects,” Ferguson explains. Some babies will point before they can even talk.
  3. Count, group and compare. This one is about numeracy. Babies love numbers and counting, and there’s research to show they’re actually born with math ability. Ferguson says caregivers can introduce their children to math vocabulary by using sentences that compare things: “Oh, look! Grandpa is tall, but grandma is short,” or “There are two oranges, but only three apples.”
  4. Explore through movement and play. “The idea is to have parents be aware that their children are learning when they play,” Ferguson said.
  5. Read and discuss stories. It’s never too early to start reading aloud—even with babies. Hearing words increases vocabulary, and relating objects to sounds starts to create connections in the brain. The Basics also put a big emphasis on discussing stories: If there’s a cat in the story and a cat in your home, point that out. That’s a piece lots of parents miss when just reading aloud.

Maximize love and manage stress, principle number one, is related to a previous article I wrote on minimizing insecurities and maximizing success (“A good childhood can prepare us for a good life,” March 21, 2018 MN Spokesman-Recorder). Evident and crucial situations involving food, housing, and family insecurities can have devastatingly adverse predictive effects on children.

For many people, this new understanding can open doorways to addressing and overcoming obstacles that can be life-changing. In a recent CBS news segment related to the issue of adverse traumatic childhood events and the way they affect subsequent human behavior, the correspondent, Oprah Winfrey, commented that this new way of looking at and understanding human behavior was “absolutely life-changing and will influence all of her future relationships.”

Principle number four must include music and art. These are essential for the developing brains of infants, too. Studies have evaluated the social, intellectual and emotional outcomes of young children who participated in art forms such as music, art, dance, theatre/acting, drawing and painting. Emerging research supports the intimate involvement in these activities and a positive influence on brain and intellectual development in children.

Dr. Ferguson has decided that the best way to spread the word on these early learning techniques is to teach them where the babies and parents are. This teaching includes hospitals, community centers, social service organizations, pediatric clinics, barbershops and hair salons, and churches.

When it comes to closing the learning gap in babies, they need love and attention. The more interactions we have with little ones, the better. Their brains are like super-sponges. They soak up everything that comes their way.

Learn and use Dr. Ferguson’s Boston Five principles. Use them as soon as your baby is born. By doing so, you will put your child in the best position to enjoy a happy, successful life.

Breast reduction surgery: For some, it’s a good option with exceptional results

Question: Dear Dr. Crutchfield, my sister recently had breast reduction surgery. She said she is delighted with the results. What is breast reduction surgery and why would anyone have it done?

Breast reduction surgery is the process of having skin, tissue and fat surgically removed from the breasts to reduce their size physically. The medical name of the procedure is “reduction mammaplasty.”

Breast reduction surgery is often considered to reduce the stress and pain on the shoulders, neck and back caused by having abnormally large breasts. It can be done to decrease one’s breast size so they look more proportional to their body.

Reduction mammaplasty can also improve a person’s self-esteem and self-image and allow them to comfortably engage in many physical activities, including various sports.

Breast reduction surgery is a serious surgery and should be considered with a skilled physician and board-certified plastic surgeon. The surgery has benefits, as well as possible complications and risks. It is essential to come to a sound understanding with your surgeon about realistic expectations and outcomes of the procedure.

Breast reduction surgery can be done at any age, including teen years. It is preferable to do so when the breasts are fully developed, but if there is enough reason to have the procedure done as a teen, a second surgery can be done later in life when the breasts are fully developed.

Men can also have breast reduction surgery, but for different reasons. The rest of this discussion will focus on breast reduction surgery for women.

Reasons to consider surgery

Reduction mammaplasty may be considered if a woman has large breasts and they are causing:

  • Back pain
  • Neck pain
  • Shoulder pain
  • Inability to participate in certain physical activities and sports
  • Chronic skin problems under the breasts
  • Difficulty in getting bras that fit
  • Poor self-esteem

In certain circumstances, reduction mammaplasty may not be appropriate. These include:

  • Persons with significant health problems such as heart disease or diabetes
  • If one is extremely overweight
  • If one wishes to avoid scars or has a history of keloid formation
  • If one smokes heavily (this is a relative contraindication)

Reduction mammaplasty may be postponed if one is considering childbirth with subsequent nursing. Nursing after mammaplasty can be difficult and challenging. There are special surgical techniques to increase the possibility of nursing, but they are not 100 percent successful. Many who consider mammaplasty will wait until after they are done having children.

Also, reduction mammaplasty may be postponed if you are considering a significant weight-loss program. Sometimes the weight-loss program may cause enough of a reduction that surgery is easier; or, more commonly, the operation will be most effective when breasts are at a stable, smaller size.

Risks include:

  • Bruising
  • Bleeding
  • Swelling
  • Infection
  • Discoloration
  • Scarring
  • Inability to breastfeed or difficulty doing so
  • Loss of sensation in the area around the nipples

The procedure

Before the surgery, your doctor will perform a complete physical examination with bloodwork. Additionally, they may take photos of the breasts and order an imaging study (mammogram). You should stop medications that will cause increased bleeding (such as aspirin or similar NSAIDs).

Your doctor will review with you the risks, goals and expectations of the surgery, including scarring and numbness. The procedure is done under general anesthesia. The exact location of the tissue removal will vary depending on how much tissue needs to be removed and the preference of the surgeon.

The surgeon will use a particular pattern that allows the breasts to maintain a natural shape and keep an optimal positioning of the nipples. The surgeon will also recommend how long you will be in the hospital. Sometimes one can go home the day of surgery, and sometimes it is better to stay in the hospital for a short while (one or two days) after the procedure. You will also be started on pain medications and antibiotics to reduce the chance of infection.

After reduction mammaplasty, your breasts will be swollen and tender. Your doctor may recommend special dressings and compression garments. Plan on plenty of ice and loose, comfortable shirts.

You should plan on taking at least a week off of work or school. You should also plan on no strenuous activities for at last one month after reduction mammaplasty.

You can see results of reduction surgery right away, but keep in mind that full healing, including swelling and maximum scar resolution, can take many months, even up to one and a half years.

Breast reduction surgery can successfully relieve pain, stress and discomfort; allow one to engage in previously prohibited activities and sports; and offer one a higher degree of self-esteem. If a physician deems it medically necessary, the cost of the procedure is usually covered by health insurance.

If you think you are a candidate for breast reduction surgery, talk to your doctor. Many of my patients have told me it was one of their best decisions.

Diverticulitis: challenging but manageable

Dear Doctor: A friend recently told me he was feeling under the weather due to a flare of his diverticulitis. What is diverticulitis?

Diverticulitis is the process of inflammation of small areas in the intestines. Occasionally, our intestines can develop small out-pouches along the length. If one or more of the pouches become inflamed, the condition is called diverticulitis.

Diverticulosis can occur anywhere along the length of the intestines, but it is most commonly observed in the intestines that reside in the left side of the abdomen. There are several reasons for diverticulosis and, without any additional complications, the condition is considered benign.

The inflammation can be relatively mild, involving only one or two areas, to the involvement of extensive areas that can lead to abscesses and breakdown and rupture of the intestines, a life-threatening emergency.

Most people with diverticulosis are unaware of it. Diverticulitis, on the other hand, can have very pronounced symptoms. In some cases, diverticulosis may cause left-sided abdominal pain and cramping that is relieved with passing gas or moving one’s bowels. The abdominal cramping pain can be extreme and severe. Also, one may experience flu-like symptoms and can even run a fever. Diverticulosis can also produce red blood in the stool.

Diverticulitis can present as a few isolated attacks, or be longstanding and chronic, without ever becoming entirely free of inflammation. With chronic diverticulitis, a blockage of the intestines can occur.

When this happens, stools can become thin, one can experience constipation or diarrhea, and stomach cramping and bloating. With extreme cases of intestinal blockage, one may also experience excruciating abdominal pain and nausea and vomiting.

Without treatment, diverticulitis can cause pockets of infection that can rupture into the abdomen and require immediate surgery, scarring that can lead to intestinal blockage, severe bleeding (that may require a blood transfusion), and a strange condition called a fistula.

A fistula occurs when an inflamed portion of the intestine (diverticulitis) touches a neighboring organ and actually forms a connection to that area. Most commonly, the connection can occur with the bladder, and when that happens, the kidneys can get infected. Other less common areas of fistula formation include connections to the vagina and the skin.

Risk factors

  • Age over 40
  • Overweight
  • Consuming a diet high in red meat
  • Taking NSAIDS or steroids on a regular basis
  • Eating a diet high in saturated fats
  • Low water intake
  • Family history
  • Personal history of polycystic kidney disease

Diagnosis

It is essential to make sure the diagnosis is correct before embarking on a treatment plan. Many conditions can cause abdominal pain. Acute appendicitis, fibroids, other intestinal infections, and cancers of the abdomen (colon and ovarian) are good examples of conditions that need to be ruled out.

If a patient has a well-documented history of diverticulosis, the diagnosis of diverticulitis may be more straightforward.

Imaging studies can be quite helpful. The imaging study of choice is a CT scan. If the patient is pregnant, a CT scan is not appropriate due to the radiation exposure, so an MRI is an acceptable alternative.

Colonoscopy can also aid in the diagnosis of diverticulosis, but in an acute flare of diverticulitis, colonoscopy should not be used because the inflamed tissue can easily damage the scope as it travels along the intestines. Colonoscopy should be done six weeks or longer after the flare of diverticulitis has subsided. Rarely, exploratory surgery may be needed to make the correct diagnosis of diverticulitis.

Treatment

The treatment of diverticulitis will depend on the severity of the flare-up.

For mild flare-ups, the treatment may be as simple as staying at home for a while with bed rest, antibiotics by mouth to address any infection, a liquid diet while inflammation and healing occur, and a mild over-the-counter pain reliever, if needed.

If the flare-up of diverticulitis is severe, the affected person may have to be hospitalized. At that time, IV antibiotics may be administered with stronger, prescription pain control medications. If there is an infected pocket, such as an abscess, it may have to be surgically drained.

If there is a consideration of a perforation of the bowel contents into the abdomen (peritonitis) or fistula formation, or even a blockage of the bowels, surgery will be required. In some cases, the diseased portion of the intestines can be removed and the intestines can be re-joined without the bad segment. This rejoining of the sections will allow patients to have regular bowel movements.

In another case, if there are large areas of involvement, the intestines may be re-routed to empty outside of the body through a colostomy, and intestinal waste drains into a bag next to the stomach. In some of these cases, if the inflammation subsides, the colostomy can be reversed, and the normal intestinal function can be restored.

If one does have diverticulitis, several lifestyle modifications can be made to minimize episodes. These include:

  • Exercise regularly
  • Maintain a healthy weight
  • Minimize red meat consumption
  • Eat plenty of high-fiber fruits and vegetables
  • Drink plenty of water
  • Minimize saturated fat intake
  • Minimize steroid and NSAID use

Diverticulitis can be a challenging disease. Fortunately, it can be managed. If you have diverticulitis, talk to your doctor about a regular visit schedule, what to do with episodes of exacerbation, and ask for advice on minimizing flare-ups.

FDA approves first new sickle cell medication in 20 years

Endari™ (L-glutamine oral powder) recently (July 7, 2017) received FDA approval as the first new medicine to treat sickle cell disease (SCD) in 20 years. Endari has been shown to decrease the number of sickle cell crises and hospitalizations in patients with sickle cell disease. Doctors expect it to be available for patients in the late fall of 2017.

Sickle cell disease affects millions of people worldwide. People with African, Spanish, Mediterranean and Indian ancestry are at increased risk. Approximately 120,000 infants are born with sickle cell disease every year.

In the U.S., approximately one in 500 African Americans and one in 1,200 Hispanic Americans are born with sickle cell disease. Approximately two million Americans — including about eight-to-12 percent of the African American population — are carriers of the disease. Carriers of the disease are said to have the “sickle cell trait.”

What exactly is SCD and what causes it?

“Sickle” red blood cells are curved like the farm tool of the same name.

SCD is an inherited condition where the proteins that carry oxygen (hemoglobin) are defective. These defective proteins change the shape of red blood cells from the normal round shape to an odd “sickle” shape.

The job of red blood cells is to carry oxygen throughout the body so that the body can function at its best. Normally, red blood cells flow smoothly through blood vessels. Without oxygen, the red blood cells form the odd sickle shape and clump and block blood vessels and the tissues downstream are damaged.

Signs of blockage, known as a “sickle cell crisis,” include excruciating pain, anemia, skin ulcers, excruciating organ damage, stroke, lung complications, and a syndrome known as “acute chest syndrome” (ACS), which may be potentially fatal and is the leading cause of death among people with SCD.

Because sickle cell disease is inherited (given from parent to child), an affected person has to get one defective sickle cell gene from each of their parents. If a person only has one sickle cell gene, they are said to be a “carrier” and do not have the disease or effects of the disease, except in very rare, extreme cases. As a carrier, you can pass the gene on to your children.

When both parents possess the sickle cell trait, each pregnancy has the following odds: a 25 percent chance of producing a child with sickle cell disease; a 25 percent chance of producing a child with neither sickle cell trait nor sickle cell disease; and a 50 percent chance of producing a child with sickle cell trait.

When only one parent has SCD, and the other has the sickle cell trait, each pregnancy has a 50 percent chance of producing a child who has either the sickle cell trait or sickle cell disease.

How is SCD diagnosed?

A simple blood test can show whether a person has sickle cell disease. Most states test for sickle cell disease before infants go home from the hospital. Doctors cannot predict which symptoms a child born with sickle cell disease will have, when they will start, or how serious they will be. There are three sub-types of sickle cell disease with similar clinical pictures.

Can SCD be prevented?

One can avoid or minimize the effects of the disease by avoiding situations that can exacerbate the disease such as high altitude, increased atmospheric pressure, low oxygen situations, cigarette smoke exposure, severe dehydration and extreme exercise.

How is SCD treated?

Patients with sickle cell disease will have a lifelong struggle fighting many associated health problems such as pain, skin ulcers, infections, anemia, organ problems and stroke. Nevertheless, many patients can have an excellent quality of life by learning to appropriately care for themselves and effectively manage the disease.

The best treatment is to prevent the attacks associated with the disease as outlined above. Early treatment includes daily antibiotics from ages two months to five years to prevent infections. Immunizations are also very important.

Many doctors will develop a pain management plan for their patients with the disease. Sometimes, periodic blood transfusions are helpful to reduce the risk of stroke and treat the symptoms of anemia (feeling weak and tired). A bone marrow transplant may also be an effective treatment in certain patients.

The most important thing a person with sickle cell disease can do is make sure they are receiving regular medical examinations with a physician who is an expert in treating the disease.

The good news

As mentioned above, the drug Endari has recently received FDA approval as the first new medicine to treat SCD in 20 years.  Endari has demonstrated its ability to reduce the most severe complications of sickle cell disease (SCD) in both adults and children age five and older. The FDA notes that some common side effects of Endari include nausea, constipation, headache, stomach pain, cough and body pain.

Endari works by reducing stress damage to red blood cells, which also reduces the formation of sickled blood cell shapes. Significantly, it is only the second FDA-approved drug to treat SCD, a serious and debilitating disease, and is now the first treatment available for the pediatric population.

Action steps for anyone with SCD

Talk to your doctor about the new medication, Endari™ (L-glutamine oral powder). Ask if it is appropriate for you.Learn what sets off painful events, such as dehydration, extreme exercise, cold exposure, long plane flights, high altitudes, and cigarettes.

Take antibiotics as instructed. Maintain a complete immunization schedule.

If you have a child with sickle cell disease, make sure caregivers and teachers know of their special requirements, including frequent drinks and bathroom trips and avoiding overexertion and cold temperatures.

Locate a good support group near you or via the internet to reduce the familial stress the disease may cause.

Develop a good working relationship with a physician who is comfortable and good at managing the condition. Develop a pain management plan with your doctor.

Want to prevent illness and disease? Wash your hands!

The numbers are in, and the Great Minnesota Get-Together, also known as the Minnesota State Fair, had a record number of attendees this year – just over two million people! In fact, I was one of them; I attended the fair this last weekend.

While there, I noticed how many surfaces we constantly touch: handles, railings, knobs and, of course, money. I also noticed how few people bothered to wash their hands when I used one of the restrooms. This got me thinking: How do we best protect ourselves from all the germs and illness around us? The answer is simple – good, old-fashioned handwashing. I thought it would be good to re-visit a “Doctor’s Advice” column from last year on the subject.

We have all seen it. At a public restroom a person bolts out without washing their hands, or just as bad, splashes water on their hands for three seconds and barely grabs a paper towel before bolting out the door. Both of these are woefully inadequate.

Of all the things you can do to prevent illness and the spread of disease, proper handwashing may be the easiest and most effective. Repeated handwashing is the best way to prevent getting sick and to prevent spreading disease. Hand cleansing can be done with soap and water or with an alcohol-containing hand sanitizer.

Here are simple guidelines to properly wash your hands. Talk to your children, friends and family members and make sure they get into the good hand-washing habit, too.

When and why should we wash our hands?

Throughout the day our hands come into contact with a variety of things such as people, phones, handrails, door handles, toys, keyboards, steering wheels, pets and other dirty surfaces that can harbor germs such as bacteria, viruses and other microbes.

Handwashing is especially important after going to the bathroom. By then touching our eyes, nose and mouth, as we all do dozens of times during the day, we can infect ourselves with the germs on our hands. It is not possible nor realistic to keep our hands completely sanitized. The goal is to wash our hands properly and frequently to minimize the spread of germs and disease.

The most important factor in proper handwashing is washing the hands with lathered soap for a minimum of a full 20 seconds.

Always wash your hands before:

  • Preparing food
  • Eating food
  • Touching contact lenses
  • Caring for a sick person
  • Caring for the wounds of an injured person
  • Taking or giving medicine
  • Touching or putting your hands or fingers in your mouth, eyes or nose

Always wash your hands after:

  • Handling any raw food, especially meats
  • Going to the bathroom
  • Changing diapers
  • Nose blowing
  • Coughing or sneezing, especially into hands
  • Petting animals
  • Handling pet toys or pet waste
  • Changing the dressing on wounds
  • Caring for a sick person
  • Handling waste or garbage
  • Handling garden or household chemicals
  • Touching dirty shoes
  • Shaking hands with people
  • Touching anything that could be contaminated with germs
  • Whenever your hands look or are dirty

Handwashing best practices

It is generally best to wash your hands with soap and water. Follow these simple steps:

  • Use running water, not a basin filled with water.
  • Either cold or warm water will work.
  • First, thoroughly wet your hands.
  • Apply a liberal amount of soap to wet hands. All soaps work well.
  • Rub hands together vigorously and well to produce a good lather.
  • Be sure to completely wash your palms, wrists, back of hands, between fingers, and under fingernails if needed.
  • Rub your hands aggressively for at least 20 seconds, or the time it takes to count silently to 20-banana (i.e. one-banana, two-banana, three-banana… to 20-banana). The length of handwashing is the most important factor in proper handwashing and cannot be shortened.
  • Rinse well for at least a seven-banana count.
  • Use a clean paper towel, clean cloth towel or air dryer to dry your hands completely.
  • Turn the faucet off with a paper towel or elbow. Do not touch the faucet to avoid re-contaminating your clean hands.
  • As you are leaving a lavatory, do not touch the door knob. Once again, use a paper towel to open the door to avoid contaminating your clean hands by touching the knob.
  • In the winter, consider applying a good moisturizer to keep the hands from becoming irritated and chapped.

Alcohol hand sanitizers can be used

Alcohol-based hand sanitizers can work acceptably when soap and water are not available. It is important to make sure the sanitizer has an alcohol content of at least 60 percent. Be sure to cover your hands completely with the sanitizer. Rub well until hands are dry.

Teach children good handwashing habits, too

It is so important to teach children the proper way to wash hands to maintain good health. Encourage them to wash their hands frequently and especially before all meals, after all toilet use, and whenever their hands appear dirty.

Show them exactly how to wash their hands and review their hand-washing performance on a regular basis to make sure they are not “backsliding.” If they are too short to reach a sink, make sure to have a children’s step-stool available for them.

Remember to have them count to 20-banana to make sure they are investing enough time to clean their hands properly. Hand sanitizers, as mentioned above, can be used when water is not available. There is also an excellent hand-washing instructional video listed at the end of this article to review personally and with family members.

A great way to stay healthy

Proper handwashing is the best way to prevent illness and disease. The key is to wash hands correctly. That means using soap and water when possible, lathering well, and doing it at least for 20 seconds.

Watch the hand-washing video, teach your children proper techniques, and insist they always wash their hands. Proper handwashing may be the very best thing you do for their good health and your own.

For an excellent video on proper handwashing techniques produced by the Centers for Disease Control, go to www.youtube.com/watch?v=lhmYLwDdPuE.

Endometriosis: A painful yet treatable condition for women

Dr. Crutchfield, my cousin was recently diagnosed with endometriosis. What is endometriosis?

Endometriosis (en-doe-me-tree-OH-sis) is a painful condition that occurs in women when cells that normally reside inside the uterus grow outside the uterus in the pelvis. Normally, these cells reside in the inner lining of the uterus called the endometrium.

During a regular menstrual cycle, under the influence of hormones, especially estrogen, the endometrial tissue swells and prepares to accept a fertilized egg. If a fertilized egg does not arrive, the endometrial tissue is shed (the bleeding associated with a woman’s period) and the monthly cycle begins over with new endometrial tissue in the uterus developing for a possible pregnancy in the future.

With endometriosis, endometrial cells can become attached to ovaries, fallopian tubes, and the lining of the pelvis (see picture above). During the regular menstrual cycle, the tissue thickens, swells, and sheds, but the ectopic (normal cells in an abnormal location) endometrial tissue does not get shed during menstruation as it normally would as a part of the inner lining of the uterus.

As a result, the tissue is trapped in place and can cause pain, scarring, and even adhesions in the pelvis.

Endometriosis is a common cause of pelvic pain and infertility. Rarely, endometriosis can be the cause of a rare form of pelvic cancer. It affects an estimated 12 percent of women (almost six million) in the U.S. and is most common in women in their 30’s and 40’s, but can occur any time after menstruation begins.

Symptoms

The primary symptom of endometriosis is significant discomfort and pain. Frequently, women can experience discomfort and cramping during menses. In endometriosis, patients report a much more intense pain and discomfort than usual. The pain of endometriosis tends to worsen over time and can be quite severe.

  • Painful periods (dysmenorrhea). The pain can also seem like it is coming from your lower back and abdomen.
  • Infertility. Endometriosis is a common cause of infertility.
  • Heavy menstrual bleeding.
  • Pain with urination and/or bowel movements. This presents most commonly during menses.
  • Pain with intercourse. This is common with endometriosis.

The severity of pain is not necessarily an indication of how severe endometriosis is. Although endometriosis is associated with pelvic pain, there are other medical conditions like ovarian cysts, inflammatory bowel disease, and pelvic inflammatory disease that can cause pelvic pain. A doctor must determine the correct diagnosis as sometimes a patient can have more than one condition causing pelvic pain.

Cause of endometriosis

Doctors are not sure what causes endometriosis. Theories include a backward flow of blood during a period to deposit endometrial tissue in the pelvis, an abnormal response to hormones causing pelvic tissue to become endometrial tissue, and endometrial tissue being present in the pelvis since birth. There are several other hypotheses, also, but no one is certain of the exact cause.

Endometriosis risk factors

  • Not ever giving birth
  • A family history of endometriosis
  • Starting menses at an early age
  • Short menstrual cycles
  • Having high levels of estrogen
  • Having an abnormally shaped uterus
  • Experiencing menopause at an older age

Diagnosis

A doctor will take a careful medical history and perform a pelvic exam. Additionally, imaging studies like ultrasound or an MRI may be obtained to assist in the diagnosis of endometriosis.

Also, a surgical procedure called laparoscopy can be performed. This is where a very small incision is made in the abdomen and a special viewing tool is inserted to inspect the areas for endometriosis directly. During this procedure a sample of tissue can be obtained and, sometimes, the area of endometriosis can be removed.

Treatment

Fortunately, many effective treatments are available. Initially, only mild pain medications may be required. Because the endometrial tissue is affected and activated by hormonal activity, especially estrogen, other treatments may include hormonal modulation and hormonal therapy.

In severe cases (including some cases of infertility), surgery may remove or reduce the affected tissue. In other instances in which pregnancy is not an issue, a hysterectomy with removal of the ovaries may be an option.

Endometriosis can be a challenging medical condition to diagnose and treat. Fortunately, endometriosis can be managed with success. If you have pelvic pain, see your doctor for appropriate evaluation, diagnosis, and treatment plan.

New advances in the war on cancer: living cell therapy

On April 6, 2016, we discussed several new successful treatments against cancer in the Minnesota Spokesman-Recorder article “Good news: We are winning the war on cancer.” This is an update on one of those treatments we referred to then as combination cell, or chimeric cell, therapy.

Researchers and reporters alike are now calling it “living cell therapy.” It works well and has been approved to treat certain resistant childhood leukemias and adult lymphoma. Unfortunately, results against solid tumors are not yet favorable. Success rates as an FDA-approved treatment is greater than 70 percent, which is remarkable considering that, in the recent past, these cancers, failing traditional therapies, were incurable.

There are particular types of immune cells called T-cells that are the real powerhouses when it comes to fighting disease and cancer. Doctors can perform a pretty slick trick where they extract a T-cell from a patient’s body and mix it with a specific virus. That is why it has been called combination cell, or chimeric cell, therapy.

This virus infects the T-cell and directs it to produce unique sticky proteins on its surface that recognize novel proteins on the cancer cells. They fit together like hand and glove. These living therapy T-cells float freely in the blood and recognize blood-born malignancies. They bind to the malignant cells in the blood and obliterate them.

This type of living cell therapy works best for specific blood-borne malignancies, especially those of the liquid form, such as leukemia and lymphoma. Here’s how it works:

Leukapheresis

Special immune T-cells are isolated from a patient’s blood using a particular filter. These cells are then frozen and sent to a unique laboratory that transforms them into living treatment cells.

Cell programming

In the lab, the T-cells are mixed with a specific virus that causes the T-cells to make unique proteins on their surface that can later recognize and stick to leukemia or lymphoma cancers cells.

Multiplication

These newly programmed T-cells are grown and multiplied over a million-fold in the laboratory, so they are in large enough numbers to fight cancer when they are needed later.

Quality review

The new group of programmed and multiplied cancer-fighting T-cells are specially checked and screened to make sure that they have only the desired cells with unique cancer-fighting properties.

Lymphocyte reduction

The number of lymphocytes in the patient is reduced so that when a large number of the newly programmed lymphocytes (originally from the cancer patient, but now grown to much larger numbers) can be more easily given back to and accepted by the patient and can function at optimal levels.

Living cell drug infusion

The newly programmed cancer-fighting T-cells are slowly injected back into the cancer patient. This is done over several minutes.

Cancer cell death via cytokine storm

The cancer-fighting T-cells can sense what size job they need to do and can increase their numbers even more inside the body, if needed. They can then launch an all-out attack on the cancer cells, killing them.

During this attack, the cancer-fighting cells release many substances called cytokines that enable the most effective attack. This release is called a cytokine storm. It usually occurs one to two weeks after the T-cells are injected back into the cancer patient.

The cytokine storm can make the patient feel like they have the flu. Oddly, that is considered a good sign, except in a few cases where the storm can be so severe it can harm or even kill the patient. Doctors are getting better and better at treating and handling the storm, so most patients do well.

A costly process

The process of transforming normal immune T-cells into cancer-fighting cells is called CAR-T production, for “Cancer Antigen Receptor T-cells.” It is an extremely expensive process: Currently, the cost to produce CAR-T cells for injection is just short of $500,000 per treatment. Prices may come down as the techniques to develop CAR-T cells improve.

Additionally, researchers are devising ways to make the CAR-T cells recognize multiple targets on cancers cells rather than the single target employed now. The ability to identify various targets on a cancer cell will make the CAR-T cells more efficient and will increase the number of successful treatments. There are over 50 CAR-T studies underway.

In conclusion

Although the war on cancer is not over, I’m delighted to report that right now we have some of the best tools ever available in the fight. In fact, former president Jimmie Carter used some of these tools to have a complete remission of malignant melanoma that metastasized to his brain.

If you or a loved one is diagnosed with cancer, it’s not the same prognosis that it was even a few short years ago. Talk to your physician about a combination of therapies including traditional surgery, radiation, and chemotherapy along with the new strategies including CAR-T living drug cancer treatments and many other new cancer therapies.

The war on cancer has never looked better than it does today.