By Kelly Evans-Hullinger, M.D.
 
As a primary care physician, I commonly encounter patients who smoke cigarettes. Most people, including those who smoke, are aware of the long term health risks posed by smoking. Of course, as a physician who cares about their current and future health, I want these patients to embrace the goal of smoking cessation. As someone who has never been a smoker myself, I admit I cannot fully understand the struggle of this task. However, the data suggest that quitting smoking can be extremely difficult. I find it helpful to understand some basic psychology when it comes to smoking cessation.
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In the 1970s, a duo of scientists named Prochaska and Diclemente, after studying subjects who smoked and their likelihood of successfully quitting, developed the Transtheoretical Model of Stages of Change.  This model is widely used today to assess readiness for change when it comes to smoking and other lifestyle changes such as diet, exercise, alcohol and other substance use. The following explains each stage and how we can apply them to help with smoking cessation:

Precontemplative stage: A person has no intention of changing their behavior soon. In this case, I “plant the seed” by providing some basic education and encouraging the patient to think about it before the next visit. Pushing or forcing change at this stage is not likely to be fruitful.

Contemplative stage: A person is thinking about making a change, perhaps in the next six months, but they may not be ready for a definitive plan. I offer specific education about quitting and ensure follow up to help with planning when they are ready.

Preparation stage: A person is ready to implement change in the next 30 days. Time to cheer on my patient and set them up for success! We might set a quit date together, consider referral to the Quitline, and discuss more specific strategies, including medication or nicotine replacement.

Action stage: This is the first six months of the big change, during which patients have a high risk of relapse. It is crucial that the patient check in often with me, their Quitline counselor, and other support people. 

Maintenance stage: After the action stage, risk of relapse decreases but does not go away. I offer my patients a safe place to discuss their urge to smoke and encourage them to stay tobacco-free. If they do slip up, I remind them not to give up. I help them focus on the hard work they’ve already done and stay successful.

Quitting smoking can be difficult, but it is truly one of the best things a person can do for their long-term health. There is support out there, starting with your primary care provider. When you are ready, ask for help!

Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.

By Debra Johnston, M.D.
 
I remember feeling jealous of my grandparents as a child. During one of our summer visits, I realized that while my siblings and I were told to brush our teeth, my grandparents would simply pop their teeth out and drop them into a glass. That seemed like a lot less work! Besides, I thought that no teeth would mean no trips to the dentist, and thus no poking and prodding of sharp instruments in my mouth. Although our dentist and his team were unfailingly caring and gentle, I was always nervous. 
 
As I recall, when I expressed my newfound enthusiasm for the convenience of false teeth, Grandma informed me that wearing dentures would mean giving up fresh corn on the cob. That was all the incentive I needed. I kept brushing.
 
Soon, I realized that a healthy smile meant something more than the ability to enjoy garden bounty. I sensed my tough-as-nails mother and grandmother each were ashamed of their smiles. Without understanding why, I could see that people were judged by the condition of their teeth. Dental health seemed to be an indication of a person’s place in society.  
 
With the benefit of age, and medical training, I learned that the impact of dental disease goes well beyond dietary inconvenience and social embarrassment. People with unhealthy mouths may suffer from malnutrition, which can be both a cause and an effect of their dental problems. Others may unfairly perceive them as less trustworthy, and less employable. 
 
Emergency rooms and medical clinics see the consequences of delayed or absent dental care. Patients seek antibiotics and pain medicines to “get them by” until they can see a dentist. These treatments may convert a raging infection to a smoldering, but temporarily bearable, one. However, they don’t fix the underlying problems.
 
There is another layer to the interplay between dental and physical health: many medical diseases and their treatments may cause or worsen dental problems. The antidepressant I give a patient might cause dry mouth, which worsens tooth decay. The medicine to prevent a broken hip may severely damage the bone of the jaw. Diabetes increases the risk for dental disease which in turn, can worsen a person’s diabetes management.
 
Additionally, research shows that poor dental health increases our risk for heart attacks and could possibly lead to premature births.
 
All in all, there are myriad reasons to take care of our teeth and gums, no matter our age. So, thanks, Grandma, for convincing an impatient child to keep brushing. 
Debra Johnston, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central. 

By Jill Kruse, D.O.
 
When you ask a physician why they became a doctor there is often a pattern that emerges. It is usually one of three things: they have family members who were doctors, they went through a significant health issue of their own, or they had a family member or close friend who when through a serious health issue. In my case, it was the latter. Sadly, there have been many such experiences with people I love but let me share with you the first I can remember. 

I was five years old. She was my neighbor, the only person who could over-rule my mother on how long I could stay at her home playing or how many cookies I could eat when we had tea parties. She was the first grown up who treated me like an adult. When she was admitted to the hospital on hospice, my mother tried to prepare me for what I would see, telling me that our friend no longer had hair. I told her that I didn’t care, I missed her, and I just wanted to see her. 

The memory is so strong that I can still smell the faint antiseptic in the air from the tile floors. The room was dimly lit with a fluorescent light over the head of the bed. My neighbor sat in the bed, her gown hanging on her frame that was now gaunt and her beautiful hair now just a memory, robbed by the chemotherapy. 
We could not stay long, children under twelve years old were not technically permitted into patient rooms at that time. I said “Hi” and gave a shy wave not knowing what else to do or say. It was enough to just be there together. My friend, that powerful woman, looked so small and frail in her bed. The woman who I knew to be so full of life was now living in the shadow of death. I did not know it at that time, but that would be the last time I saw her alive.   
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Pancreatic cancer took her away from me just a few months after the diagnosis was given. I had so many questions. Most of them started with “Why?” That was the first time I had ever been in a hospital, but it would be just one of many times throughout my life where I would be a concerned loved one visiting a sick friend or family member. The death of my neighbor started my journey to become a doctor, a journey to find answers, only to learn that there is always another patient and another question, yet I persist. This is how I honor her memory.                                   
Jill Kruse, D.O. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.  

By Andrew Ellsworth, M.D.
 
Weakness on one side of the body, slurred speech, facial drooping, inability to find or understand words; these are symptoms of a stroke which are typically sudden in onset. The symptoms can be subtle, or they can be severe. Regardless, rapid diagnosis and treatment is the key to recovery. 
 
Not long ago, not much could have been done for someone as they were having a stroke. Often, we could only wait and see how the patient recovered with rehabilitation. For years, prevention was the only tool we had to combat initial and recurring strokes. Preventative measures such as blood pressure control, aspirin or other blood thinners, cholesterol control, and of course, a healthy diet and exercise remain especially important today. Thankfully, we now have a few more options. 
 
Clot-busting medications have been a great advancement in the treatment of strokes since the mid-1990s. If administered soon enough, sometimes these clot-busting medications can work to break up a clot that is blocking blood flow in an area of the brain thus restoring circulation. This can help to preserve or at least minimize the area of the brain that would be permanently damaged.
 
There are risks to these meds, such as bleeding, but the chance of improving the outcome usually justifies their use. To minimize risks, the clot-busting medication must be initiated within three to four- and one-half hours following the onset of symptoms. Physicians also consider other criteria before treating with clot-busting meds, including the patient’s medical history, blood test results, and they must rule out a hemorrhagic stroke using CT imaging of the brain. A hemorrhagic stroke is when damage is done by a ruptured blood vessel rather than from blockage.  
 
More recently, technological developments have changed the emergent care offered for very severe strokes. It is now possible to manually restore blood flow to the brain using minimally invasive surgery. A surgeon inserts a system of catheters and wires into an artery in the arm or groin, advances this system up through the neck and into the brain. Then, at the location of the blood vessel blockage, the blood clot is removed and the circulation to the affected area is restored.
 
Highly specialized, this new procedure seems almost miraculous. It has been referred to as the “Lazarus” procedure as it literally brings people back to life and sometimes immediate improvement is noted as soon as during the procedure.
 
The keys are recognition and time. Know the signs and get help quickly. Think of the acronym FAST:  Face drooping? Arm weakness? Speech difficulty? Time to call 9-1-1. 

Andrew Ellsworth, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.        

By Kelly Evans-Hullinger, M.D.
 
It is a classic presentation: The middle-aged man who develops a painful, swollen, great toe the morning after indulging in a steak dinner with a few beers. The savvy clinician will immediately identify this diagnosis, and I imagine much of the general public might recognize it as well. It’s “The Gout.”
Gout is a unique type of inflammatory arthritis in which a substance called uric acid, accumulating in too-high amounts in the bloodstream, forms crystals within a joint. The presence of those microscopic crystals causes the immune system to attack the “foreign” substance, and the result is excruciating pain. I have seen many a patient limp or be wheelchaired into the exam room when this process occurs in their toe, ankle, or knee. In the most severe cases, patients might be admitted to the hospital.
Gout has been recognized as a disease for many centuries, being described in ancient Egyptian texts in 2600 B.C. and later by the famed Greek physician Hippocrates around 400 B.C. It was once known as the “arthritis of the rich,” and the “disease of kings,” given its propensity to occur after consuming rich food and alcohol. Uric acid crystals were first visualized under a microscope in 1679, during the microscope’s early years, by another famous historical scientist, Antoni van Leeuwenhoek. The chemical composition of what he saw, however, was not known until more than a century later.
If you have had the agony of experiencing a gout attack, know that you are in excellent company. Both Benjamin Franklin and Thomas Jefferson were known to suffer from gout, and historians have speculated that their shared experience led to their strong connection at the time of the American Revolution. In fact, reports have stated that Franklin, unable to walk due to a gouty attack, was carried on a chair into the Constitutional Convention by convicts. Western history and literature are full of references to “The Gout.”
Today, gouty arthritis is a fairly common disease. It tends to affect men more than women, and generally occurs in middle-aged and older adults. Treatment of the acute episode is fairly simple; often we just use anti-inflammatory medication. In patients who have recurrent problems with gout we consider daily medication that lowers the level of uric acid in the bloodstream altogether, which is typically highly effective.
“The Gout” of ancient times was a life-altering condition and as such found its way into many historical texts and literature. Today, well, it’s just gout. And usually, we can treat it very effectively.
Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central. 

By Debra Johnston, M.D.
 
Early in the pandemic, I had occasion to page through photo albums my mother assembled during my childhood. Some of those happy images chilled my physician heart. There I was, two months old, sleeping peacefully on my stomach, in the middle of a sheepskin rug.
 
There I am, seven years later, seated with my siblings on lawn chairs in the bed of the pickup truck as my parents drove us home. We navigated that 15-mile trip multiple times a week for months.
 
There I am, age 12, grinning from my perch atop a wagon load of corn. On the way home from the co-op, I would ride standing on the wagon hitch while my siblings sat on the fenders.
 
Bear in mind, my parents seemed especially safety conscious for the time as evidenced by snapshots of us buckled into our primitive car seats. And, when sunscreen was introduced, I remember my classmates basking in baby-oil while I was slathering on the SPF4.
 
As the saying goes, when we know better, we can do better. That philosophy should apply to us all, throughout our lives.
 
During my years in medical school, we taught parents to lay their babies down for sleep on their backs or their sides. Now we know better…back sleeping on a firm mattress with a taut fitted sheet and no blankets or teddy bears, presents the lowest risk of SIDS. And, research continues. 
 
Early in my career, we recommended children not be allowed to eat peanut products until at least age two to reduce allergy risk. Now we know better…early introduction to small amounts of peanut butter and other highly allergenic foods is the preferred strategy for most children. Still, research continues.
 
The history of medicine, and of science, is one of constant research and evolution. Some things we once thought we knew, did not hold up under further objective study. It is critically important that we challenge and examine our options and re-evaluate the way we have always done things. We must expect adjustments and be willing to change when healthier alternatives are revealed.
Obviously, I survived the dangerous situations of my childhood. However, too many children do not. We can never eliminate all risk, but we can, and must, continue to invest in the scientific process, using the best available data to determine the most effective solutions, even to old questions. 
Debra Johnston, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.  

By Jill Kruse, D.O.
 
When I was younger my parents would let me stay up late to watch “The Tonight Show” with Johnny Carson. I will never forget when it was announced that he would be leaving the show and Jay Leno would be the new host. I was shocked and upset. How could anyone possibly sit behind that desk and host the show as well as Johnny? My family begrudgingly started watching Jay Leno as he took the stage.  The show was not the same, but over time we came to accept the new host and what he brought to the show that was different and new.
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Change is difficult for everyone, but change is one of the few constants in this world. The Prairie Doc® organization is experiencing our own version of change after the death of our founder Dr. Richard Holm in March 2020. None of us will ever replace our Dr. Holm with his wisdom and charisma; however, we bring our own unique strengths and experiences to the programs to make them our own while supporting his mission. Dr. Holm embraced change as was evidenced in many of his writings:

“Change is something we all must face in life, and I have observed that those who embrace change seem to flourish,” wrote Holm.

“As the seasons turn, we are reminded that to survive in this life we must face change,” he wrote in his book Life’s Final Season. “Not too long ago, I attended two funerals in one month and wondered how both surviving eighty-year-old men were going to handle the loss of their spouses and all the changes that were about to occur. Usually people need about six months to mourn before they are expected to recover and move on. The standard teaching in medical school is to begin being concerned when mourning lasts longer than that, but every situation is different.”
 
Referring to the surviving spouses, Holm wrote, “When love is true, (the deceased) would want the one left alone to see change as an opportunity to continue in another way, to find fresh interests, to discover new joy.”
 
We invite you to join us in respecting Dr. Holm’s wishes as we continue his legacy and accept his challenge to embrace change. His message is clear, “I believe the ability to handle change is like working and stretching a muscle. If you don’t use it, you will lose it. Stagnation can cause rigidity, weakness, despondency and death; but movement can cause flexibility, strength, happiness and life.”
 
We hope that our loyal audience will continue to watch the show, listen to the radio program, and podcast, and read the newspaper articles or blog posts. The torch has been passed and I, along with the other Prairie Docs and our guests, accept it humbly and graciously. We hope you enjoy this new season as we honor Dr. Holm and continue to bring you useful information based on honest science, provided in a respectful and compassionate manner.  
 
Jill Kruse, D.O. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.  

By Kenneth A. Bartholomew, M.D.
 
Albert Einstein conducted thought experiments to figure out theoretical problems. Let’s do one of our own. Suppose that you fell and broke your left leg and had to be in a cast for eight weeks. Would you expect your left leg to be as strong as your right leg when the cast was removed? Of course not. You know that muscle that is not exercised gets smaller and softer. Secondly, would you expect that, by sitting in a recliner for the next two months, your left calf would magically grow back and strengthen to where it was before? Of course, you wouldn’t.
 
However, that is exactly what many of us do with our brains. We sit around passively and take our brains for granted. We don’t exercise the brain, yet we expect it to take care of itself. But all cells in the body need to be used or they suffer from what is called disuse atrophy. When body builders start lifting, they use muscle cells that were previously sitting idle. As these cells are exercised vigorously, they hypertrophy, the opposite of atrophy. We can do the very same thing with our brain cells, and the potential is enormous.
 
The human brain is composed of approximately one hundred billion cells, and neuroscientists using PET scans and other devices estimate that we only use about ten billion of these cells in our lifetime. That means that there are ninety billion cells just sitting on top of our shoulders waiting for something to do!
 
Different areas of our brains control different functions such as speech, walking, writing, music, math, and coordination. So, just as the body builder targets each muscle group with specific exercises, we must exercise all the different parts of our brains.
 
For example, balance is a function of multiple areas of the brain all of which can be strengthened by walking. When we walk, we strengthen the legs but at the same time we stimulate the nerves that signal the balance centers of the brain. These signals fire millions of times a second, coordinating our eyesight with inner ear and cerebellar inputs. By practicing walking in a straight line, we target the balance and coordination centers, making them stronger which can help prevent falls and that dreaded broken hip.
 
Our brains have incredible potential, but nothing happens by itself. It starts with us making the decision to exercise our brain. This decision itself originates in a different part of the brain and that, too, will get stronger with repeated use. The fact is, decisions we make daily, will change our brain every day for the rest of our lives. Decisions we make today will affect how our brain functions ten years from now.
 
We can make it happen. We can do math, balance our checkbook in our head then double-check it with our calculator. We can study history, explore music, take educational courses online or via DVD. We can learn a new language, do crosswords, read, read, read. The more we do now the better our brain, and in turn, our lives will be. 
 
Ken Bartholomew, M.D. is a contributing Prairie Doc® columnist. He practices in Pierre, South Dakota and serves on the Healing Words Foundation Board of Directors, a 501c3 which provides funding for Prairie Doc® programs. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPB most Thursdays at 7 p.m. central.   

By Mark E. Bubak, M.D.
 
Summer and fall are prime seasons for mold allergy problems. Mold spores are smaller than pollen grains allowing them to not only effect the eyes and nose of allergy sufferers, but they can infiltrate the bronchial tubes and cause asthma. If the allergy or asthma is combined with participation in sports or a rhinovirus cold at the start of school, it could result in asthma attack. 
 
Sudden asphyxic asthma is a condition during peak mold time in which younger patients with alternaria mold allergy can go from breathing well on their own to severe asthma on a ventilator in an afternoon. There are methods to be prepared and take steps to avert this situation.
 
Most mold spores originate outdoors. Staying indoors and keeping the house, office, and car closed is the main avoidance method. The air conditioner with its filter and dehumidification can help a bit more. Additional filters receive some anecdotal praise but are rarely proven clinically helpful.
 
We cannot stay indoors all the time. For most sufferers, topical corticosteroid nasal or inhaler preventative (controller) sprays must be started prior to the season. And always keep rescue antihistamines and bronchodilators on hand. Oral or injections of steroids may be needed. Allergy shots (immunotherapy) can be immensely helpful if avoidances and medications do not work well. Shots are the only treatment that makes the patient less allergic to the mold and thus reduce symptoms. Unfortunately, under the tongue immunotherapy has not been highly effective for mold allergy. More recently, new medications call biologics have arrived on the market and may be necessary.
 
Mold is a major contributor to fall allergy and asthma suffering, but the worst reactions are typically brought on by a combination of triggers. Getting your flu shot can make the flares of allergic asthma far less likely to happen. Washing your hands helps prevent colds and other infections which can exacerbate the problem. And, using your albuterol before sports activity can help.
 
If you suspect you may have a mold allergy, talk to your primary care physician first. Mold allergies can best be diagnosed with a thorough patient history and physical examination. If allergies are suspected, your doctor can refer you to an allergy specialist who can confirm the diagnosis with allergy testing. If confirmed, you and your doctor can work together to create an allergy and asthma action plan.
 
In the end, much of the responsibility for staying well is up to each of us. The best way to manage mold allergies is to be proactive, ask for help, then follow the prescribed action plan.
 
Mark E. Bubak, M.D. practicing in Sioux Falls, South Dakota is a contributing Prairie Doc® columnist. He is certified by the American Board of Allergy and Immunology to care for adults and children with asthma and allergies. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.        

By Lauren Wood Thum, M.D.
 
Just because something is common does not mean it is normal. Many diseases are common nowadays, yet few would consider them normal. For example, while obesity and diabetes are rampant, none would argue that these conditions are normal or should go untreated. However, when it comes to problems of the urinary tract, this is often the case. Millions of individuals suffer from urinary incontinence – the involuntary loss of urine. Leakage can occur due to a strong “gotta go, gotta go” urge, activity such as coughing or laughing, or even without awareness. Few people seek treatment for these bothersome, yet very treatable, conditions. 
 
On average, patients wait six years or more to bring these urinary complaints to their physicians. And some never do. Many are under the impression that incontinence is a normal part of aging, or something one must simply live with. This could not be further from the truth. Leakage itself is rarely dangerous, however serious consequences can arise from incontinence. Waking frequently at night or rushing to the bathroom can lead to falls, which in turn can result in injury and even the need for nursing home care.
 
These situations, while dangerous, are oftentimes completely preventable. The first step is a careful history and physical examination by a specialist. People leak for a multitude of reasons, and successful treatment depends upon correct diagnosis. Most types of leakage can be eliminated or cured. Depending on the cause, often a trial of simple behavioral modifications can do the trick. These may include limiting fluid intake, avoiding bladder irritants or urinating on a set schedule. Pelvic floor physical therapy may also be an option. 
 
Some patients with a constant urge to urinate, frequent urination, or night waking may require the help of a medication. And not all medications have bothersome side effects. Fortunately, other options do exist. If medication does not work or is not appropriate, we have a multitude of office-based procedures in addition to minor surgical ones. For leakage with activity, a ten-minute procedure can cure leakage for years to come. Not every treatment option is appropriate for every patient, but the bottom line is that options do exist.
 
It saddens me to think of the number of individuals who suffer in silence with these and other very treatable complaints. And while these conditions affect up to half or more of all adults, they are not “normal”. If you are bothered by urinary complaints, be sure to let your doctor know and seek out the help of a urologist who specializes in pelvic medicine. Your quality of life could improve dramatically, and you will be glad you did.
 
Lauren Wood Thum, M.D. practicing urology in Sioux Falls, South Dakota, is a contributing Prairie Doc® columnist and guest on the Prairie Doc® television show. For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow Prairie Doc® on Facebook featuring On Call with the Prairie Doc® a medical Q&A show streaming on Facebook and broadcast on SDPTV most Thursdays at 7 p.m. central.