Gout: An Ancient Malady
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.
When We Know Better
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.
Passing the Torch
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.
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.
Let’s Exercise Our Brains
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.
Plan Ahead for Fall Mold Allergies
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.
Seek Help for Urinary Incontinence
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.
Behind the Mask
By Mandi Greenway, M.D.
Last week I looked in the mirror and saw something I don’t usually see, a breakout of pimples. As a dermatologist I am fortunate enough to have the right tricks to keep my skin blemish free most of the time (some lucky genetics don’t hurt either). I’m also seeing a lot more acne and rosacea breakouts in my patients over the last few months. What might be the culprit? Wearing a face mask.
As the COVID-19 pandemic rages on, wearing a face mask is one of the most important ways we can prevent the spread of the disease. I urge you all to wear a cloth mask when you can’t social distance and when in public spaces. The data regarding face masks is clear, but our skin doesn’t always behave itself with frequent wearing. The good thing is that there are some simple steps you can take to keep your skin healthy while wearing a mask to protect those around you.
Skin issues from wearing masks can include dry skin, acne, and rosacea. Make sure to wash your face before and after wearing masks with a gentle cleanser. Cleansers are different than soaps and can clean the skin without removing normal oils. Apply a moisturizer that is tailored to your skin type: gel moisturizers for oily skin (or during those humid summer days), lotion for normal skin, and cream for dry skin. Try to get this moisturizer on after each time you wash your face as well as before bed. Dry lips are best treated with plain Vaseline.
If you’re going to be wearing a mask for longer periods of time it’s best to skip wearing makeup under the mask. Treat your skin gently and avoid harsh treatments like chemical peels or exfoliating. Some of the medicines we use to treat acne with can ironically cause more skin irritation while wearing masks, so be sure to discuss with your physician if you are having problems.
Lastly, be sure you are wearing the correct mask and washing them frequently. Cotton is the least irritating fabric and anyone with acne or rosacea should make sure that the layer that touches the face is cotton. Masks that fit well (snug but not tight) will be less irritating than masks that are too big and slide around on the face.
Hopefully, these simple tips help your skin stay healthy as you continue to wear your mask!
Mandi Greenway, M.D. is a contributing Prairie Doc® columnist. She practices dermatology in Mitchell, 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.
Kindness is the Best Medicine
by Joanie Holm, C.N.P.
My name is Joanie Holm. I am a certified nurse practitioner in Brookings, South Dakota and I am the person fortunate to have been the life partner of the original Prairie Doc®, Richard P. Holm, M.D. Rick and I were married for 40 years before his passing in March of 2020.
During those wonderful decades together, if I could point to one powerful action that strengthened our relationship with each other, with our family, our community and with our patients, it would be the act of kindness.
Thankfully, Rick was alive to see the recognition and formalization of kindness as an essential element of medical education. Medical schools across the country have started to offer courses on compassion and caring. One of the first to do so was the University of South Dakota Sanford School of Medicine.
Dr. Mary Nettleman, dean of the USD medical school, explained why the school embraced kindness as part of its core curriculum. “People want a physician who is not only competent, but also kind, so we will work to elevate this value throughout the school. By approaching this intentionally, we hope that students will learn how important kindness is in medicine and how they can incorporate it into their everyday practice. A culture of kindness can make us exceptional,” said Nettleman.
I celebrate this awareness and elevation of kindness in medical education and I salute educators for enriching their medical students in this way.
Since Rick’s death, I have received many wonderful notes of condolence that have been very meaningful to me and my family. With permission from the author of one such letter, I share the following message which further illustrates kindness.
Dear Mrs. Holm,
I’m one of the people who knew your husband through his TV show, and I learned from him. I have cerebral palsy and sometimes it’s hard for people to understand me. One day, my mom and I were having dinner in Sioux Falls and you were seated close to us. When Dr. Holm walked by my table, I put my hand out and he stopped and talked to me. I wanted to tell him that we were praying for him and I will never forget how he made me feel. I have worked with many doctors and he was one of the best!
My dear husband practiced kindness in all he did. Regardless of our profession, may we all embrace acts of kindness and stop to hold the outreached hand of a fellow human being.
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.
Prairie Doc® Perspectives for week of July 26, 2020
By Debra Johnston, M.D.
Sometimes, life has lessons for us that we don’t truly appreciate until much later.
Many years ago, when I was a very wet behind the ears new doctor, I had the privilege of being part of the care team for an elderly Native American woman. She had been transferred from somewhere in rural South Dakota to our hospital in the city in hopes of identifying her disease and ascertaining how best to help her. Her daughter accompanied her. The medical team was convinced we knew “best,” while her daughter was determined that we were not going to take a single step that might conflict with her mother’s values. The stage was set for conflict.
As an intern on one of my first rotations, I just could not understand why someone would come to us for help, and then not be willing to follow our recommendations for testing and procedures that we felt would give us information we needed. We were frustrated. I didn’t recognize it at the time, but I learned a lot from that fierce patient advocate.
In retrospect, the most obvious lesson was the importance of acknowledging that people have different values, and those values are shaped by many things, including culture and religion. While it may be true that some values are shared across cultures, it is a mistake to assume that we can understand another person’s values and priorities through the prism of our own, or based upon what we think we know about them.
Healthcare providers can best help their patients by taking time to discuss cultural values, sacred traditions, and priorities with patients. This is especially true when it comes to end of life care, but it also applies to situations such as acceptance of medical testing, preferences regarding prescription drugs versus non-pharmaceutical alternatives and culture-based healing practices.
Another lesson was the importance of an advocate for the sick and vulnerable. It is extremely valuable for both the patient and the care team to have someone else present with the patient. This is a person the patient trusts to help clarify their concerns, to remember information, and to pass that information along to the patient’s loved ones. Prior to the covid-19 pandemic, few patients utilized an advocate, except in the gravest of circumstances. Now, procedures in place to protect patients, staff, and family from this dreadful virus, limit the opportunity for patients to have an advocate physically present. However, most facilities support connection to patient advocates via phone call or video call.
In the end, a wise chaplain arranged for a traditional healer to visit our patient in her hospital room. I was not present for the ceremony, but the senior physicians and the daughter agreed on a plan of action. We didn’t cure the patient, but we were able to offer her physical comfort in her final days, and I believe that by blending her culture and traditions with our medical ethos, we helped both the patient and her daughter find spiritual comfort as well.
Debra Johnston, MD 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.
Choosing Healthy Habits
By Andrew Ellsworth, MD
Early on in the coronavirus pandemic with many people spending a lot of time at home, a wise friend told me that people will likely come out of this “a chunk, a hunk, or a drunk.” So, here we are four months later, and I have observed these outcomes in several of my patients.
Some admit they have been drinking more, some say they have been snacking more, and thankfully, some have actually lost weight and have been eating healthier and exercising more. One man realized early on that he could not continue letting himself go. He started counting calories, lost 20 pounds, and is feeling great. He feels he has more energy to do the things he wants to do. He is not alone, and you can do it, too!
This pandemic has disrupted our normal routines, which I believe makes this the perfect time to establish new habits. And, since we are forced to change our habits, we might as well choose healthy ones. Start with a little walk. Plan some time for a bike ride. Maybe you can borrow a used piece of home exercise equipment or dig out the old NordicTrack from the basement. If you need some motivation and could use a companion, make plans to work out with a friend or family member in person or on the phone. If you are ready for a long-term commitment, maybe get a dog and take it regularly for a walk.
Now is also a great time to stop smoking. A new routine or being away from your regular workplace for an extended period allows you to avoid some of the triggers that make you want to smoke, such as your usual “smoke break time,” your favorite locations to smoke, and perhaps the people with whom you smoke.
Certainly, times are tougher and none of this is easy, but please do not make it harder for yourself by becoming addicted to a substance. That will not solve your problems and will only make them worse. If you feel like you should cut down on your drinking, if you feel annoyed by people criticizing your drinking, if you feel guilty about your drinking, or if you find you need a drink in the morning, then it is probably time to cut down on your drinking. If cutting down is difficult, then please ask for help. Consider contacting someone from Alcoholics Anonymous, your primary care provider, a friend or family member, or do an internet search for help in your area.
Whatever you decide to do to make yourself healthier, now is the best time to start. Start small, do it regularly, and soon you will have some new habits, a healthier you, and a little silver lining from these unusual times.
Andrew Ellsworth, MD 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.