By Kelly Evans-Hullinger, M.D.
 
Hypothyroidism, the condition of the thyroid gland not making enough thyroid hormone, is a common hormonal disorder. Perhaps because hypothyroidism is common and its symptoms can be widespread and vague, misconceptions abound. Let’s cover the facts.

Symptoms of hypothyroidism can include fatigue, dry skin, weight gain, and hair loss. These symptoms can occur for many other reasons, so fortunately a very simple blood test can tell us whether an underactive thyroid is the culprit.

If hypothyroidism is suspected, the best thing to test first is TSH, or Thyroid Stimulating Hormone. TSH is made by the pituitary gland in the brain which physiologically responds to levels of thyroid hormone circulating in the patient’s body. Under normal conditions, the pituitary gland signals the thyroid gland to make more thyroid hormone. So, if thyroid hormone levels are low, TSH levels will be high. The pituitary gland is trying to tell the thyroid gland, “wake up and make some more hormone, pal!”

If the TSH level is normal, in short, the thyroid is not the problem and probably no other testing needs to be done along those lines. If the TSH is elevated, another blood test for free T4 should be done. Free T4 is one type of thyroid hormone. Other types of thyroid hormones do exist but testing for them is far less reliable. In hypothyroidism, the TSH will be elevated, and the free T4 will be low.

Okay, so when we find a patient has hypothyroidism, what next? In general, we do not need to dig for a cause. Unless the person has had removal or ablation of the thyroid gland, we can assume they have Hashimoto’s thyroiditis, the most common reason for hypothyroidism. Hashimoto’s is an autoimmune disease which eventually destroys thyroid producing cells. Antibody testing is possible for Hashimoto’s disease, but it generally is not necessary.

Treatment of Hashimoto’s thyroiditis and any cause of hypothyroidism is simple…replace the thyroid hormone. This is done with a synthetic version of T4 hormone, the most reliable and standardized form of which is levothyroxine. Other types of thyroid replacement exist, but levothyroxine is universally recommended in all but a small minority of cases. Pretty much all patients can expect to take medicine indefinitely, though repeat TSH testing should be done periodically to make sure the dose is proper.

In summary, hypothyroidism is an easily diagnosed and easily treated condition. If you are having symptoms of this hormonal deficiency, discuss a TSH blood test with your primary care provider to see if a simple intervention might help you feel better.
​
Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.   

By Debra Johnston, M.D.
 
I don’t know how you feel, but in my opinion, parenting is hard! Someone must have forgotten to hand me the instruction manual when my children came home. I have yet to meet a parent who wouldn’t appreciate one.
 
New parents can count on getting lots of advice from well-meaning friends and relatives, and sometimes even perfect strangers. Some of that advice is welcome and useful. Some, not so much. And sometimes that advice is downright dangerous.
 
Many grandparents raised their own children at a time when doctors thought it was best to put babies on their stomachs to sleep. Research in the 1990s showed that this sleeping position significantly increased the risk of sudden infant death syndrome. And all those cute stuffed animals and fluffy blankets increase the risk of suffocation.
 
Many great grandparents started their newborns on solid food soon after birth. Now we understand more about infant nutrition and recommend waiting until six months for most babies. This helps ensure the baby is developmentally ready to swallow solids and reduces the risk of some health problems that can persist well into adulthood.
 
My own generation was told to avoid exposure to common allergens like nuts and fish in the hopes of reducing the risk of food allergies. More recent research indicates the opposite: early introduction to these foods reduces that risk. Of course, parents still need to be mindful of choking hazards. Try thinned smooth peanut butter, not whole peanuts. We still recommend avoiding honey, because of the risk of botulism, and liquid milk, because it is more difficult to digest. Besides, formula and breast milk provide more complete nutrition.
 
Parents today often swear by sleep nests or wedges. These are cushions meant to prop babies in a particular position. Although these devices are popular, they are dangerous and increase the risk of suffocation. Walkers are popular too, but they are associated with injuries, and have not been shown to help babies learn to walk. In fact, motor skills may be delayed if baby uses a walker.
 
So how can families sort out all this advice? Look for trustworthy sources of information, such as the American Academy of Pediatrics’ on-line resource, healthychildren.org, or the American Academy of Family Physicians’ educational website, familydoctor.org. Best of all, take advantage of regular well-child visits with your primary care provider. Your doctor desires a strong relationship and will work with you to help your child grow up safe and healthy.
 
Debra Johnston, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.                     

By Jill Kruse, D.O.
 
Over the course of my career, I have performed countless pelvic exams on women of all ages from all walks of life. There are two common patient behaviors that I have observed. First, most women leave their socks on. This could be the fact that most stirrups are cold, but it also seems like one feels just a little less exposed when wearing at least one item of their own clothing. The other thing that almost every woman does in the exam room is hide her undergarments under her pile of clothes. It is interesting that almost everyone, me included, feels the need to cover and hide their “unmentionables” when they are about to bare the very areas normally covered by these garments. 

Therefore, it is no surprise that it can be difficult for women to voice concerns when it comes to their “private areas.” These areas are just that, private! Women do not often visit with family or friends about incontinence, menstrual irregularities, or pelvic pain. It may be easy to discuss gallbladder issues or a migraine headache, but it is much more embarrassing to ask a friend if she leaks a bit of urine when she sneezes, jumps, or coughs after birthing a child. This condition is common, and it can be treated. But if we don’t talk about it, we may not realize when something is “normal” or if it is something to be concerned about.

It is perfectly fine for women to hide our underwear from our health care provider, but let’s not hide our concerns or be embarrassed about discussing the areas covered by these garments. If we choose not to talk about it, what may seem like a minor nuisance could lead to a bigger problem. For example, vaginal spotting or bleeding after menopause is never normal and should always be reported to your provider. It could be caused by harmless uterine fibroids, but it might also be a sign of uterine cancer. The sooner you discuss it with your doctor, the better.

Unfortunately, I have seen too many women who suffer in silence because they figure whatever is happening to them must be “normal” or just a sign of “getting older” or is the “price of having children”. Primary care providers and obstetrician-gynecologists are ready to help you talk about these sensitive topics. When you uncover and discuss your concerns, they will listen, diagnose, and treat with care.

So go ahead, keep your socks on and hide your “unmentionable” clothing, but please, never hide your health concerns.

Jill Kruse, D.O. is part of The Prairie Doc® team of physicians and currently practices as a hospitalist in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc®, a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.   

By Andrew Ellsworth, M.D.
 
The act of breathing is essential to life and can be done with or without thinking about it. You can control your breath and vary it, but eventually air must come in, and air must go out. 
 
The breath of life and breathing exercises are an important aspect of many religions. In the book of Genesis, when God created man, he formed man of the dust of the ground, and breathed into his nostrils the breath of life. Several Eastern religions use controlled breathing in meditation and prayer, helping in the processes of consciousness, mindfulness, and visualization. 
 
In this time of increased stress and anxiety over money, wars, and numerous other matters, I encourage us all to take time to focus on our breathing. 
 
One of the simplest ways to combat stress and anxiety is to breathe. It does not cost any money and does not have to take much time. However, deep breathing can decrease your stress, help you feel calmer, reduce pain, reduce your blood pressure, help you focus, and improve digestion. It can also increase your energy and improve your immunity. 
 
How do you do it? Easy! Just do it. Make sure you are somewhere safe and close your eyes. Breathe in gently through your nose, take about four to five seconds, and fill your belly and chest. Perhaps hold it for another couple seconds. Then release it through your open mouth over five seconds or more, whatever is comfortable. Repeat this at least five times.
 
When I have patients that have anxiety or panic attacks, I often take a little time to practice this with them. Every time I feel calmer myself, and I hope they find it calming as well. 
 
This week, our television program, On Call with the Prairie Doc®, is celebrating its 20th season of providing truthful, tested, and timely medical information. We are taking time to breathe in and reflect on our past, feeling grateful for our founders, the late Dr. Richard Holm and his wife Joanie, and celebrating the contributions of everyone on our team.

Thank you, our readers, for taking the time to read our columns through the years, and I hope there are many more to come. Now, please take a moment to do some deep breathing. First you breathe in, then breathe out. 
 
Andrew Ellsworth, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.                                     

By Kelly Evans-Hullinger, M.D.
 
From Babe Ruth to John Wayne, Americans have seen chewing tobacco in popular culture for over a century. Spitting chew has been a trademark of cowboys and professional athletes alike and chewing tobacco use continues at high rates in the United States. In 2018 a survey showed 2.4 percent of American adults used smokeless tobacco, with snuff or snus pouch use on the rise and chewing tobacco on the decline.
​
Though smokeless tobacco use is not associated with lung cancer like smoking is, it has its own set of potential dangers. First, smokeless tobacco does contain nicotine, causes nicotine addiction, and thus can be very difficult to quit.

Chewing tobacco can wreak havoc on a person’s teeth and gums. It causes tooth discoloration, dental cavities, tooth loss, and recession of the gums, sometimes requiring oral surgery.

Smokeless tobacco is a major risk factor for cancer of the oral cavity and throat. Smoking cigarettes also increases the risk of this type of cancer. Cancer of this region can be devastating partly because its treatment may result in the inability for a patient to use their mouth, throat, and vocal cords.

A person who uses or has used smokeless tobacco as well as current and former smokers should discuss that with their primary care provider as well as their dentist and dental hygienist, as those professionals can perform thorough oral and neck exams as part of their regular care. Any abnormality found should be investigated thoroughly.

Another crucial note is that many oral, head, and neck cancers are also associated with human papilloma virus, or HPV, infection. If you are on the fence about getting your children or yourself, if eligible, vaccinated for HPV, this disease is another excellent reason to do so.

The iconic Babe Ruth, who chewed tobacco and smoked cigarettes, died prematurely of throat cancer at age 53. Major League Baseball finally prohibited the use of smokeless tobacco in 2016.

If you use smokeless tobacco and are ready to quit, the advice is similar to that for quitting smoking. First, make a plan and talk to people who can help hold you accountable. Get rid of all stashes of tobacco at your home, workplace, and vehicle. Consider use of nicotine replacement therapy, such as patches and/or gum, or prescription medication which may make kicking your nicotine addiction a little easier. Finally, if you aren’t successful this time, regear your plan and try again. It will absolutely be worth it.
​
Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.

By Debra Johnston, M.D.
 
Skin is the largest organ in the human body, but it’s easy to take it for granted. Unless we notice pain or itching or funny spots, most people don’t give it much thought.
 
However, the skin is critically important. It helps regulate our body temperature and fluid and electrolyte balance. It provides us critical information about our environment, and it protects us from invasion by the sea of germs we encounter every day. Some of the sickest patients doctors ever treat are those who have had significant skin loss, whether due to illness like toxic epidermal necrolysis, or injury like burns.
 
This important organ can give doctors clues to diseases elsewhere in the body. Rashes might suggest celiac disease, or an overactive immune system, or internal cancers. Skin discoloration might alert us to liver diseases, hormonal conditions, or dangerous exposures.
 
The skin itself is subject to diseases. Genetics plays a role in conditions like eczema and psoriasis. Sometimes our habits can set the stage for skin problems. Sun exposure increases the risk of skin cancer, but it also accelerates the development of wrinkles. Smoking does, too. 
 
So, what can we do to protect our skin, especially as summer approaches?
 
One big step is to protect it from the sun. Sunscreen is very useful! Use one that blocks both UVA and UVB light. Choose SPF 30 or higher, and don’t forget to re-apply every two hours. Most sunscreens break down when exposed to the sun, so even if you are wearing SPF100 it won’t last through the afternoon. Sunscreen takes about 15 minutes to bind to your skin and protect you, so put it on before you head out. Use enough: the average adult needs at least a shot glass worth for each application. One bottle might not last your family through the whole weekend at the lake. Water resistance is useful, but sunscreen is never truly waterproof, so re-apply after swimming or sweating. Ultraviolet light penetrates cloud cover, so sunscreen is important even on overcast days. Don’t forget your lips: many skin cancers develop there, so wear lip balm with SPF.
 
Sunscreen isn’t the only protective measure you can take. Consider the tried-and-true approach of covering up. Wear long sleeves and wide brimmed hats. Stay inside, if you can, especially during the parts of the day with the most direct sunlight.
 
Your skin has a big job, protecting you from the environment. You can return the favor, and protect it, too.
 
Debra Johnston, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.                     

By Jill Kruse, D.O.
 
Post-traumatic stress disorder, or PTSD, was first listed as a medical diagnosis in 1980. However, it has been recognized and called by many different names throughout history. The first recorded description of PTSD is in the Epic of Gilgamesh which dates back to 2100 B.C. In The Iliad and The Odyssey, Homer wrote about Trojan War soldiers exhibiting the symptoms of PTSD. Shakespeare described a character in King Henry IV who suffered from post-traumatic nightmares.

During the Civil War, the terms “irritable heart” and “soldier’s heart” were used to describe PTSD symptoms. In World War I it was called “combat stress” or “shell-shock”. In World War II it became “battle fatigue” and “combat exhaustion”. PTSD is not limited to soldiers, as the terms “concentration camp syndrome”, “survivor syndrome”, “battered child syndrome”, and “rape trauma syndrome” were all recognized as conditions in the aftermath of WWII. 

PTSD is a mental health condition resulting from experiencing trauma firsthand or from witnessing others undergoing a severely traumatic event. It can also result from repeated exposure to distressing details of an event. For example, many firefighters and other rescue personnel who searched for survivors after the 9/11 attacks suffer from PTSD.

The traumatic experience can lead to flashbacks or nightmares which can progress to physical reactions such as rapid heart rate or shaking when reminded of the event. Individuals with PTSD will often avoid any person, place, activity, or object that could trigger memories of the event. As a result, they may feel detached from others, or have persistent negative thoughts of themselves or others. They may have difficulty experiencing positive emotions like joy and happiness.

Another common symptom of PTSD is hyper vigilance and always feeling “on guard”. This in turn can cause problems such as excessive sleeping, irritability, aggressive behavior, heightened startle response, or difficulty concentrating. If these symptoms last more than one month and interfere with multiple areas of a person’s life, then they meet criteria for the diagnosis of PTSD.

PTSD is best treated by psychiatrists and psychotherapists with special training in this condition. Treatment often involves a combination of medication and therapy. Support groups, exercise, and mindfulness practices are also healthy coping strategies. And, as with any sickness, compassion from family and friends is crucial.
While the name for this illness may have changed, PTSD has been acknowledged for centuries. If you or someone you know is suffering from PTSD, don’t wait. Talk to your doctor, counselor, or spiritual leader. For more information, call the Substance Abuse and Mental Health Services Administration National Helpline at 1-800-662-HELP (4357) or text HELP4U (435748).

Jill Kruse, D.O. is part of The Prairie Doc® team of physicians and currently practices as a hospitalist in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc®, a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.

By Jill Kruse, D.O.
 
I enjoy visiting with my colleagues who are medical specialists. We dive in and explore the depths of a particular condition. However, there is something to say about the breadth of knowledge that a family medicine physician is expected to have. Your family doctor can run through the alphabet of conditions from acne to the zika virus.

A 2004 study in the Annals of Family Medicine found that a family medicine physician managed an average of 3.05 problems per clinic visit. For patients over 65 years of age, that number went up to 3.88 problems and patients with diabetes had an average of 4.60 problems addressed at each visit. A specialist physician will generally focus on one problem at each visit.
 
However, patients are not made up of individual problems. The body functions as a unit and issues in one area can affect another unrelated organ system. We know that chronic pain can lead to depression and vice versa. Stooped posture due to compression fractures from osteoporosis can lead to lung issues as the ribs cannot open up as fully as they normally do. We continue to learn more on how the micro biome of the bacteria in the body affect things from a person’s weight to immune system function. 

This is why it is so important to have a primary care physician and to make sure they have access to your complete medical history. With a comprehensive view of your records, symptoms that might otherwise seem unrelated can be assessed and may assist with diagnosis. Talk to your doctor to determine if all your medical information and testing results are consolidated into one record, especially if you have doctors who work in different health care systems.

The primary care physician also serves as a guide between the patient and the specialist, offering valuable medical detail to the specialist and providing clarification to the patient.

Recently I had a patient who timidly started their question with the preface, “I’m not sure if I should ask you this, but….” I quickly reassured them that in primary care, any question is fair game. If it is something that I can answer, I will. If I do not have the answer, I can do some research, consult with a colleague, or refer you on to someone who does have that answer for you. So, no matter your condition from acne and amblyopia to zika virus and zoster, your family doctor should have you covered. Go ahead, ask anything from A to Z!
​
Jill Kruse, D.O. is part of The Prairie Doc® team of physicians and currently practices as a hospitalist in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc®, a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.                                                                

By Andrew Ellsworth, M.D.
 
Since ancient times, marijuana has been used for medicinal and recreational purposes in many cultures. In the United States, it became illegal during prohibition, like alcohol. Later, under the Controlled Substances Act in the 1970’s, the federal government classified marijuana a Schedule 1 drug. This classification includes heroin, LSD, and ecstasy, all deemed to have no safe, effective medical use and a high potential for abuse.
 
This Schedule 1 status imposes bureaucratic and legal barriers, making it difficult to conduct scientific research on the medical benefits from marijuana. Studies that have been conducted are small and limited. Thus, physicians are less confident recommending marijuana for patients. Not to mention, use or possession remains illegal federally and in many states. 
 
The word cannabis refers to all products derived from the plant cannabis sativa. There are hundreds of compounds in this plant, called cannabinoids. Cannabidiol (CBD) is one of them, and tetrahydrocannabinol (THC) is another. The word marijuana often refers to products from the plant that contain large amounts of THC, which is psychoactive and can alter someone’s mental state. 
 
Cannabinoids can trigger receptors in the brain to release neurotransmitters to affect mood, sleep, pain, and memory. Drugs with cannabinoids may be helpful in treating nausea and vomiting from cancer treatments, loss of appetite and weight loss from AIDS, chronic pain syndrome, multiple sclerosis symptoms, glaucoma and children suffering from seizures. There may be other medical benefits we are not yet aware of. We need more research to determine safe treatments and establish confidence. 
 
Marijuana use can cause harm. It can do more than dull the brain and give someone the munchies. It can increase the risk of motor vehicle crashes. In some individuals it can increase the risk of developing schizophrenia or other mental illnesses. Frequent use by adults and use in adolescence can decrease attention and memory, or cause cannabis use disorder, which has symptoms of craving, withdrawal, lack of control, and negative effects on personal and professional responsibilities. Sometimes people develop recurrent severe vomiting. Vaping products with THC have resulted in severe lung injury. 
 
Marijuana has been used as a medicine for a very long time in various cultures. Yes, it can be addictive, and it can cause problems. Although, when you consider the harms from alcohol, tobacco, narcotic pain killers, and other medications, perhaps cannabis deserves a chance to be further studied and used when medically appropriate. 
 
Andrew Ellsworth, M.D. is part of The Prairie Doc® team of physicians and currently practices family medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.                                     

By Kelly Evans-Hullinger, M.D.
 
Life expectancy is a measure commonly considered when it comes to the overall health of a population. In this day and age, when most of us think about which medical interventions are most important to increase life expectancy, we probably think about things like treatment of cancer, interventions to treat heart attacks, or surgeries for life threatening illnesses. While those things are all important, their overall impact on a population’s life expectancy pales in comparison to the prevention of infectious disease.

Average life expectancy around the world has doubled in the last two hundred years, from about 40 years to 80 years, with the bulk of that change occurring long before we had effective cancer treatment or cardiac catheterization. Before the 20th century, infant and childhood death was extremely common due to infections spread by contaminated water and food. It is estimated that through most of human history nearly half of children died before adulthood, almost entirely due to infections.

Armed with the new knowledge of germ theory, societies in the late 1800’s began instituting early public health interventions such as sewage management, water treatment, milk pasteurization, and garbage collection, which resulted in rapid decreases in death from food and water borne infections, and thus increased population wide life expectancy.

Later, widespread use of vaccines for many fatal diseases led to enormous improvements in the health and longevity of populations across the globe. Try to imagine a world in which almost everyone is affected by the death of children due to polio, measles, smallpox, tetanus, the list goes on. That these deaths are now extremely rare or eliminated altogether is nothing short of a modern miracle, and we ought not take it for granted.

Antibiotic use has exploded since the discovery of penicillin in 1928, and the proper use of antibiotics continues to help us prevent early death due to infections that might have been fatal left untreated. Modern science has led to effective treatments for even the most challenging infections such as tuberculosis and HIV.

Modern medicine uses abundant, wonderful technologies and treatments which help us extend lives and reduce suffering of our individual patients. But statistically, no fancy new development is likely to have the quantitative impact on human society that compares to those early public health measures. As a society, we would be careless to forget the worth of our public health institutions which have helped us thrive and double our average life expectancy.

Kelly Evans-Hullinger, M.D. is part of The Prairie Doc® team of physicians and currently practices internal medicine in Brookings, South Dakota. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show celebrating its twentieth season of truthful, tested, and timely medical information, broadcast on SDPB and streaming live on Facebook most Thursdays at 7 p.m. central.