Category Archives: Dr. Croft’s Blog

Lurking Within You?

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Here is the latest news from our blog, featuring Sara Reeves, FNP, who is one of our providers here at EFFM/FIM.

Lurking Within You?

Hepatitis C Virus (HCV) is a contagious liver disease spread through contact with the blood of a person who has the virus. It can result in serious liver damage, including liver failure. Chronic Hep C affects an estimated 2.4 million people in the United States.

A onetime HCV screening is now recommended for all individuals who were born between 1945 and 1965. Other individuals considered high-risk who should also be tested include injectable drug users (now or even one time in the past), anyone who received blood products including transfusions, dialysis, or an organ transplant before July 1992, and those who are HIV positive.

At the beginning, HCV usually has no symptoms and usually shows itself through routine lab testing. Liver enzyme elevation is commonly the first indication that someone has HCV. There is no predicting how quickly the virus will cause permanent damage, so early detection is important. Over time, Hep C will cause scarring and cirrhosis of the liver. These conditions can encourage the development of liver cancer (about 5% of those infected). More common is the development of liver failure secondary to cirrhosis and fibrosis (scarring) that can require a liver transplant. Fifteen to twenty percent of those infected with HCV recover without treatment. The remaining 80-85% progress to chronic Hep C.

Testing for HCV is quick and easy, requiring a simple blood test. While testing liver enzymes in part of a routine metabolic panel that is usually done yearly, HCV testing is not. There is no vaccine for HCV. Many insurances cover the test at no cost.
HCV is now treatable. Treatment is 90-100% effective in curing this disease progression. Treatment at any stage will stop the progression of the disease and prevent further damage from any existing liver disease. Medications can be very expensive and not all insurance plans cover them. Medication assistance programs are common and help to make this treatment affordable for most people.
If you are unsure if you need to be tested, please discuss it with your primary care provider. If you have been tested in the past, please make sure that your current provider is aware of this and your results.

Sara Reeves, FNP
East Flagstaff Family Medicine

A Breath of Fresh Air

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                “Snore, snore…….SNORE, snore, snore……. SNORE, snore…..”  If you have ever heard this breathing pattern before, you may have been witness to sleep apnea.  These pauses in breathing may last from a few to prolonged seconds, happening fifteen, thirty, even sixty or more times in an hour.  Another presentation of sleep apnea may be present as very shallow breathing.  Either problem will commonly disrupt sleep as it drives sleep patterns from deep to shallow sleep.  The result of this poor quality sleep may cause daytime fatigue and tiredness.  Signs of this include falling asleep during the day, at work, or while driving.  Other signs and symptoms may include morning headaches, memory complaints, irritability or depression, frequent nighttime awakenings and dry mouth or sore throat upon awakening.

                Mild sleep apnea affects about one out of five people, and moderate to severe impacts one out of fifteen.  In the United States, that influences about 22 million Americans.  As there are no physical findings or lab tests that diagnose the problem, sleep apnea is not a problem that can be found on a routine exam.  Most often, the question is brought to the attention of the patient or physician by the spouse or bed partner.     

Obstructive sleep apnea, the more common form of this sleep disorder, occurs when the muscles of the throat and tongue relax excessively and allow the tissues to collapse, blocking off the upper airway.  When breathing stops and oxygen levels drop, the brain is triggered to disrupt sleep, tighten the muscles and stimulate a breath.  But in addition to disruptive sleep, the stress hormones that are released can raise your heart rate and increase the risk for high blood pressure, heart attack, stroke and arrhythmias (irregular heartbeats).  Although sleep apnea can occur in anyone, it is commonly associated with men more than women, and increases with age.  People who are overweight may be prone to sleep apnea as well as those who drink alcohol, smoke, take sleep aids, or sleep on their back.  Other considerations include those with smaller upper airways, allergies or other airway congestion, facial disfiguration, or in children, swollen tonsils.

Central sleep apnea is less common than obstructive, and occurs when the brain fails to send the correct message for the respiratory muscles to function properly.  As a result, breathing simply ceases momentarily.  Although snoring doesn’t typically occur with central apnea, there can be mixed apnea, that both forms are present in a patient.

When sleep apnea is suspected, testing includes an overnight study. Screening may be done at home, (commonly the preference of many insurances) measuring breathing patterns and air flow, heart rate, lung expansion and oxygen levels of the patient in his own bed.  More extensive evaluation may be required in a sleep lab clinic that includes, among other measurements, heart and brainwave monitoring by a technician.

The treatments for sleep apnea depend on type and severity.  In mild cases, a dental appliance worn in the mouth while sleeping may be effective.  The most common treatment of more severe apnea consists of CPAP – continuous positive airway pressure.  A mask covers the nose, nose and mouth, or inserted into the nose (nasal pillows) and is connected by a tube to a small pressure pump.  The onboard computer monitors airway resistance, and increases air pressure when resistance increases or breathing diminishes.  This pressure balance keeps the airway open and prevents the collapse and obstruction.   

Untreated apnea may shorten your expected lifespan eight to ten years, as well as make other diseases more difficult to treat.  If you have concerns regarding sleep apnea, please contact your health care provider. 

Bradford Croft, DO

East Flagstaff Family Medicine

Zzzz….zzzz…

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 “How much sleep do I need?” is not easily answered.  As we spend an average of one third of our life asleep, it is an important healthy life activity.  There are multiple factors that influence our sleep including our personal sleep needs, underlying disease considerations, personal habits and bedroom environments.  As we mature, our sleep duration needs diminish over time.

The National Sleep Foundation has recently updated their suggestions of sleep times:

  • Newborns (0-3 months):  14-17 hours each day (previously it was 12-18)
  • Infants (4-11 months):  12-15 hours (previously it was 14-15)
  • Toddlers (1-2 years):  11-14 hours (previously it was 12-14)
  • Preschoolers (3-5):  10-13 hours (previously it was 11-13)
  • School age children (6-13):  9-11 hours (previously it was 10-11)
  • Teenagers (14-17):  8-10 hours (previously it was 8.5-9.5)
  • Younger adults (18-25):  7-9 hours (new age category)
  • Adults (26-64):  7-9 hours (unchanged)
  • Older adults (65+):  7-8 hours (new age category)

Pay attention to how you feel after a “good” night’s sleep versus a poor one.  What is your attitude, mood and energy?  How long has it been since a good night’s sleep?  You are probably fine if you are healthy, happy, alert and productive whatever your present sleep pattern.  However, if it has been awhile or you just can’t remember when you last good sleep has been, you may want to examine your barriers to sleep.

  • Maintain a schedule of bedtime and awakening times, even on weekends.
  • Practice a relaxing bedtime ritual such as reading, deep breathing, visual imagery, or meditation.
  • Daily exercise will help assure improved sleep.
  • A comfortable, quiet and dark bedroom is essential.  Remember the bedroom is for sleep.
  • Do not watch TV or work on your computer in the bedroom. Go somewhere else in the house.
  • Even limited amounts of caffeine or alcohol can impair restorative sleep.  Stop either or both.

Poor sleep patterns may also a sign of underlying health problems.  Anxiety and depression very commonly will negatively affect sleep patterns presenting as insomnia or excessive sleepiness.  Frequent awakening to use the bathroom may be an issue as well.  Obstructive sleep apnea (OSA) is becoming a more frequent finding as we learn to screen for it.  OSA is caused by a temporary collapse of the airway which prevents a breath from being completed.  Every time this happens, most individuals will “almost” wake up, and occasionally completely wake up.  As this may occur as often as every few minutes through the course of sleep, most will awaken unrested and fatigued.  The Sleep Apnea Foundation estimates that there are 22 million with OSA, and over 80% are undiagnosed.  Untreated, those individuals likely can lose eight to ten years of life expectancy.

There are a number of over-the-counter sleep aids available.  For infrequent or temporary use, most may be an appropriate treatment for occasional sleep problems.  If you have consistent problems with sleep, please consult your health care professional, as there may be more than meets the eye.

Bradford Croft, DO / East Flagstaff Family Medicine

Working Smarter

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Every June, the National Safety Council targets this month as National Safety Month.  Work place safety should be an ongoing effort of injury and illness prevention by employers and employees alike.  The first step to lowering the risk of getting hurt at work begins with a healthy employee at home. 

Adults usually need an average of six to eight hours of restful sleep each night.  Commonly this can be promoted by maintaining a dark, quiet bedroom and minimizing caffeine.  Weight maintenance is important, and can become more of a challenge as we age.  Eating a healthy diet is recommended along with maintaining a regular exercise program, typically consisting of a balance of muscle strengthening and aerobic activities.  Stress management is becoming an increasing concern to address our social pressures.

One of the most common work related injuries is the low back.  According to the Bureau of Labor Statistics, there were over 155,000 work-related back injuries in 2015.  Some general lifting-safety tips include bending at the knees, not the waist.  Keeping your feet shoulder width apart and a straight back with lifting may also be helpful – use your legs to lift.  If an object is too heavy to nudge with your foot, get help in lifting.  MedlinePlus is a resource from the U.S. National Library of Medicine that has additional suggestions under the search “lifting and bending the right way”.

Some employers require the use of personal protective equipment (PPE).  Examples of PPE include earplugs or hearing protective devices, safety glasses or goggles, work gloves, hard hats and hard-toed shoes.  When PPE is obliged, there will be guidelines for its use.  The most common injuries that occur when PPE is required are when the employee fails to properly use the equipment.  If you are compelled to use it, please use it correctly.

Work place injuries may also occur from sedentary activity.  Cumulative trauma injuries, also known as repetitive motion disorder, may occur from repetitive low force motions.  Some examples include carpal tunnel syndrome, bursitis, tendinitis, epicondylitis, tenosynovitis and trigger finger.  Usual causes include excessive uninterrupted repetitions of an action or motion, unnatural or awkward motions such as twisting the arm or wrist, incorrect posture or muscle fatigue.  Proper set up of your work station and equipment is necessary.  Sitting or standing straight along with proper height adjustment of chair and desk are necessary.  Keeping tools within easy reach of your workstation is important.  Taking breaks and stretching while doing repetitive tasks may be helpful.  Many larger employers may offer an “ergonomic assessment” of your work area upon request.  Make the work station fit the employee rather than adapt the employee to an improper work station.  A helpful guide can be found at https://www.ors.od.nih.gov/sr/dohs/Documents/ORS_Ergonomics_Poster_Rd5.pdf.

Some simple prevention can be helpful such as stretching before work.  Taking stretch breaks during repetitive tasks may also be helpful.  Even a short five-minute break during the work day may allow for better productivity as well as provide some stress relief.  Many additional resources are available on line.  Specifically, some examples provided by the National Institute of Health are available at https://www.ors.od.nih.gov/sr/dohs/HealthAndWellness/Ergonomics/Pages/exercises.aspx Certain employers may already have health resources available for the asking.  Any employer would likely appreciate suggestions or recommendations you may have to improve safety at work, so please speak up!

Bradford Croft, DO

East Flagstaff Family Medicine, LTD

Tough To Stomach

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The occasion of an “acid stomach” or “heartburn” is a common occurrence for many of us from time to time.  If the incidence and intensity increases over time, however, it may evolve into a more serious and long lasting form of reflux known as Gastroesophageal Reflux Disease (GERD).   A fairly common disease, the National Institute of Health estimates that one out of five individuals has some degree of GERD. 

Anyone can develop GERD, but individuals more prone to this problem tend to be overweight or obese.  It is also a common problem with women during pregnancy.  Smokers and those exposed to second-hand smoke seem to have a higher incidence of reflux disease as well. There are commonly used medications that treat asthma, allergy, blood pressure, depression, insomnia and painkillers all know to contribute to GERD.

GERD arises from irritation of the esophagus (connecting mouth to stomach) when stomach acid leaks upward through the lower esophageal sphincter that normally restricts acid from washing into the esophagus.  Most commonly, the complaint is that of a painful burning feeling behind the breastbone, back of the throat or middle of the abdomen.  Other symptoms may include bitter taste in the back of the throat, nausea and vomiting, painful swallowing, possible breathing problems and thinning of tooth enamel.     

As inflammation continues, there are complications of GERD that can develop.  When the acid irritates the airway and lungs, there can be persisting cough, sore throat or hoarseness. As inflammation increases, problems such as asthma and wheezing, chest congestion or fluid in the lungs, or even pneumonia can develop.  Persisting inflammation of the esophagus may lead to a condition called Barrett’s esophagus.  The tissues actually change in appearance over time, and for some individuals may lead to a rare cancer of the esophagus.

There are lifestyle changes that may help treat GERD.  Avoiding food and beverages such as greasy or spicy foods and alcoholic drinks may help.  Some other common foods that may worsen GERD include chocolate, peppermint, tomatoes or tomato products and coffee.  Not overeating and not eating within a few hours before bedtime may also be beneficial.  Additionally, sleeping on a mattress adjusted at a slight angle may help.  This can be achieved by safely putting six-inch blocks under the bedposts at the head of the bed.  Of course, weight loss and quitting smoking both may be helpful as well.

There are non-prescription medicines that are available to treat reflux.  Antacids such as Maalox, Mylanta and Rolaids work by buffering stomach acid.  H2 Blockers such as Tagamet, Pepcid AC and Zantac reduce the amount of acid produced.  Proton Pump Inhibitors (PPI’s) also reduce acid production, but more effectively than H2 Blockers.  Some brand names of this group include Nexium, Prilosec and Prevacid. 

It is important to see your doctor if GERD symptoms do not readily resolve within a few weeks of treatment.  There are several tests that may be appropriate if symptoms do not improve or return frequently.  You should be seen immediately if you vomit fluids that are green or yellow, look like coffee grounds or contains blood.  As well, you should be seen right away if you have problems breathing after vomiting, pain in mouth or throat with eating, or difficulty or pain with swallowing. 

Bradford Croft, DO

East Flagstaff Family Medicine

Spot On

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As the days are getting longer in the springtime, we are starting to emerge from the winter shadows to warm up after a cold winter.  But as we do, how many of us are thinking about the impact of the sun relating to our increased risk of cancer?  Over time, we accumulate the long term effects of our solar exposures with an increasing risk to develop skin cancers. 

The most common and widespread of cancers in the United States are those of basal cell and squamous cell carcinomas.  There are about four million and one million respectively diagnosed annually.  Generating from the layers that make up skin structures, these skin cancers usually develop as a response to repeated exposure to ultraviolet (UV) light.  The most common source of UV light is sun exposure.  Not to be forgotten is the risk associated with the use of tanning beds. 

A basal cell cancer commonly presents as a skin colored, pearly looking bump or growth that does not go away.  Sometimes it may develop as a pink or red scaly patch or have a waxy surface.  A squamous cancer may be a thick, rough scaly patch that sometimes bleeds and refuses to heal.  They may look initially like a wart, and sometimes have a crusty surface.  Both cancers may grow over time, but usually grow slowly.   With early intervention, both of these cancers can be usually cured with medication or surgery.  With delay of treatment, these treatments may become expensive, prolonged and disfiguring.

A much less frequent but much more deadly form of skin cancer is melanoma.  Originating from the melanocytes (the cells that give skin its pigment or color), this type is also associated with UV exposure.   About half of these cancers on discovery are surface level.  The other half likely have already penetrated into deeper levels of the skin, requiring more extensive treatment.  Lesions of this type typically may show up earlier in life as compared to the basal and squamous cancers, but all kinds may also show up as we mature.  Melanoma is responsible for over 9000 deaths annually in the US, about one out of every ten of these cancers once diagnosed.   

To help tell a melanoma from a common mole, use the ABCDE:

“A” is for asymmetrical.  Does the mole have an irregular shape with different looking parts?

“B” stands for border. Is the border jagged or irregular?

“C” is for color.  Is the color uneven shades of brown, or with any black or bluish color?

“D” stands for diameter.  Is the spot larger than the size of a pea?

“E” is for evolving.  In the past few weeks or months, has the spot changed?

Actinic keratosis are changes to skin that indicates sun damage, but has not yet evolved to a cancer diagnosis.  These scaly patches on a reddish base also have treatments available, the earlier the better. Although sun protection is the keystone to healthy skin, many of us in the Southwest get unintentional exposure.  It is likely you may have developed some spots and patches over time you wonder about. Should you have skin lesions of question, the earlier you seek a professional opinion with your primary care provider or dermatologist, the better your outcome likely will be.

Bradford Croft, DO

East Flagstaff Family Medicine

Something to Sneeze About

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The latest news from our blog, written by our guest author Andrew Conboy, PA-C

As spring approaches, many of us will dread the sneezing, itchy eyes, itchy nose, and coughing associated with our seasonal allergies.

Allergic rhinitis, also known as seasonal allergies, hay fever, or allergic rhinosinusitis (inflammation of the nose and sinuses both) affects many of us. According to the US Department of Health and Human Services, the number of people affected varies between 10-30% in the U.S. and other industrialized countries. This malady is characterized by runny nose, sneezing and nasal itching. However, many people also experience post-nasal drip, coughing, fatigue, and irritability. In children additional physical signs may include darkening under the eyes-often referred to as “allergic shiners”, accentuated folds or lines under the eyes, or a crease across the nose from repeatedly pushing the tip of the nose up with the hand.

Symptoms may be present on a “seasonal” basis in which symptoms are only present during a particular time of year, or they may be “perennial” where symptoms are caused by allergens that are present throughout the year. The seasonal allergies are generally caused by outdoor allergens- pollens from plants we are all familiar with- pine, juniper, Black-Eyed Susan, etc. Whereas, the perennial allergies are associated with indoor allergens such as dust mites, animal dander, cockroaches, and mold spores. Don’t be alarmed if your allergic rhinitis is accompanied by several other conditions. One example is asthma, which highly associated with allergic rhinitis. It is estimated that up to 50% of patients with asthma will also have allergic rhinitis.

Allergic conjunctivitis is a very common condition. Up to 60% of people who suffer from allergic rhinitis will also deal with symptoms of allergic conjunctivitis. Not to be confused with bacterial conjunctivitis (pink eye), which generally impacts one eye, symptoms of allergic conjunctivitis include itching, tearing, and burning of both eyes, as well as sensitivity to light.

Sinus infections may also occur. The nasal inflammation caused by allergic rhinitis can cause obstruction of the sinus openings. This can predispose you to a bacterial sinus infection. Symptoms of a bacterial sinus infection may include nasal congestion, cough, fever, facial pain and dental pain.

Eczema in children generally presents as itchy, red patches found on the face, arms, legs, or trunk. Whereas in adults, it usually appears as thickened areas of skin on flexural areas on the neck, fold of elbow, or the back of the knee. Although allergens may not be the sole cause of eczema, they certainly can contribute to it.

What can you do to ease the symptoms of seasonal allergies? Fortunately, there are good over-the-counter and prescription treatment options for allergic rhinitis and the associated symptoms. These treatment options won’t cure your seasonal allergies, but focus on decreasing the inflammation and congestion which causes your discomfort. Non-prescription options include nasal rinses, bedside humidifier, antihistamines, nasal steroid sprays, and expectorants.

Allergy testing may be available to pinpoint your individual allergens if treatment offers inadequate control. Once allergy testing is performed, immunotherapy is an additional treatment that can be considered. This treatment plan provides your body with gradually increasing doses of the specific allergens that affect you. Over time, your body may improve its tolerance to these allergens. This immunotherapy can be performed with a series of “allergy shots” or sublingual (under the tongue) drops.

With the change of the seasons, the increased prevalence of allergic rhinitis is inevitable. However, your suffering from seasonal allergies does not have to be. Keep the above treatment options in mind to ease your symptoms or visit your local family practice to discuss individualized options.

Andrew Conboy, PA-C
East Flagstaff Family Medicine

Being In Control

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High blood pressure (hypertension) is one of the leading contributors to death here in the United States.  According to the CDC, about 75 million people, or one out of three adults have hypertension.  Unfortunately, only about half of the population with hypertension have their high blood pressure under control.  If your blood pressure is not controlled, you are four times more likely to die from a stroke and three times more likely to die from heart disease.  In fact, 69% of people who have their first heart attack, 77% who have their first stroke and 74% with chronic heart failure all have high blood pressure.  As well, hypertension is not just an “old folks” disease.  An American Academy of Pediatrics study shows that up to 15% of teenagers may have either elevated blood pressures or outright hypertension.

Blood pressure measures the force of your blood inside your arteries. The top number (systolic) is the pressure when your heart contracts, and the bottom number (diastolic) is the pressure when relaxed.  If your systolic measures 120 and diastolic measures 80, the reading is “120 over 80”, or written, 120/80 mmHg.  The CDC guidelines provide “normal” blood pressure as systolic less than 120 and diastolic less than 80, “pre-hypertension” (at risk for hypertension) as systolic 120-139 and diastolic 80-89, and “high” as systolic 140 or higher and diastolic as 90 or higher.

Lifestyle choices may have significant influence on blood pressure.  A diet that is too high in sodium or low in potassium may put you at risk.  Sodium is the element in table salt that raises your pressure and commonly comes from processed and restaurant food.  About half of individuals who limit their salt intake may see a positive response in their blood pressure.  Those low in potassium intake may want to include bananas, beans, yogurt and potatoes in their daily diet.  Individuals who are overweight may likely see an increase of their blood pressure as their weight goes up.  Increasing physical activity has many benefits, and weight loss can be one of them.  However, losing weight may not guarantee lower blood pressure, as there are people who are not overweight who have hypertension.  Drinking too much alcohol can raise blood pressure, and the CDC recommends women to have no more than one drink per day and men no more than two.  Nicotine use includes cigarette smoking, chewing tobacco and vaping, all which increase heart rate and blood pressure as well as restrict blood flow to the heart, significantly increasing cardiovascular risk.    

Hypertension is known as the “silent killer”, as you rarely feel the presence of high blood pressure.  However, the effects of high pressure over time can damage circulation resulting in stroke, heart attack, heart failure, and kidney failure.  Controlling blood pressure may include the previously mentioned lifestyle changes such as diet modifications, increasing activity/exercise levels and not smoking as first line therapies. Many of us will need the addition of some medication to reach adequate levels of control. 

As February is American Heart Month, it is a good time to see if you are at risk.  A simple blood pressure check is the first step to determine your risk.  Your doctor’s office should readily be able to check your blood pressure on request.  The health kiosks commonly seen at your pharmacy and grocery store are usually accurate for screening purposes.  And most fire departments will be happy to check your blood pressure, as they are trained professionals and have the proper equipment to do so.  Even if you have a normal blood pressure with one reading, do not stop there.  Blood pressure will vary throughout the day, so additional checks at different times are important for consistent accuracy of screenings.  The tendency is for blood pressure to increase as we age.  Ongoing regular screenings provide early detection and the opportunity for early intervention, limiting the risk of developing hypertension in the future.  Do your heart a favor and check your blood pressure.

                                                                                                                               

Bradford Croft, DO

East Flagstaff Family Medicine

Dollars and Sense

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As we enter the new year of 2019, you may get a call out of the blue from your doctor’s office, a care management program like an ACO, or possibly your health insurance company.  One likely reason would be to schedule your annual wellness exam.  Other reasons could be to schedule an age based recommended mammogram, colonoscopy or Pap smear.  Perhaps it is to remind you of procedures like an eye exam for diabetics or labs that are scheduled or otherwise due.  For those patients with chronic diseases, it is critical to receive preventive and proactive care, as most problems will otherwise just get worse – and more expensive to treat.

The concept is called Population Health Management, and comes as both public and private payers focus on “value-based care”.  If we are able to be preemptive in providing timely care, we may be able to prevent or better control common diseases.  Primary care has been tasked by insurance companies with the challenge of tracking and coordination of a person’s care.  Communication between primary, specialty and hospital care may prevent duplication of services or tests, thus keeps cost down.  Awareness and reconciliation of medications provided to patients among these entities may also minimize the risk of dangerous drug interactions. 

The challenge of primary care providing population health can be difficult but not impossible.  It is necessary to identify those chronic disease patients who may benefit from outreach programs.  To do so requires electronic health records to compile and organize this data.  As a rule, a health care team manages the scheduling, tests and outcome records to assure that no patient is overlooked.  Such a program provides an opportunity for improvement, and truly does help patient care.

My first visualization of population health was that of my patients becoming rows and columns on a spreadsheet.  I would no longer be caring for my patients, but be asked to treat all of the “red” cells on the form.  But now, seeing the benefits of this organized data, we can easily find a patient who is due for timely lab or coming due for a visit and contact them accordingly.  It also allows reporting, for example, that our diabetics are achieving their treatment goals, or that routine preventive care has been provided.     

Care Management Services (CMS) is already providing financial payments or penalties to physicians for their Medicare patients who are meeting the guidelines or not.  Private payers may determine their continued contracting with your doctor depending on practices meeting the performance measures designed by the carrier.  As these programs expand and develop, we should have better data and better processes to gain markedly improved outcomes.

Health care costs continue to rise despite the Affordable Care Act.  We still have an uninsured and underinsured population.  The United States continues to spend the most money per capita of any country in the world, costing almost half again the Scandinavian countries who provide universal care to their entire populace.  If we are to curb our exploding cost of care, we need to embrace better accountability of health care and outcomes.  When asked to schedule your annual wellness exam, get medical testing, or follow up for your chronic health care, I encourage your compliance.  Ask your provider if they are participating in Population Management, as this may be the best means yet to improve health care, compliance, costs and outcomes.

                                                                                                                               

Bradford Croft, DO

East Flagstaff Family Medicine

Too Bad, so SAD?

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When the days are getting shorter and the temperature colder, do you find yourself getting a little more irritable?  Have a little less energy?  Feel a little more moody?  And if you find that this pattern is consistent year after year, starting every fall and disappearing each spring, you may be suffering from Seasonal Affective Disorder, or SAD.

Seasonal Affective Disorder is a subset of major depression, and may have general characteristics of daylong depression and low energy.  Feelings of hopelessness or worthlessness, as well as no interest in activities that once were enjoyable are common.  Poor sleep patterns, difficulty concentrating, changes of appetite or weight and feelings of agitation are also frequent.  Specific to SAD include craving starches and subsequent weight gain, heavy feelings of the arms and legs, as well as trouble with interpersonal relationships including hypersensitivity to rejection and problems getting along with others.

Although the specific cause is not known, some factors are likely contributing to the development of the disease.  It is season specific, commonly starting as days get shorter and diminishing as longer days return.  The decrease in sunlight may disrupt your circadian rhythm or “bio clock” which sets your wake/sleep cycle.  Disruption of this cycle may lead to depression.  Reduced sunlight can also cause a drop of serotonin which is known to affect mood and contribute to depression.   Melatonin, another neurotransmitter, can be disrupted by a shrinking photo period and will affect sleep patterns and mood.

Females seem to be more likely to suffer from SAD, but males may experience greater severity of symptoms.  Younger individuals are at greater risk for SAD, however the risk does decrease with increasing age.  Those with a personal history of depression or family history of Seasonal Affective Disorder are also more likely to have SAD.  The greater the swing of day/night intervals, the greater likelihood of this disorder as well.

The diagnosis of Seasonal Affective Disorder may be difficult to make.  Health problems and lab tests that contribute to depression need to be investigated.  Additional types of depression may muddy the picture as well and need be considered.  There are some factors that do support the SAD diagnosis if present for over two years.  These include depression that begins during a specific season every year, and ends during another specific season annually, there are no episodes of depression during seasons of normal mood, and there are more seasons of depression than seasons without depression over time.

There are treatments for Seasonal Affective Disorder, but must be used with caution if there is a concern for additional underlying bipolar depression.  Light therapy (phototherapy) involves exposure to a special type of light.  The light source mimics the natural light of the outdoors and seems to influence the brain chemicals linked to mood.  After days to weeks of consistent periods of exposure, this treatment seems to have a positive effect with most people suffering from SAD.  Consult your doctor regarding light therapy treatment, as you need to assure the proper equipment for efficacy and safety.  A common medication for preventing SAD is bupropion, an antidepressant.  This may be considered for severe SAD, and is usually started every year before the onset of symptoms and continued beyond the usual seasonal recovery time before stopping the prescription.  Psychotherapy can help control negative thoughts and behavior as well as assist developing healthy coping skills and stress management.  Of course, should you identify with these symptoms, please consult your health care provider as soon as possible.

Bradford Croft, DO

East Flagstaff Family Medicine