Neuropathic Pain

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Neuropathic Pain

Your peripheral nervous system acts as the hardwiring of your body. Each nerve serves one of two essential functions. Afferent nerves bring sensory messages to the central system such as smell, touch, taste, or pain. Efferent nerves send motor function messages to the body, such as ‘make a fist’ or ‘stand up.’ Have you ever been sitting too long, and when you get up, you “can’t feel your legs”? On occasion, you might even stand or try to walk and your legs “give out” from under you. These transient episodes are the result of irritation or compression of a nerve resulting in temporary impairment of function.

However, there are other nerve related circumstances that are harbingers of problems that persist. These are usually resulting from the progression of chronic diseases and subsequent ongoing damage to the nervous system. One quite common disease resulting in neuropathy is the progression of diabetes. As longstanding elevated blood glucose gradually damages the peripheral nerves, commonly in the lower extremities, the ability to feel becomes compromised. Without the perception of pain, ulcers may occur, or small injuries may readily become infected. As circulation concurrently diminishes, these wounds may result in a need for amputation. Pins and needles sensation may give way to chronic pain or no sensation at all. Muscle weakness may also develop, contributing to balance and coordination issues. As multiple nerves are impacted, there are other system failures that may develop including vision, digestive and urogenital systems.

Multiple myeloma, multiple sclerosis and cancer are also diseases that can cause similar neurologic changes to occur. Chronic use of alcohol over time can also contribute to multiple health problems. Long term toxicity from alcohol has a possibility of causing chronic nerve damage as well with similar outcomes to diabetes. These nerve problems are progressive and unrelenting.

Injury is another widespread problem that may give rise to neurogenic pain. Damage to nerves from trauma may provide a source of chronic pain mediated directly from the nerve itself. An example of such trauma would be a herniated disc in the spine. As the disc extrudes, it can trap the nerve root and physically compress it. This acts as a source of constant pain until the nerve is decompressed. In addition to significant pain, this entrapment can also cause subsequent permanent muscle weakness to develop.

Infection is not a usual source of neurogenic pain, apart from shingles. This viral infection from childhood chicken pox will live and remain dormant in the spinal cord for decades. Later in life there may be some compromise to one’s resistance and the virus will break out. This presents as a painful, blistering red rash that follows the course of a nerve, commonly on the scalp, trunk, or extremity. As the inflammation occurs directly in the involved nerves, the pain can be severe and last for weeks to months. There are occasions that the pain does not resolve, causing persisting post-herpetic neuralgia. Fortunately, there is a readily available vaccine available from your doctor or pharmacy for shingles outbreak prevention.

The final example is the “phantom limb.” There are occasions where an amputated extremity continues to be perceived by the brain. This instance results from damage to the nerve at the site of the amputation which “misfires,” producing the perception of the persisting absent appendage.

Prevention and early treatments may be the best way to address the onset of neuropathic pain. When unsuccessful, there are alternative treatments that may be available including surgery, medications, and other interventional procedures. As with all health issues, your best resource for information should be

your primary care provider. Please consult your PCP should you have any issues, concerns or questions regarding your risks or treatments of neurogenic pain.

Bradford Croft, DO

East Flagstaff Family Medicine

Spot On

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Spot On

As the days are longer in the summertime, we are outdoors a lot. But as we are, 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

Go With the Flow

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There is a lot of public awareness regarding heart attack and stroke.  Lesser known may be the presentation of vascular disease other than the heart or brain, commonly referred to as peripheral vascular disease or PVD.  Blood vessels may narrow, spasm or obstruct in arteries or veins.  Often seen in legs, PVD commonly presents as pain and fatigue, especially during exercise, and may improve with rest.  Arms and internal organs can be also be affected.  A large percentage of this disease is specific to the arteries, known as peripheral artery disease, or PAD.  Both terms commonly may refer to the same condition.   According to the CDC, over 8.5 million people over 60 have PAD in the United States.

Two different situations occur to develop vascular blockage.  Hardening of the arteries or atherosclerosis develops from plaques or blockages that slowly build up over time.  As vessels slowly narrow, circulation is diminished.  If the plaque ruptures or clots, there is an immediate and complete blockage of the vessel causing acute symptoms.   When this occurs in the heart or brain, the result is a heart attack or stroke.  With PVD, muscles demand higher oxygen during exertion, but the inability to provide adequate circulation results in pain and spasm.  In some situations, a blood vessel that is otherwise undamaged may go into spasm and prevent circulation with similar outcomes.  This can occur from exposure to cold temperatures, vibrating machines or tools, emotional stress or drugs that cause vessel spasm, such as some stimulants.  There are diseases that greatly contribute to the development of PVD.  Those individuals who have high blood pressure, high cholesterol and diabetes are at much greater risk of PVD.  Smokers are at great risk as well from the damaging effects of smoking harming the blood vessels over time.  Just the ageing process alone is a risk to those over sixty.

Common symptoms of PVD known as claudication may be the spasm, aches and fatigue of exertion, but sometimes may occur during sleep.  Over time, there may be a noticeable reduction in the growth of hair on the legs.  Thin or pale skin may develop as well, leading to the development of sores or ulcers that will not heal.  Discoloration or blueish skin, especially fingers or toes may become evident.  With continued diminishing blood flow, tissues may subsequently die leading to gangrene and amputation.   An acute blockage results in significant pain along with a cold, pulseless and pale or blue skin.  This is a medical emergency and needs immediate attention.

There are multiple ways to evaluate for PVD.  Doppler ultrasound measures the sound waves from the blood flow in arteries and veins and can determine compromises.  Ankle-brachial index, or ABI, compares the blood pressures of the upper and lower extremities.  As blood pressures are generally consistent throughout the body, a difference between extremities can indicate PVD.  Angiography injects contrast into the blood vessels and can visualize narrowing or obstruction in the arteries.  Magnetic Resonance Angiography (MRA) or Computerized Tomography Angiography (CTA) are also radiology studies that image vessels to visualize disease.

The main goals of care are to stop the disease and manage the pain.  Treatment may initially involve diet, increased exercise, weight loss and stop smoking.  Management of underlying chronic disease is critical.  There are various medications that may be appropriate as early treatment.  In more severe cases, surgical intervention may be necessary to open and re-establish blood flow in the obstructed vessel.  Early diagnosis is critical.  Symptoms of PVD?  Contact your primary care provider as soon as possible!

Bradford Croft, DO

East Flagstaff Family Medicine

What’s the Buzz?

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Many folks start their day with a cup of coffee.  In fact, according to the Food and Drug Administration, about 80% of us consume caffeine on a daily basis.  Most people are aware of the stimulating effects of caffeine, but a lot of us do not know the other impacts of caffeinated beverages.

Caffeine is the most commonly used psychoactive drug worldwide.  Coffee, tea and sodas are typical sources of the caffeine we ingest, for many of us regularly.  But foods, nutritional supplements and medications may also be sources.  For healthy adults, a moderate intake of up to 300mg per daily intake is considered “generally safe” by the FDA.  The Dietary Guidelines of America recommends, however, women who are pregnant and those breast feeding consult their health care providers for advice on caffeine consumption.  For children and adolescents, the American Academy of Pediatrics takes the stance that there is “no place for stimulant-containing energy drinks” for this population.

Federal guidelines require that the presence of caffeine in beverages or foods be listed as an ingredient.  However, the amount of caffeine does not.  To give you an idea as to how much caffeine is present, here are some common listings from www.medicinenet.com based on an eight ounce serving:

Brewed coffee                   102-200mg.             Brewed decaf                  3-12mg.

Expresso (1 oz.)                30-90mg.                 Brewed black tea            40-70mg.

Brewed green tea             40-120mg.                Cold brew coffee             110-200mg.

The following sodas contain the following based on a twelve ounce serving:

Pepsi One                              57mg.                                     Pepsi                                      39mg.

Diet Pepsi                              37mg.                                     Coke Zero                              36mg.

Coca-Cola                              34mg.                                     Diet Coke                               46mg.

Mountain Dew                        54mg.                                     Dr. Pepper                            41mg.

IBC Root Beer                         0mg                                      Orange Crush                         0mg.

A Monster Energy Drink contains 80mg caffeine in an eight ounce serving and has 27gm of sugar.

Many non-prescription medications that treat drowsiness, headaches and migraines will commonly have caffeine, from 60 to 200mg per dose.

The most commonly anticipated effect of caffeine is to stimulate the brain.  Within minutes, there is increased alertness, and there may be a buffering of drowsiness and fatigue – our morning “wake-up”.  Other positives include a decreased suicide risk as well as developing Alzheimer’s and dementia for those who consume caffeine on a regular basis. In addition is a reported decreased risk of oral and throat cancer.

According to the Mayo Clinic, there may be some negative effects may occur after 400mg of caffeine is consumed routinely (about four cups of coffee).  If the brain is over-stimulated, there may be side effects of restlessness, anxiety, headaches or insomnia.  Urine output is increased, producing a diuretic effect.  There may be an increase of symptoms from those already suffering from bladder problems.  Gastrointestinal stimulation may produce heartburn and diarrhea, with nausea and vomiting developing at higher doses of ingestion.  Calcium absorption into the bones is decreased, increasing the risk of developing osteoporosis and fracture.  The cardiac effects of caffeine increase heart rate, blood pressure and contribute to skipping beats.

Over time, your body becomes more tolerant to your daily dose.  Should you develop adverse effects from your caffeine consumption or just be concerned to the long term effects as listed, you should taper down gradually.  Headaches are the most common presentation of caffeine withdrawal.  There are websites available providing information about caffeine from the FDA and Mayo Clinic, among others.  How much caffeine are you consuming?

Bradford Croft, DO

East Flagstaff Family Medicine

Assess MS

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Multiple Sclerosis is a disease of the brain and nervous system. The body immune systems create a response that destroys the insulation sheath (myelin) that protects nerves. As the disease progresses, it can disrupt the messages carried from the brain to the rest of the body that can potentially become crippling over time. A common presentation interferes with the ability to walk but may initially return to normal for extended periods of time.

Depending on the nerves involved, symptoms may include numbness or weakness that may occur in limbs, electric shock sensations in limbs, and / or tremor or lack of coordination when put to task. Balance issues may be another that may present temporarily. Many of these signs will improve spontaneously at first. Eye complaints may include partial or full loss of vision and may be associated with eye pain. Double vision or blurring of sight may also present. Additional nerve complaints may include slurring of speech, fatigue, dizziness, or bladder / bowel control difficulties.

The typical presentation of MS initially develops varied symptoms over days or weeks but then improve either partially or completely for a duration of months to even years. This is the most usual form of MS that follow such a relapsing / remitting course. About half of these cases will show a steady degree of progression over the next ten to twenty years of the onset known as secondary progressive MS.

The cause of MS is unknown. The usual onset is in those between twenty and forty years old but may vary above or below those ranges. Women are two to three times more likely to develop MS. Those with parents or siblings with a history of disease have a higher risk as well. White people have the highest risk associated. Asian, African, and Native American descent have the lowest risk.

There are other health related issues that may increase the likelihood of MS. Those with low vitamin D levels and minimal exposure to sunlight may be at risk. As well, other autoimmune diseases such as thyroid disorders, pernicious anemia, psoriasis, type one diabetes, and inflammatory bowel disease are shown to have an increased risk as well. And smokers, as with many other health problems, are at a higher risk of developing MS than non-smokers.

With progression of the disease, muscle spasm or paralysis may develop directly. Other effects may include worsening problems with bowel, bladder, or sexual function. Additionally, the onset of depression or even epilepsy may occur. There are associations from infections such the Epstein-Barr virus responsible for mononucleosis, as well as those with Guillain-Barre that directly affects the spinal cord. Conversely, there is no increased risk of developing MS after receiving any of the following immunizations: HBP, HPV, influenza, MMR, variola, tetanus, BCG, polio, or diphtheria. There have been only two reported cases of MS relapse after receiving the COVID-19 vaccine, which were due to exacerbating the known underlying disease rather than causing it.

There are no specific tests that diagnose MS, the diagnosis is made from the clinical course combined with radiologic imaging and nerve studies. As well, there are no medications or treatments that will cure the disease, but there are medications and therapies designed to improve current symptoms and manage the progression of symptom development. Earlier intervention typically leads to best outcomes. Should you have concerns or questions about MS, consult your health care provider.

Bradford Croft, DO
East Flagstaff Family Medicine

Time to Talk About Colon Cancer Again

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Colorectal cancer (cancer of the colon and rectum) continues to be the second leading cancer-causing death of both men and women in the U.S. It is, however, the third most common cancer diagnosed in our country. The only more common cancers in men are that of prostate and lung, and women are breast and lung. According to the most recent statistics of the CDC, 141,125 people were diagnosed with colorectal cancer in 2017 with 52,547 deaths. Of every 100,000 people, there are 37 diagnosed with colorectal cancer and 14 deaths.

Colorectal cancer begins in early stages as growths or polyps that develop in the large bowel. The most common polyps are adenomatous. These are not initially cancer by nature but are likely to turn into a cancer over time. There are also inflammatory, hyperplastic, and villous polyps ranging from minimal to significant risk of evolving into colon cancer. As cancer evolves, one may eventually have complaints of blood in the bowel movement, persisting abdominal pains or cramps, or unexplained weight loss. Although these symptoms are not exclusive to colon cancer, immediate medical help should be sought if these complaints are present. Early on, there may be absolutely no symptoms at all.

Although there are no absolute reasons that individuals develop colon cancer, there are some risk factors to consider. As we age, our probabilities increase. According to the CDC, more than 90% of cancers occur in those over fifty. As such, the general recommendations are that men and women begin routine screening at forty-five years old. There is an increased incidence for those with underlying inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease. If you have a family history (mother, father, sister, or brother) with a diagnosis of colon cancer discovered before age 50, or if you have a genetic syndrome such as familial adenomatous polyposis or hereditary non-polyposis colorectal cancer, you may have an increased risk and require screening earlier than the routine recommendation of 45 years old.

As March is Colorectal Cancer Awareness Month, your family physician can help you evaluate your risk and screening options and may provide preliminary testing in office. There are several screening tests. Most involve the evaluation of a stool specimen, such as the guaiac-based fecal occult blood test (gFOBT) which tests for the presence of blood, the fecal immunochemical test (FIT) that measures antibodies that indicate bleeding, and the FIT-DNA test, checking for altered DNA combined with the antibody test. Although a positive screening test is not an assurance of cancer, it is a marker for timely evaluation.

Colonoscopy is a procedure that checks for cancer in the rectum and entire colon. With the patient under sedation, a long, thin, flexible scope is used to painlessly visualize the bowel and remove polyps as well as biopsy areas of suspicion. This is also the procedure commonly used if any of the previous screening tests return as positive. Usually, this screening test is only needed once every ten years as opposed to annually for the less reliable gFOBT and FIT, or every three years for FIT-DNA, commonly marketed as Cologuard.

Additional techniques include capsule endoscopy (swallowing a camera in a pill) and virtual colonoscopy (a series CT radiology pictures combined to provide an image of the bowel). As relatively new procedures, they may not be covered by insurance or available in your area. Along with recommendations from your doctor, check with your insurance coverage to determine which tests may be choices for your screening evaluation.

Bradford Croft, DO
East Flagstaff Family Medicine, LTD

Take It to Heart

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In addition to St. Valentine, February helps to remind us of other things that impact the heart. Multiple factors can influence your risk of heart disease that include several health conditions, your lifestyle, age and family history.   It is important to know your risk factors as some can be changed, others cannot.  As heart disease is still the number one killer of both men and women in the US, these are issues that should truly be taken to heart.

According to the Center for Disease Control, almost half of the US population have at least one of three main risk factors of cardiovascular disease: high blood pressure, elevated cholesterol and smoking.  High blood pressure can silently damage the heart, kidneys and brain among other systems over time.  When the damage comes, its first symptom will usually be a heart attack, kidney failure or stroke.   As there are rarely any physical complaints associated with untreated hypertension, the only way to determine the problem is to check your blood pressure.  If elevated, treatments may include lifestyle changes as well as medication.

Cholesterol is a natural substance in the body, but with elevated levels may cause deposits in the blood vessels over time.  As these plaques occur, circulation can be compromised to organ systems, again leading to damage to brain, heart and kidneys.  And again, its first symptom may present as a stroke, heart attack or kidney failure.  The two major cholesterol subgroups include HDL (good cholesterol), the higher the better, and LDL (bad cholesterol), better lower.  Depending on risk factors, the goals for the cholesterol components may vary among individuals.  A simple blood test can determine your values and imply your risk.

Smoking is well known to increase the negative effects of both hypertension and hyperlipidemia.  The effects of nicotine, either smoking or vaping, will further heighten blood vessel resistance, contributing to worsening hypertension and vascular damage.  High cholesterol will be adversely affected by further lowering HDL, further increasing plaque formation.

Diabetes will compound the likelihood of cardiovascular death.  Management of diabetes is critical to decreasing the risk of cardiovascular disease.  The impact of obesity further worsens adverse cholesterol and elevates blood pressure.  Poor dietary habits, sedentary lifestyle, excessive alcohol intake and uncontrolled anger or stress all are additional contributors as risk factors.  As difficult as it may be, however, all of these risks can be modified and improved with lifestyle and medical intervention.

Some risk factors can’t be changed including family history (following genetic blueprints), age (risk increases with age), gender (males more likely than females, but the odds equilibrate after menopause), and race (African American, Native American and Hispanic American are at higher risk than Caucasian).  Even though these risks cannot be changed, the spectrum and contribution of the additional treatable risks can be addressed and monitored over time to improve the outcomes and minimize the cardiovascular consequences.  If you are not aware if you have any of these risk factors, this would be the month to visit with your primary care provider for screening.  If you do have any of these risk factors, this would be the month to visit with your primary care provider for treatment.  Take it to heart.

Bradford Croft, DO

East Flagstaff Family Medicine

The Silent Hepatitis C

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Hepatitis is the diagnosis of an inflammation of the liver.  There are a number of different sources, including viral infections, certain medications and irritation from alcohol and chemical exposures.  Hepatitis C is an increasingly common infection showing up in ageing adults, and may exist without any symptoms or complaints for years or decades after the initial infection.  Sources of this infection include any current or remote history of drug injection with shared needles or syringes, or receiving an organ transplant, blood products or transfusions prior to the early 1990’s.  However once this virus had been identified around that era, screenings have been in place to minimize the possibility of transmission of this infection.  There continues to be a risk of infection to health care workers who may experience an accidental needle stick from an infected patient or those using injectable drugs.  There is up to ninety percent likelihood that a person infected with HIV using IV drugs will develop Hepatitis C as well.

There are other common hepatitis infections, including Hepatitis A and Hepatitis B.  Hepatitis A usually will resolve without medical treatment after an acute infection.  Hepatitis B may persist chronically within an infected person, but since the development of both Hepatitis A and B immunizations, the incidence continues to decrease over time for both infections in the past twenty years.  Unfortunately there is not yet an immunization for Hepatitis C.

The CDC estimates that 3.2 million people in the US have chronic Hepatitis C.  Up to twenty five percent of people who became infected will have the virus clear their system without treatment. But many of those with infection will develop chronic liver disease resulting in liver damage, failure, cancer and even death.  For those diagnosed with chronic Hepatitis C, there are several treatments now available that are more effective with fewer side effects than some of the older medications.

There are several blood tests for Hepatitis C.  Some are ordered individually, others may be a part of a panel or screen.  Hepatitis C is also a concern for causing elevated liver function that has no confirmed explanation.  The initial test is usually for the presence of Hepatitis C antibodies in the individual. The presence of antibodies indicates a prior exposure to the infection but does not confirm active or present infection.  A positive screen is usually followed by a second test looking for the presence of the virus in the system.  This ‘viral load’ is also used as a marker to determine the success of treatment.

The incidence of Hepatitis C is increasing in the US population over the past decade. As the “baby boomers” are getting older, be aware of this concern with changes in liver function tests.  If you have a potential exposure to this infection, talk to your family physician if you may be at risk of Hepatitis C.

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

A Head of Trauma – TBI

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Traumatic brain injury (TBI) is caused by an acute bump, blow or penetrating head injury that disrupts the normal brain function. If you ever “saw stars” because of head trauma, even without loss of consciousness, you may have experienced a mild concussion.  The source of the experience is due to the physical bruising of the brain against the inside of the skull.  Likely, you recovered without a problem.

Not every blow to the head results in TBI.  Those that do may have a wide range of severity from mild, a brief change in consciousness or thought process, to severe, a prolonged period of unconsciousness or coma.  The lasting effects of TBI are also quite variable, lasting from days or weeks in many cases to prolonged, causing lifelong consequences.

TBI contributes to one third of all trauma related deaths.  Although three out of four TBIs are mild, there are 153 people who die every day from sustaining a severe TBI.

According to the CDC, the leading cause of TBI resulting in ED visits, hospitalization and death is from falls, accounting for almost half of all reported cases.  The young, up to age 14, and the elderly, those over 65, are a greater risk than the general population, accounting for fifty-four and seventy-nine percent of all TBI cases respectively.  The sources of TBI related trauma that result in death are the greatest in ages 65 and older from falls, 25 to 64 years old from intentional self-harm, 5 to 24 years old from motor vehicle accidents, and 0 to 4 years old from assault.

There are four categories of concussion symptoms.  “Thinking and remembering” may present as difficulty with reasoning, feeling slow mentally, difficulty concentrating and difficulty remembering new information.   “Physical effects” may include fuzzy or blurry vision and headache, nausea and vomiting, sensitivity to noise and light, dizziness, balance problems and feeling tired and no energy.  “Sleep patterns” may include sleeping more than usual, less than usual or difficulty falling asleep. “Emotional and mood changes” may include irritability, sadness, emotional lability and nervousness or anxiety.  Some symptoms may be noticed immediately, whereas others may not show up for weeks to months after the incident.  If presenting symptoms are subtle, they may initially be overlooked by family, physicians and even the patient.

Those with a history of previous concussion are at greater risk to have another and may also find it takes longer to recover with repeated incidents.  With the recent attention from the NFL, it is also known that repeated brain trauma may lead to Chronic Traumatic Encephalopathy (CTE), a disease with progressive development of any of the concussion symptoms previously discussed.

Those who experience milder forms of TBI should consult their health care provider as soon as possible.  It is important to get adequate rest and limit activity.  Protection from additional trauma is critical.  Physical activity may need to be restricted for a period of time.  Medications should be reviewed, and alcohol should be avoided.  Severe TBI which may include loss of consciousness should be evaluated emergently.  It should also be treated after the acute phase with a formal rehabilitation program to improve the likelihood of better long term outcomes.  More information is available at this link: https://www.cdc.gov/traumaticbraininjury/. 

Bradford Croft, DO

East Flagstaff Family Medicine