31
October
2007
MRSA stands for Methicillin-Resistant Staphylococcus Aureus. S. aureus (which I will just call staph) is a bacteria commonly found on a lot of people’s skin and inside the nose (25-30% healthy people). Some Staph types weren’t responding to the antibiotic penicillin, so methicillin was developed to kill these resistant forms of staph in 1959. But MRSA is a sneaky bacterium and started to be resistant against methicillin by the early 1960’s – thereby earning the name MRSA (pronounced Mer-sa). About 1-2% people carry MRSA on their skin or in the nose. In 2005, MRSA was responsible for 94,000 life-threatening infections and 19,000 deaths in USA.
There are 2 types of MRSA: hospital associated (HA) and community-associated (CA) depending on the genetic makeup of the MRSA. But HA vs CA MRSA are now intertwining, so you can see each of them in the “wrong” setting – so some MRSA in the hospital are actually CA-MRSA and some community folks will have Ha-MRSA. 85% of infections are HA and 15% are CA
MRSA isn’t usually a problem and a lot of people probably have it but aren’t aware of it – because who gets routinely tested for MRSA? Almost nobody except those in a hospital or nursing home. So MRSA generally doesn’t cause trouble unless it enters the body through broken skin.
Those at risk for MRSA are those in the hospital and healthcare facilities, especially for those with prolonged hospital stays. Those who receive multiple antibiotics are also at risk for carrying MRSA. Other risk factors: overweight, cosmetic body shaving, skin trauma, lineman or linebacker position in football, prisoner, military, tattoo receipients, illicit drug use, having multiple health problems, and previous antibiotic use. And MRSA can be spread by direct contract with skin, clothes, linens, athletic equipment, hot tub or sauna benches. That is why in a hospital you have to “gown up” if a person is isolated for MRSA – so you don’t carry it and spread it around. MRSA likes to like in warm moist places, like the nostrils, navel, underarms, and groin.
Clinical: Colonization means the person carries MRSA on the skin or in the nose – but there is no infection. Infection means the MRSA is inside the skin or inside the body and causing harm.
For hospitalized patients who acquire MRSA, 10-30% will have a problem with infection during or after their hospital stay. So found example after surgery a wound can not heal well due to MRSA infection. Skin infections from bed sores or needles can occur. UTIs especially those with a Foley catheter.
If the skin becomes infected (such as a scrape occurs so the MRSA can enter), an abscess can form – which is a pocket of pus. The abscess usually is red, warm, tender, swollen – also called a boil. If the MRSA gets into the blood stream, it can infect internal organs like the lungs, bone, bladder, and brain. A fever is common when MRSA enters the blood stream. CA-MRSA has been known to cause necrotizing pneumonia, necrotizing fasciitis, and endocarditis (heart valve infection) are examples of MRSA infection.
Treatment: In general, CA-MRSA is easier to treat with antibiotics than HA-MRSA. So CA-MRSA often will be susceptible to Bactrim and Clindamycin while HA-MRSA won’t. For those with MRSA in the blood, IV antibiotics are often used. For the skin, the doctor can do an I&D (incision and drainage) of the abscess because oral antibiotics will not enter a pocket of pus well. So it has to be drained and then cleaned well until it heals.
We do not treat colonization, but washes well in time can get rid of it.
Prevention: as always – wash your hands, tend any wounds well, stay out of contact with someone you know has MRSA, don’t share personal items (like athletic equipment, bathroom items), don’t demand for antibiotics for viral infections like the cold, and if you do take antibiotics make sure you finish your course so you don’t develop resistance. Alcohol-based hand sanitizers can work if hands are not visibly soiled.
Unfortunately a 17 year old Virginian boy died 10/15/07 of MRSA, though I do not have the details so I don’t know how he got MRSA inside of his body to lead to multi-organ infection. It is a very sad story.
drjohnhong 
Uncategorized, infections 
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17
October
2007
Obsessive-Compulsive Disorder (OCD) affects 2-3% of Americans, and usually starts around age 10 or 21. OCD means having anxiety-provoking intrusive thoughts and repetitive behaviors. The intrusive thoughts are unwelcomed and can interfere with a person’s day. Obsessions include aggressive thoughts and impulses, fear someone will be harmed, or fears of germs or dirt. Compulsions are repetitive behaviors like washing hands over and over, checking to make sure the door is locked over and over, or counting things like the tiles on the floor. The compulsive behavior is to overcome the fears.
OCD symptoms overlap some other mental disorders. Trichotillomania is a type of compulsive behavior of hair pulling, so it can lead to bald spots on the head, eye browns, arms, etc. Skin picking and nail-biting can lead to infections. Hypocondriasis is the belief of having a specific disease. Other OCD related disorders include gambling addiction, kleptomania, sexual compulsions, autism, Tourette’s Syndrome, Body dysmorphic disorder, and anorexia nervosa.
Obsession: the person realizes that they are obsessing and that they aren’t hallucinating or in psychosis. But they have a hard time getting rid of the senseless, intrusive thoughts. Many obsessive thoughts have a theme: a small oversight will be disastrous, fear of contamination, desire to put things in order nice and neat, aggressive impulses like hurting someone, and sexual thoughts.
Compulsions: a behavior is done over and over to cool down the obsession. Some people count, others arrange things into a neat order, wash hands, pick skin, pull hair, others touch (like David Sedaris wrote in one of his books about touching people’s heads).
Quality of life is often hurt by OCD – in particular interpersonal relationships. There is shame and distress over the OCD and many patients won’t seek help due to the shame.
One study followed 144 OCD patients for 40 years. 2/3 had some improvement in OCD within 10 years, 1/5 no longer had OCD. However, 1/5 who recovered relapsed.
Treatment: it is difficult. For those with mild to moderate OCD, cognitive-behavioral therapy and medications can help. SSRIs or Clomipramine are drugs of choice.
drjohnhong Psych Comments (0) » |
10
October
2007
Acute Back Pain. Back pain in general is the #2 reason to visit the doctor. 84% adults have low back pain in their lifetimes. 1989-1990 US survey showed about 15 million doctor’s office visits for back pain (and about the same in 2002 survey). Estimate $100 billion per year for the total cost of back pain; 75% of this cost is due to only 5% of those with back pain. About ¾ who seek treatment for back pain give up sports or exercise, 60% cannot do some daily activities, and ½ give up sex due to back pain.
Risk factors for back pain: smoking, obesity, older age, women, physically strenuous work but also sedentary work, psychologically stressful work, low education, worker’s compensation, job dissatisfaction, depression, anxiety, and somatization. In England a study showed physical activity outside the workplace was not associated with back pain; instead poor physical health was associated with back pain, in particular in heavier weighing women.
Acute low back pain goes away about 80% of the time within 2 weeks, 90% of the time in 3 weeks. One study showed 90% of people with low back pain did not see their doctor after 3 months. Good prognosis for those without sciatica or systemic symptoms.
Cause of acute low back pain: 85% of the time the physiologic cause cannot be found. It is though 70% are due to a lumbar strain or sprain. Other cause include degenerative disc disease, arthritis of vertebrae, herniated disk, osteoporotic compression fracture, spinal stenosis, and spondylolisthesis (a vertebra slips forward).
Emergency acute low back pain means immediate medical attention is necessary to prevent nerve damage, such as due to abscess, tumor compression. Less than 5% of back pain seen in primary care will be something really bad like this. Cauda Equina Syndrome – bladder and/or bowel dysfunction occurs. This can be a sign of a tumor or a huge midline disk herniation and this requires immediate attention by a neurosurgeon or orthopedic specialist in back surgery. Numbness in the perineum (between the legs called Saddle Anesthesia) going down both legs also occurs. Weakness in the foot/ankle can occur as well. So systemic problems causing back pain include unexplained fever, weight loss, HIV/Immunusuppressed, cancer history, IV drug use, osteoporosis, history of prolonged steroid use, >70 years old, focal neurological deficit.
Sciatica means a lumbar nerve root is pinched. This causes parathesias (pins and needle pain or a numbness) down the buttock, back of the thigh or side of thigh to the foot. If sciatica is due to a disk herniation, increasing pressure will make the sciatica pain worse (like coughing or sneezing)
Most people with acute low back pain don’t need an X-ray or other imaging if there aren’t complicating factors. CT scan and MRI are good to show herniated disks, spinal stenosis, infection and cancer.
drjohnhong Bones & Muscles, Pain Comments (0) » |
3
October
2007
Chronic Kidney Disease (CKD) affects about 20 million American adults (1 in 9). CKD as defined by the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative workgroup: “The presence of markers of kidney damage for 3 months, as defined by structural or functional abnormalities of the kidney with or without decreased glomerular filtration rate (GFR), that can lead to decreased GFR, manifest by either pathological abnormalities or other markers of kidney damage, including abnormalities in the composition of blood or urine, or abnormalities in imaging tests OR The presence of GFR <60 mL/min/1.73 m2 for 3 months, with or without other signs of kidney damage as described above. “
So basically means the kidneys are filtering the blood too slowly, and/or the kidneys are not filtering well and allowing proteins to spill through. GFR can be calculated by collecting a 24 hour urine sample, but now a days it is easier to estimate it by checking the blood and using some equations based on age, sex, weight, height. Normal GFR is 90-125/ml/min per 1.73m2
Stage 1 CKD: normal GFR but albumin in urine (a protein)
Stage 2 CKD: GFR 60-89 with albumin in urine
Stage 3 CKD: GFR 30-59
Stage 4 CKD: GFR 15-29
Stage 5 CKD (ESRD): <15
The Medicare-funded End-Stage Renal Disease (ESRD) program continues to increase. In 1973 there were 10,000 beneficiaries and in 2004 there were 472,099. Perhaps preventing CKD and managing CKD before it progresses to ESRD will save lives. Also the ESRD program cost about $32.5 billion in 2004, and it is anticipated another $28 billion more by 2010.
Risk factors for CKD include: High Blood Pressure, Diabetes, Family History, Older Age, Autoimmune Diseases like Lupus, Kidney stones, Kidney toxic drugs. US ethnic minorities have more CKD than US Caucasions, including African Americans, American Indians, Hispanics, Asian or Pacific Islanders
Screening/Testing: Blood creatinine to estimate the GFR. Urine for albumin/creatinine ratio to estimate if there is microalbumin – a even earlier detection of CKD.
CKD and Morbidity: many people with CKD have cardiovascular disease as well. Those with CKD have increased hospitalization by 3x. Mostly quality of life is decreased in CKD.
www.kidney.org and www.kidneyva.org are resources
drjohnhong infections Comments (0) » |
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