A mother, award-winning actress, renowned philanthropist and partner of Brad Pitt, Angelina Jolie appears to have it all. She is a vibrant woman who recently made the courageous decision to have a double mastectomy. Many women, especially those at heightened risk for breast cancer, may now be wondering if she made the best decision, and whether it is a decision they should also consider making.

Jolie underwent a preventive double mastectomy because she learned that she carries a rare mutation of the BRCA1 gene, which significantly boosts her risk of developing both breast and ovarian cancer. Her mother also died of ovarian cancer at 56.

“My doctors estimated that I had an 87 percent risk of breast cancer and a 50 percent risk of ovarian cancer, although the risk is different in the case of each woman,” Jolie wrote in an op-ed in the New York Times. “Once I knew that was my reality, I decided to be proactive and to minimize the risk as much as I could.”

As noted by the National Cancer Institute, BRCA stands for breast cancer susceptibility genes, a class of genes referred to as tumor suppressors. Mutations of the BRCA1 and BRCA2 genes have been linked to hereditary breast and ovarian cancer. A blood test can determine if a woman is at very high risk of these cancers.

While Jolie’s choice was certainly a difficult one, it gives her greater peace of mind by reducing her risk of developing breast cancer from 87 percent to under 5 percent. “For any woman reading this, I hope it helps you to know you have options,” she wrote. “I want to encourage every woman, especially if you have a family history of breast or ovarian cancer, to seek out the information and medical experts who can help you through this aspect of your life, and to make your own informed choices.”

Not every woman who has a higher risk of breast or ovarian cancer should have a preventive procedure like Jolie’s. In fact, the U.S. Preventive Services Task Force recommends that only women with a strong family history of cancer be evaluated for genetic testing for BRCA mutations. This group represents only about 2 percent of adult women in America.

For women who have breast cancer (without genetic mutations like Jolie’s), there are newer procedures becoming available, even right here in southwest Michigan. Today, breakthrough approaches to surgery are changing the way having a lumpectomy (a breast lump removed) or a mastectomy (removal of the whole breast) is performed, offering women faster treatment, smaller scars, fewer long-term side effects, and enhanced cosmetic results. In short, breast cancer surgery is trending toward the minimally invasive, providing women access to better treatment options than ever before.

Daniel Barnas, MD, FACS, is Kalamazoo’s first fellowship trained breast surgeon, and part of Borgess Surgical Specialties.  To speak with someone at Borgess Surgical Specialties, please call (269) 226.5456.

Written by: Megan Foley, RN CPNP

Vomiting and diarrhea are common problems in infancy and childhood.  Although many think of vomiting and diarrhea as “the flu,” it is not influenza.

Influenza is a viral illness causing high fever, headache, sore throat, cough, lethargy and other symptoms.  Influenza rarely causes vomiting and diarrhea.  The flu or influenza vaccine DOES NOT protect against vomiting and diarrhea.  In most cases, a different virus causes vomiting and diarrhea, not the influenza virus.  The virus responsible for vomiting and diarrhea causes gastroenteritis or an inflammation of the gastro-intestinal tract.  The virus usually involves a fever and vomiting at the start of the illness, then diarrhea develops.  Viral causes of diarrhea should resolve within one week.  The diagnosis of gastroentiritis is usually based on symptoms, physical exam and sometimes the presence of similar cases in your community.  In some cases, your provider may submit a stool sample to diagnose certain illnesses or rule out a bacterial or parasitic cause for vomiting and diarrhea.  It is important to monitor the frequency and volume of vomiting and diarrhea.  Monitor the amount of fluids and foods taken in and frequency of voiding or wet diapers.   This information is helpful for your provider to understand the symptoms.

What causes vomiting and diarrhea?

Viruses are the most common cause of vomiting and diarrhea.  The virus paralyzes the part of the intestine which absorbs water and nutrients.  When the fluid is not absorbed, it must be removed either by vomiting or diarrhea.  Occasionally, vomiting and diarrhea can be bacterial, most commonly caused by spoiled or contaminated foods.  Examples of bacteria that can contaminate food include salmonella, shigella, e-coli and staphylococcus.  If diarrhea persists greater than one week, follow up with your primary care provider.

What is the best treatment?

Since a virus is the most common cause of vomiting and diarrhea, most medications will not be effective.  The most important treatment is to maintain good hydration.

If vomiting is present, first rest the gut by not eating or drinking.  Sources vary on how long they recommend resting the gut, and it may depend on the frequency of vomiting and diarrhea.  Most sources recommend resting the gut from 20 minutes to 4 hours, but all agree to go slowly when introducing fluids.  It is recommended to start with a small amount of fluids, such as one to two sips or teaspoons of electrolyte hydrating replacement fluids such as Enfalyte, Pedialyte, LiquiLyte, or Rehydralyte.  These products are available at your local pharmacy.  Gradually increase fluids by two to three teaspoons every 10 minutes.  Your child may be very thirsty and want to drink too much.  Go slowly and only increase the volume if your child is tolerating the fluid.  Balanced electrolyte solutions such as Pedialyte will help replenish lost nutrients.  These solutions can be somewhat salty, so they may need to be diluted.  Fruit juice and soda pop can be very high in sugar and can worsen diarrhea.  Avoid juices with sorbital because it can worsen diarrhea.  Soft drinks, soda pop, soups, juices, sports drinks and boiled skim milk have the wrong amounts of sugar and salt and may make your child sicker.  Electrolyte replacements fluids are still the best, such as Enfalyte, Pedialyte, LiquiLyte or Rehydralyte.  IT IS NOT ENCOURAGED TO MAKE YOUR OWN unless instructions provided by your primary care provider.

If your breastfed infant is vomiting, you can continue nursing for short amounts of time at first, five minutes on one side every 30 to 60 minutes.  After four hours of no vomiting, return to regular nursing.  If vomiting persists, change to electrolyte fluids for four hours.  Use one to three teaspoons every five to ten minutes of electrolyte fluids.  If the fluid is tolerated, then restart nursing as above.

Continue nursing frequently if your infant has diarrhea.  If an infant is on formula and vomiting more than once, offer one to two teaspoons of electrolyte fluids (Pedialyte) every five to ten minutes.  After four hours without vomiting, double the amount of electrolyte fluid.  After eight hours without vomiting, restart formula and return to regular diet including solids within 24 to 48 hours.  You may start with half strength formula for the first few feedings, but go to full strength as soon as tolerated.  The lactose in formula does not contribute to diarrhea so you can continue your child’s regular formula.  If your child seems bloated or gassy after drinking cow’s milk or formula, discuss with your primary care provider.

As your child tolerates fluids well and is acting hungry, you can begin small amounts of solid foods.  Choose bland foods to start with and advance as tolerated.  Starchy foods such as crackers, bread, rice and cereals are easiest to digest.  Early feedings seems to lead to faster resolution of diarrhea.  Yogurt, if old enough, is a great food to help resolve diarrhea due to the probiotics available in yogurt.  Probiotics may also be helpful, and can be found at your local pharmacy.  Avoid sugary foods such as ice cream, sodas and candy because they can worsen diarrhea.

For mild to moderate diarrhea, continue to give your child a normal diet including breast milk, formula or milk or electrolyte solutions that have been designed to replace water and salts lost during diarrhea.

Are there medications that can help?

There is no specific medical treatment for diarrhea and vomiting caused by a virus or viral gastroenteritis.  Antibioics are NOT effective against viruses and overusing them may contribute to the development of antibiotic- resistant strains of bacteria.  Treatment for diarrhea and vomiting consists of the care measures outlined.  A frequent side effect of antibiotics is vomiting and diarrhea, so antibiotics could actually worsen viral symptoms.  Medications such as Pepto Bismol, Kaopectate and Immodium do not help.  These over the counter medications are not safe for small children and may prolong diarrhea.

How can I help my child prevent diarrhea and vomiting?

The most important way to prevent vomiting and diarrhea caused by a virus is frequent hand washing, especially after using the bathroom and prior to eating.  If your child is in daycare, they should not return to daycare until the diarrhea has resolved.

Are there other symptoms that may mean vomiting and diarrhea may be caused by something other than a virus?

• If there is blood in the stool or the stools are black
• Sharp pains in the stomach
• Diarrhea and vomiting is accomplanied by a high fever
• Vomiting lasting greater then 24 hours or diarrhea lasting more than seven days
• If your child is vomiting and cannot keep any fluids down, especially vomiting for more than 24 hours.  If your child is under six months old, they should be monitored closely, especially for signs of dehydration including:
  • No longer active or seems very tired
  • Dry or sandpaper mouth (no drool)
  • Dry or cracked lips
  • No tears when crying
  • No wet diapers for more than six to 12 hours or less than three to six wet diapers in 24 hours
  • Very fussy or very sleepy all the time

If present these symptoms are present, contact your primary care provider for further follow up.

This article was written by Megan Foley, RN CPNP.  If you would like to schedule an appointment with Megan or any provider at ProMed Pediatrics, please call (269) 552.2500.  We are currently accepting new patients.

Resources

Mayo Clinic Family Health Book, 4th Edition.  www.mayoclinic.com/health/viral-gastroenteritis

AAP’s Pateint Education Online; Common Childhood Infections.  http://patiented.aap.org/contentaspx?aid=5456

In Michigan, the spring and summer months bring an entire new array of outdoor activities that people of all ages take part in. One specific activity that only continues to grow in popularity is bicycling. Unfortunately, with popularity also comes an increased risk of danger. In fact, the death rate of youth bicyclists increases by 45% during the summer months alone (Safe Kids Coalition, 2009).

Why do these deaths occur? Most commonly, deaths due to a bicycle accident result because the bicyclist suffered a traumatic brain injury (TBI) during the accident. The brain essentially acts as the computer of the body and when it undergoes trauma, it will stop functioning properly and it will lose its ability to control other body functions that keep a person alive. With this in mind, it is important to understand bicycle safety—from the rules of the road to the necessary protective equipment that any person should utilize when riding a bike, which include a helmet. According to the Safe Kids Coalition, “bicycle helmets have been proven to reduce the risk of head and brain injury when a crash occurs by as much as 85 to 88 percent” (2009).

Bicycle safety tips from the State of Michigan:

Bicyclists should…

• Always ride WITH other traffic;
• Obey the rules of the road as any other vehicle operator, including all traffic signs, lane markings and signals, and use hand signals to indicate turns, slowing or stopping;
• Wear bicycle helmets and reflective clothing;
• Stay as far to the right as practical when riding in traffic lanes;
• Not ride more than two side-by-side in a single lane, and only do this if it does not interfere with the normal flow of vehicular traffic;
• Avoid entering the roadway without first stopping to look for vehicles;
• Ride predictably and defensively, and do not ride while drunk or distracted;
• Always yield to pedestrians;
• Have a white front headlight and a red rear reflector if riding after dark or in low light conditions.

This article was written by Morgan Robinson of Borgess Trauma Services.  For more information, to schedule a free bicycle safety event or to purchase a bicycle helmet, contact Morgan at (269) 226.7075 or morgan.robinson@borgess.com or visit trauma.borgess.com.

View a video of Dr. Blackwell sharing a moment of love with his family at mile 17 of the Boston Marathon.

The start of the Boston Marathon is a special thing. I always experience nervous jitters as I enter “Athletes Village” on race morning which worsen as I proceed to the starting line. I get chills and usually well-up with emotion as our National Anthem is played. This year was no different. The starting gun went off, the legs started moving east toward Boston and I eagerly awaited the pain and excitement of the 26.2 miles ahead of me. The crowds seemed to be larger and more boisterous than my previous years here. Heartbreak Hill was just as painful as I recall from prior years.

I eventually entered Boston and took that final left turn onto Bolyston Street, where its amazing crowd didn’t seem to tire while offering continuous cheering. Approaching that Boston Marathon finishing tunnel after running 26 hilly miles is always just an incredible feeling. My legs were on fire and my lungs burned. My greatest annual running experience was again cherished as I crossed that historic finish line. I proceeded through the finish line and food/water areas while trying to not get sick. The physical anguish is so great that I promised myself, as I do every year, that this is the last marathon I’ll run.

Once back at the hotel my wife received a text message asking if we were okay. We turned on the TV to see the immediate aftermath of the bombings. It didn’t seem real. Why would a marathon be a target? This is not happening here. Not THIS sport. Not THIS marathon. Not in Boston. We watched footage of the finish line on TV while hearing non-stop sirens outside of our hotel window. We followed police advice to stay put inside for the remainder of the day.

Although I was so thankful that my family was unharmed other families were not. Their lives were torn apart that day on Boylston Street. Those hurt and killed were spectators. Supporters. Runners know how important these family and friends are to our running. They are the fuel that keeps us driven, focused, and determined to accomplish something that at one point in our lives seemed so unobtainable. They sacrifice so much of their time so we can “get our run in.” They stand for hours in often miserable weather just to see us run by for a few seconds. They share in our successes and comfort us during difficult races and injuries. I hated that this terrorist act targeted our supporters.

My wife and I needed to provide some words to our kids who were witnessing this with us. We focused on how this ONE horribly “evil” act by a person/s was swiftly countered by an over whelming amount of “Good” from the bystanders, volunteers, police, EMTs, etc.

Our next lesson to them, and really ourselves, was about terrorism. Terrorism is intended to instill fear in people’s routine and daily living. To disrupt or change what people do or where they go because of fear of a recurrent event. We, as a family, will not let this happen.

The 2014 Boston Marathon is going to be different than any other. Those I’ve talked to within the running community have an intense desire to be part of the 2014 Boston Marathon. The terrorists attacked our race, our families, our supporters. Next year it will be an incredibly patriotic event appropriately occuring on Patriot’s Day. And I, with my family cheering me on, will be there. Boston Strong! Please continue to pray for all those affected.

Eric Blackwell, MD is a physician with Borgess Emergency & Trauma Center. This was his sixth consecutive Boston Marathon. During the chaotic hours immediately after the bombings, he was interviewed by WKZO and emphasized the importance of remaining calm during such situations.

A recent study compared four of the most popular mainstream diets in an attempt to determine their effectiveness at reducing weight and associated health risk.  A study published in the Journal of the American Medical Association compared the Weight Watchers, Atkins, Ornish, and Zone diets to determine which diet was most likely to yield long term, healthy weight loss success.  Their findings revealed that each of these diets had the ability to reduce weight and improve several cardiac risk factors and other conditions.  However, the most important finding of the study revealed that problems with these diets lies not with the nutritional elements, but with people’s adherence to the diets themselves. In fact, the study revealed that no single diet produced satisfactory adherence rates, and adherence scores were identical among all four diets. The researchers concluded that these diets are simply too extreme for people to maintain long term because they involve elements that are unrealistic and deviate too much from a person’s normal eating behavior.

You have probably heard the saying that developing a “healthy eating lifestyle” is better than going on a diet.  Diet research seems to be in full support of that recommendation.  According to the researchers, sticking with a diet is more likely occur when greater emphasis is placed on matching individual food preferences, lifestyles, and cardiovascular risks to the weight loss plan itself (Dansinger et.al. 2005).

Instead of dieting, try making these simple adjustments to your nutritional plan:

• Reduce calories – Try to eat fewer calories each day than your body burns for energy.  This reduction does not need to be drastic to yield results (example -200 calories/day).
• Eat more fruits and vegetables – These foods are low in calories and high in nutrients and will help to fill you up and curb your cravings.
• Drink more water – Water will also fill you up and play a role in healthy metabolism.
• Limit junk food – Junk food is high in calories, fat, sugar, and sodium and should be eaten in moderation or not at all.
• Don’t skip meals – Your body in a machine and needs to be fueled to perform optimally.  Skipping meals will make weight loss very difficult.

Gary Strehlke, MS, NASMCPT, CES, PES, is a wellness specialist with Borgess CorpFit, specializing in occupational health and wellness.  For more information about Borgess CorpFit, call (269) 226.8154 or visit corpfit.borgess.com.

Source:

Dansinger, M., Gleason, J., Griffith, J., Selker, H., Schaefer, E. (2005). Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for Weight Loss and Heart Disease Risk Reduction. The Journal of the American Medical Association, 293(1)43-53.

The Governors Highway Safety Association recently reported that within the first 6-months of 2012, the death toll from vehicle crashes increased by 19% among teen drivers (16 – 17 year olds).  Within the Borgess Medical Center Emergency Department (ED), it has been estimated that about 30% of all trauma that comes to the ED are due to vehicle crashes, and about 90% of these are due to distracted driving.  Distracted driving isn’t just about texting and driving or using a cell phone while driving anymore.  According to the US Government Website for Distracted Driving, distracted driving is “any activity that could divert a person’s attention away from the primary task of driving.”

Some prevention tips you can use in your day-to-day driving include:

• Don’t use your cell phone while driving
• Pull over to a safe location before making or receiving calls and texts
• Deputize your passenger to make or receive calls or texts for you, change the radio station, reach for something in the back seat, etc.
• Wait until you are finished driving to eat, adjust the radio station, do your hair/make-up, etc.
• Be a driver who cares about the safety of others and is not selfish…distracted driving is selfish

Borgess Trauma Services is offering a free “End Distracted Driving” presentation to area schools, community centers, churches and other venues to help prevent distracted driving.  For more information or to schedule a free presentation, visit trauma.borgess.com or contact Morgan at (269) 226.7075 or morgan.robinson@borgess.com.

This article was written by Morgan Robinson of Borgess Trauma Services.  For more information, contact Morgan at (269) 226.7075 or morgan.robinson@borgess.com.

Written by: Thomas Goodwin, MD

It was likely the most gruesome injury ever witnessed on a basketball court. Louisville basketball player Kevin Ware’s horrifying leg fracture (on March 31, 2013) may have been caused by previously undetected stress fractures or weakening of the bones.

Dr. Robert Glatter, an emergency medicine physician at Lenox Hill Hospital in New York and a former sideline doctor for the New York Jets noted, “He came down hard, landing in an awkward way. That combined with an underlying bone issue or an existing stress fracture predisposes someone to this type of injury.”

Tim Hewet, the director of sports medicine research at Ohio State University, added that Ware’s diet could have been deficient in vitamin D and calcium, resulting in more porous bones.

An open fracture, whereby the bone goes through the skin, is a rare type of fracture in any sport, and especially rare in basketball. Injuries of this kind are typically suffered in car accidents or other types of blunt trauma. Sometimes, in sports with even greater player-to-player contact, open fractures are seen. For example, former Washington Redskins quarterback Joe Theisman sustained a broken leg in a Monday Night Football game against the New York Giants in 1985.

Fortunately, Ware underwent successful surgery at Methodist Hospital in Indianapolis. (To lift his spirits further, his teammates also went on to beat Duke in the NCAA Midwest Regional final.) During the two-hour operation, surgeons reset his bone and inserted a rod into his leg to stabilize the injury while it heals. The puncture wound caused by the bone going through the skin was closed as well.

While this kind of injury is dangerous (the risk of infection due to the bone breaking through the skin is high), if Ware stays healthy and has no serious underlying medical conditions, he could be back on the basketball court within a year or less.

Bone Up on Bone Health

Whether you’re a gifted athlete like Ware or someone who simply enjoys being independent and active, taking good care of your bones is important. Here are some quick tips for keeping your bones in shape for a lifetime:

• Eat a well-balanced diet that includes grains, fruits and vegetables, nonfat or low-fat dairy products or other calcium-rich foods, and meat or beans.
• Most Americans do not consume the daily recommended levels of calcium. Adolescent males and females require 1,300 milligrams of calcium per day. For ages 18 to 50, calcium requirements are 1,000 milligrams per day. Athletes should strive to eat three to four dairy products a day, such as a slice of cheese in a sandwich at lunch, yogurt for an afternoon snack and a glass of milk at dinner. Try to get most of your calcium from food, using supplements only as an extra boost (not a replacement).
• Be sure your diet is rich in vitamin D. Vitamin D is also available in supplements for those who can’t get enough through sunshine and what they’re eating.
• Combined with meeting recommended guidelines for exercise (at least 30 minutes a day on most days of the week), certain strength and weight-bearing activities (e.g., weight training, running or brisk walking, team sports) are essential to building and maintaining bone mass.

Thomas Goodwin, DO, is a primary care sports medicine physician with Borgess Orthopedics, specializing in injury prevention, concussion management and general musculoskeletal issues.  For more information on Dr. Goodwin or sports medicine at Borgess, call (269) 343.1535 or visit sportsmedicine.borgess.com.

Written by: Travis Jager, PT, DPT, Cert MDT

Chances are you may know someone with Scoliosis- possibly from one of those screenings back in grade school. The prevalence of scoliosis is 1% to 2% in schoolchildren and 8% in those over 25. Many people choose to treat their scoliosis with the wait and see approach but there are other options.

As a physical therapist, I have done a lot of research on scoliosis management. I came across “The Schroth Method,” which is a treatment philosophy that attempts to restore the “normal” mechanics of the joints and muscles around the spine by focusing on posture, breathing and strengthening.

To understand posture, think about your body as bunch of building blocks. If you wanted to build a tall tower of blocks you stack the blocks right up on top of each other; this is equal to good posture. If you started to stagger your blocks off to one side your tower would soon fall, since we do not like to walk and fall, our bodies compensate for this and will actually start to stagger our blocks (vertebrae) in alternating fashions. Scoliosis happens when some of our vertebrae are shifted to the left, others to the right and some can even be rotated to the right or left. What we will do in physical therapy is correct or overcorrect the posture (restack the blocks) and teach functional exercises.

One of the most important muscles to train is your diaphragm. This is the large muscle that pulls down on your ribs to force air into your lungs. If you have heard the phrase “belly breather,” that is referring to diaphragmatic breathing. Once the patient has been able to achieve this “normal’ breathing pattern, we progress the movements and exercises to build the muscles which assist in spinal corrections. These exercises can get quite complex, but can be quickly taught by a skilled physical therapist. Once the patient has mastered the exercise, they will repeat it several times per day in their home exercise program.

A number of patients have made great progress with their spinal curve, in only a couple of visits spread out over several weeks. With a motivated patient and the right type of exercise there can be noticeable progress. I have seen improved endurance (by teaching the patient to breath more effectively), posture and strength- in one case, a mother being able to pick up her child again without pain.

Though people with scoliosis frequently assume there is nothing they can do to alter their condition, as you can see there are treatment options available which can help lead to happier, healthier lives.

Travis Jager, PT, DPT, Cert MDT is a physical therapist with Borgess Spine, specializing in rehabilitation for back pain and various spine issues.  For more information on physical therapy or treatment for scoliosis, call (269) 552.2225 or visit BorgessSpine.com.

• 3 egg whites
• 1/4 tsp cream of tartar
• 1 cup sugar
• 1/2 cup crushed saltines (about 12 crackers)
• 1/4 cup chopped pecans
• 1 tsp vanilla extract
• 2 pints fresh strawberries, divided
• 4 cups miniature marshmallows
• 1 tub (8 oz) fat-free whipped topping

Now that you have the ingredients, you are ready to go! Follow the following steps and enjoy!

1. Preheat oven to 350°.
2. In a mixing bowl, beat egg whites and cream of tartar on medium speed until soft peaks form. Gradually beat in sugar, 1 tbsp a time, on high until stiff glossy peaks form and sugar is dissolved. Fold in the crackers, pecans and vanilla.
3. Spread onto the bottom and up the sides of a greased 10-inch deep-dish pie plate.
4. Bake for 25-30 minutes or until meringue is lightly browned. Cool on wire rack.
5. Set aside one strawberry for garnish.
6. Slice half of the strawberries and set aside.
7. In a bowl, mash the remaining strawberries and drain the juice reserving 1/2 cup.
8. In a saucepan, combine marshmallows and reserved juice. Cook and stir over low heat until marshmallows are melted. Refrigerate until partially set.
9. Fold the sliced and mashed strawberries and whipped topping into marshmallow mixture. Add food coloring if desired. Spoon into meringue shell. Garnish with the reserved strawberry.
10. Refrigerate for 3 hours or until set.
11. Refrigerate leftovers.

Once you get done trying it, be sure to let us know what you think! You can get more great recipes like this in the Borgess Light Hearted Living Cookbook, available at cookbook.borgess.com or by visiting the Seasons Gift Shop located inside the Atrium at Borgess Medical Center.

Written by: Eric J. Slosberg, MD

Just what is Tourette’s syndrome?

Tourette’s syndrome is a neurological disorder reported in 1885 by Gilles de la Tourette, a French neurologist, consisting of involuntary tics or movements.  These tics are frequent, sudden, brief, intermittent and stereotyped.  The frequency and severity of the tics may wax and wane over time.

What are the symptoms of Tourette’s syndrome?

There are two types of tics.  The motor tics often consist of facial twitches, grimaces, shoulder shrugs, jerking, eye blinking, or obscene gestures. While the vocal tics may manifest as grunting, barking, sniffing, throat clearing, or swearing.

Children with Tourette’s syndrome cannot voluntarily control their tic behaviors, except briefly (like an itch that must be scratched sooner or later).  Many children with Tourette’s syndrome will have motor and phonic tics even while sleeping.

Children with Tourette’s syndrome are often misunderstood and teased by other children.  In reality, most children with Tourette’s syndrome just want to be treated normally – like everybody else.

Can children with Tourette’s syndrome control their tics?

The answer to this question is a bit complicated.  The tics of Tourette’s syndrome are considered unvoluntary rather that strictly involuntary.  Folks with Tourette’s syndrome can suppress their tics for a short time.  However, they experience a build up in tension that ultimately results in tics expressed against their will.  This phenomenon is much like an itch that can be delayed for a short while but which ultimately must be scratched.  Emotional stress, fatigue, and anxiety are known to worsen the severity and frequency of tics.

Are there any associated symptoms in addition to the tic behaviors?

Although motor and vocal tics are the hallmark of Tourette’s syndrome, patients may also experience restless, difficult sleep, bedwetting, and nightmares.

In addition, there is a high frequency of other associated conditions (co-morbidities) in patients with Tourette’s syndrome.  These co-morbid conditions include: attentional disorders (ADHD and ADD), oppositional defiant disorder (ODD), conduct disorder, obsessive-compulsive disorder (OCD), migraine headaches, and learning problems.  Children with autistic spectrum disorder experience Tourette’s syndrome in approximately 20% of cases.

Tourette’s syndrome is not known to adversely affect intelligence nor life expectancy.

How often does Tourette’s syndrome occur?

Tourette’s syndrome is significantly more common than originally believed.  Tourette’s syndrome occurs in 7-8 children per 1000 of the population.  However, it is much more common in boys than girls.  Tourette’s syndrome most often presents before the age of 11 years, but may begin any time between the ages of 2 and 18 years.

How do you test for Tourette’s syndrome?

The diagnosis of Tourette’s syndrome is made solely on clinical grounds.  That is, your provider will diagnose Tourette’s syndrome based on your child’s symptoms.  The diagnosis is on firmer ground if vocal tics are present along with motor tics some time during the illness, although it is not necessary to have both motor and vocal tics at the same time.  The tic behaviors should begin prior to the 21st year of life and last longer than a year.  The presence of co-morbid conditions (see above) known to be associated with Tourette’s syndrome also may help to confirm a diagnosis.

Laboratory tests, EEG’s and X-ray’s and other imaging tests such as CAT Scans are not helpful in the diagnosis of Tourette’s syndrome.  Recently, MRI Scans and PET Scans have identified some brain abnormalities in Tourette’s syndrome patients in research settings.

Sometimes, however, blood tests, EEG’s or imaging studies are performed to rule out other conditions that may imitate Tourette’s syndrome.

How did my child catch Tourette’s syndrome?

Tourette’s syndrome is felt to be an inherited disorder. The genetics were felt to be largely autosomal dominant with incomplete penetrance.  However, more recent work is revealing a more complex pattern.  Mutations have been identified in the SLITRK1 gene on chromosome 13q31.1 and, more rarely, on the HDC gene on chromosome 15q21-q22.

If a parent has Tourette’s syndrome, the risk of having a child with Tourette’s syndrome is 22%.  The siblings of an affected child have an 8% chance of developing Tourette’s syndrome.

PANDAS, a movement disorder felt to be caused by untreated strep throat, is no longer assumed to be a direct cause of Tourette’s syndrome.

Other non-genetic, post-infectious, environmental and psychosocial factors can affect the severity of Tourette’s syndrome.

What treatments are available for Tourette’s syndrome?

Patients with mild Tourette’s syndrome symptoms that do not interfere with their daily activities of living may not require specific treatment.  However, if your child is having difficultly with the normal activities of school, or at social gatherings, or with friends; or if your child is the victim of teasing or bullying; or if your child is having difficulty performing every day tasks, then you might consider treatment options.

Certain medications are available which decrease the frequency and severity of tic behaviors.  In particular, the alpha-adrenergic agonist class of drugs may prove beneficial.  The most commonly used medications are clonidine (Catapres and Kapvay) and guanfacine (Intuniv and Tenex).  These medications may also benefit the attentional disorders associated with Tourette’s syndrome.

Some antipsychotic medications, in certain settings, have also been shown to decrease motor and vocal tics: risperidone (Risperdal), aripiprazole (Abilify) and other related compounds. Drugs that block dopamine receptors such as fluphenazine (Prolixin), pimozide (Orap) or tetrabenazine (Xenazine) may also be considered.

Botulinum toxin (Botox) may be considered in severe cases.  Its use should only be considered by a specialist very familiar with its use.

Selective Serotonin Reuptake inhibitors (SSRI’s) like Zoloft, Prozac, and Luvox may be used to treat the anxiety and OCD symptoms associated with Tourette’s syndrome.

Some medications may exacerbate (make worse rather than cause) tic behaviors and should be avoided, when feasible, in children with Tourette’s syndrome.  In particular, the stimulant class of medications used to treat attention deficit disorder (ADD, ADHD) may fall into the category of unmasking tics.  In such cases, a non-stimulant such as Intuniv (improves tics) or Strattera (largely tic neutral) should be considered.

Habit reversal training is a therapy shown to have some success in Tourette’s syndrome patients.  Habit reversal training requires a therapist trained in this specific technique as applied to patients with Tourette’s syndrome.

Will my child outgrow Tourette’s syndrome?

There is no cure for this disorder.  However, about one half of children with Tourette’s syndrome have greatly reduced tic behaviors as adults.  Occasionally, the tics may return late in life.

In Summary

The proper management of Tourette’s syndrome includes the accurate and timely diagnosis of the ailment; education of patients, parents, teachers and friends; genetic counseling; behavioral and pharmacologic treatments if indicated; and generous support and understanding by the community.

Written by: Lisa Kanwischer, PA-C

Almost everyone gets constipated at some time during his or her life. It affects approximately 2% of the population of the United States. Most children have a bowel movement 1 or 2 times a day. Others may go 2 or 3 days between BMs. However, if the stool remains in the colon for too long, it can become larger and more difficult to pass and hard and dried out making it more painful to pass. Constipation can even occur in children who appear to be stooling every day. If the colon never gets fully emptied, the stool accumulates and can cause pain and cramping.

Causes of constipation include:

• Too little fiber and too little water in the diet.
• Withholding stool. Children withhold for many reasons – painful BMs, not wanting to stop playing to take time to use the bathroom, toddlers and pre-schoolers who want to control as much as they can and refuse to use the toilet when the urge is present, older children who don’t like using public toilets and hold it until they get home.
• Disruption of regular diet or routine, traveling.
• Too little activity or exercise.

Signs of constipation include hard, painful or infrequent stools, stomach aches and cramping, rectal bleeding from tears, poor appetite and cranky behavior. Constipation is usually diagnosed after a thorough history and exam by a healthcare provider. Occasionally, a simple x-ray will be taken to determine the amount of stool in the colon and to check for obstruction of the bowel.

Constipation can get worse if it isn’t treated. The longer stool stays inside the body, the larger and drier it gets. This leads to painful BMs. The child becomes afraid to go and holds it even more and the problem snowballs. Increasing the fiber and fluids in the diet can help, but sometimes medication is necessary. Fiber supplements can be used if dietary changes alone are not enough. Mineral oil is sometimes used to lubricate the colon allowing stool to pass through more easily. It also makes withholding more difficult. Medications called osmotics, like Miralax, are used to pull fluids into the stool. Your child’s healthcare provider can determine that approach is best for your child.

Constipation can be prevented:

• Encourage your child to drink lots of water. Try warm liquids, especially in the morning. Limit milk and cheese if your child gets more than two or three servings a day.
• Encourage your child to eat more high-fiber foods. Aim for 5 grams of fiber plus your child’s age per day. A 2 year old should get 7 grams of fiber a day; a 10 year old, 12 grams. Check for dietary fiber on the Nutrition Facts label of the foods you buy. Look for foods with at least 2 grams of fiber per serving. See the chart below for some examples.

• Hold off on toilet training until your child shows an interest.
• If your child is toilet trained, set up a toileting routine with your child. Pick a regular time each day to sit on the toilet (like after a meal.) Have something under your child’s feet to push on; this makes it easier to push.
• Encourage your child to take a break from playing if they feel the need to use the bathroom.
• Encourage your child to be active. This can keep the muscles of the colon healthy.

Constipation is a common problem for both children and adults; if diagnosed early,  it can usually be treated fairly easily and then changes in diet and activities can prevent it from reoccurring. Contact your healthcare provider if you think your child is constipated and needs treatment.

Sources: AAP.org, WebMD.com, mayoclinic.com

Moses Walker and Julie Rogers pose for a photo at the annual Martin Luther King Jr. Celebration.

On January 21, MLK Day, I had the pleasure of being a part of the 9th annual Martin Luther King Celebration in the Lawrence Education Center.  I felt pride that nearly 100 people braved the icy roads to attend our event.

I look forward to this event each year for several reasons.  First, it is a collaborative effort between Borgess and Bronson in Kalamazoo.  Each year we alternate which hospital hosts the celebration.  It is great to see old faces from previous years that we normally don’t come into contact with from across town.  Secondly, I think it is important to take time to remember our history in America, both to note how far we’ve come in dealing with racism and in how far we have yet to go.

Our keynote speaker, Moses Walker, touched on this during his speech about voting and civil rights.  He gave a detailed chronological history of the passage of laws protecting civil rights.

In the past year, I have served as a member of the Borgess Diversity Council, which has planned and sponsored this event.   The Health Disparities Taskforce, a subset of the Borgess Diversity Council, is currently in the assessment phase of analyzing our patients’ demographic data in Kalamazoo, with the hopes of developing a plan to address disparities between racial/ethnic groups in areas like cancer detection and diabetes.  We hope to narrow the gaps in delivering quality health care to all our residents.

This post was submitted by Julie Rogers, PT, Cert MDT.  Julie has served on the Borgess Diversity Council, which is responsible for planning and sponsoring this event.  Learn more about diversity at Borgess.

Written by: Thomas Akland, MD

Like me, I know a lot of you have made some New Year’s resolutions to be healthier. As a pediatrician and a father, I know that the kids are watching and learning from our example. As we look to becoming more active and eating better in this New Year, here are a few thoughts.

Don’t hibernate
Don’t let the cold winter keep you on the couch and indoors. Take a few minutes each day to do some simple exercises indoors. Kids and adults benefit from daily physical activity, but it doesn’t have to be all at once. Short 10-15 minute bouts of activity throughout the day are just as good as a longer activity and may fit into your busy life a little better.

Get out
Make the time to bundle up and enjoy the great outdoors. There is something exciting about bundling up and taking a simple walk or a run outdoors in the winter. And who doesn’t love finding the perfect sledding hill? Take advantage of the great places we have within a short drive to ski and skate.
Getting outside benefits your children in many ways. Connecting to nature will encourage your child’s curiosity and stimulate their imagination. It has been shown that even a short time outdoors can boost your mood. And, a growing body of research links our mental and physical health to our connection with nature – in a positive way. Look for ways to connect your kids to the nature around them. Point out the trees and the birds in the backyard.

Discourage inactive pastimes by setting limits on the amount of time your family spends in front of the television or playing video games. This is very important for children and adolescents during the winter. Aim to make good use of their free, unstructured time.

Eat well
Encourage healthy eating habits in your family. Buy and serve more fruits and vegetables. Let your child choose the fruits and vegetables at the store. Buy fewer soft drinks and high fat and high calorie snack foods like chips, cookies, and candies. These are ok once and a while, but keep a bunch of healthy snack foods on the kitchen table or counter and offer them to your kids often.

Be a good role model
Children learn from what they see. Choose healthy foods and active pastimes. Your children will follow your healthy habits and these lessons can last a lifetime.

Written by: Sandhya Sood-McMillen, MD

The cold weather is fast approaching, so now is a good time to make sure that you have everything you need to keep your kids safe this winter.

What to wear
When heading out for some winter fun, make sure that your child is dressed appropriately for the weather. Dressing in layers can be helpful so your child stays warm enough but can remove layers on a sunny day to avoid becoming overheated. Warm socks, hats and gloves are also important to prevent cold related injuries and frostbite. And don’t forget about applying sunscreen to exposed areas, even on cloudy days.

Car seat safety
It is important to be cautious about using winter coats in car seats. Some winter coats are too thick and do not allow for the straps to be tightened properly, which can raise the risk that your child might be ejected from the vehicle in a collision. Also be careful about using buntings or car seat covers. It is not safe to put anything under the baby or between the baby and the car seat that did not come with the car seat. These types of buntings or “sleeping bags” can interfere with strap positioning and make it impossible to tighten and position straps correctly on your baby. It is safer to use a car seat cover that goes over the car seat and does not interfere with the straps.

Winter sports
Helmets are probably one of the most important pieces of safety equipment that your child needs for skiing or snowboarding. Make sure that the helmet is actually meant for skiing or snowboarding. Do not just use a bike helmet or football helmet. Make sure the helmet fits your child properly and that the chin strap is fastened at all times. If you have questions about ski or snowboard helmets, please ask your pediatric provider. Our clinical staff is trained in fitting skiing and snowboarding helmets and these are available at our office, as well as at Borgess Medical Center – Trauma Services and local sporting good stores and ski shops. Similarly consider placing a helmet on your child for sledding and ice skating and make sure to review safety precautions with your child before they participate in these activities.

It is also important to make sure that your child’s ski or snowboard equipment, including boots and bindings, is properly sized for your child and that your equipment is checked before every season to make sure it is functioning properly.

Snowmobiling
The American Academy of Pediatrics (AAP) has established guidelines for children and snowmobile use:

• The AAP recommends that children under age 16 not operate snowmobiles and that children under age 6 never ride on snowmobiles.
• Do not use a snowmobile to pull a sled or skiers.
• Wear goggles and a safety helmet approved for use on motorized vehicles like motorcycles.
• Travel at safe speeds.
• Never snowmobile alone or at night.
• Stay on marked trails, away from roads, water, railroads and pedestrians.

Christmas tree and fire safety
Make sure that if you are using an artificial tree, it is labeled as “fire resistant,” and if you are using a fresh, live tree that you keep the base filled with water so that it does not dry out. Keep your tree away from fireplaces and heaters. Check all lights for burned out bulbs or frayed wires and turn off all lights before you go to bed at night. Make sure all decorations are also fire resistant, and in homes with small children, watch for decorations that could be choking hazards. Also make sure that you have smoke and carbon monoxide alarms installed on every level in your home, and smoke alarms in every bedroom. Make sure to test these monthly, and replace batteries every six months. Also make sure that you practice fire drills with your family and have an exit plan for every room in your home.

Wishing you a happy and healthy holiday—please feel free to ask your pediatric provider about any concerns you have about keeping your children safe this winter. We are here to help!

Written by: Melissa Reffitt, CPNP

What is a concussion?
A concussion is an injury to the brain that results in temporary loss of normal brain function. Although a blow to the head usually causes concussions, they can also happen when the head and upper body are violently shaken. In most cases, a person with a concussion never loses consciousness.

What are the symptoms?
Symptoms of a concussion are generally temporary and can include problems with memory, vision, concentration, balance or coordination, headache, or sensitivity to light and noise.

How is concussion diagnosed?
While computerized tomography (CT) scans and magnetic resonance imaging (MRI) can be useful for diagnosing brain bleeds (from trauma), they do not diagnose concussions. The diagnosis of concussion is based on a person’s symptoms. Most people with a concussion have a normal CT/MRI.

What about ImPACT™ testing?
Some schools have computerized tests; ImPACT™ is one option, available to help with return-to-play decisions. These tests do not diagnose concussions, but do help doctors determine whether an athlete has returned to his/her baseline mental function.

What is the treatment?
Rest! The brain must rest to heal. A student athlete should not return to sports or activities—even school. Teachers and school counselors should be notified of the head injury. Driving, video games, texting and other mentally stimulating activities should also be avoided.

How long is recovery?
Most people will fully recover from a concussion in one to two weeks. This may take longer in athletes who have had previous concussions.

When is it safe to return to play?
Return to play will be a stepwise approach, with a gradual increase in activity intensity each day as long as symptoms do not recur. After ANY concussion, no matter how minor it may seem, a person should be out of contact sports for at least one week. This may take longer in athletes who have been previously concussed and younger athletes.

Are there any complications?
Returning to play too soon after a concussion may make a person more susceptible to a more serious head injury that could cause permanent damage or death. Multiple concussions, especially in young athletes whose brains are still developing, can potentially lead to learning/memory disorders or depression.

ProMed Pediatrics can also work in conjunction with Borgess Sports Medicine to help injured athletes recover and stay on top of their game. Learn more at sportsmedicine.borgess.com.