By Julie Wiekamp, MPAS, PA-C
Everyone remembers a bad case of poison ivy. The itchy rash is not easily forgotten. Yet, the plant is hard to spot and there are many misconceptions on how it is spread. Allergic rashes caused by plants are usually a result of poison ivy, poison oak, and poison sumac. All of these plants contain the oil urushiol. Urushiol is found in stems, leaves, roots and fruit.  Approximately 50% of individuals will break out in a rash after coming into contact with the oil in nature.  No skin type is immune to the oil- all ethnicities are affected.

Poison ivy and oak’s leaves are arranged in a group of three that arise from a single stem, thus the phrase, “Leaves of three, let them be.” The plants produce an off-white fruit in the autumn. Poison sumac is different from poison ivy in that the leaves are often seen in groups of 5 or more. Plant removal is often difficult. Burning the plants is not recommended since inhaling the oil may cause irritation to the lungs. The oil will not penetrate heavy vinyl gloves, although it will penetrate through rubber or latex gloves.

Those who work or play outside are at a higher risk for running into the plants. If you have accidentally made contact with urushiol containing plants, it is best to gently wash the skin as soon as possible. It is, of course, best to wash the oil off within 10 minutes of exposure. However, washing your skin even 1-2 hours after exposure provides some benefit. You can be exposed to the plant oil by touching clothing or fur that has come into direct contact with the plant. Therefore, if you suspect you have been around poison ivy, it is best to wash all clothes, shoes and camping items. Remember to wash your pet as well! The rash is not spread by the blister fluid. You must come into contact with the oil itself in order to get the rash.

A poison ivy rash is often reddened and itchy. It is usually readily identified in clinic- although sometimes it may mimic other types of rash. Over the counter treatments such as calamine lotion and oatmeal baths are helpful to calm and soothe the itch. More moderate to severe rashes require prescription steroids to help stop the allergic response. On occasion, scratching will bring about bacterial infection. Watch carefully for signs of secondary infection to include redness, swelling, crusting and drainage.

Identification of the plant is key to prevention. For further help in identifying the plant see the links below:
http://msue.anr.msu.edu/news/identifying_poison_ivy_isnt_always_easy_to_do
https://unlcms.unl.edu/ianr/extension/hort-update/PoisonIvy

By Julie Wiekamp, MPAS, PA-C
Summer. After a long winter, nothing beats playing outside in the sun with your family and friends. Here are a few tips for making your outdoor activities even more enjoyable.

1. Stay hydrated! Remember to pack a water bottle. This is particularly important if you plan on working or exercising outside. Too many forget to stay hydrated and will develop heat exhaustion or heat stroke. Most healthy adults need to consume around 2 liters of water per day. This need increases with strenuous activity or time spent in the heat. Sports drinks, such as Gatorade, replenish electrolytes lost through sweating and may be useful if you have been exercising. Signs of heat related illness may at first be mild. However, symptoms can become progressively worse and may involve elevated temperatures, lightheadedness, nausea, vomiting and muscle cramps. Severe dehydration often requires emergent treatment and IV hydration. Remember, the best treatment for dehydration is truly prevention!

2. Pack sunscreen! Pick a broad spectrum sunscreen that blocks both UVA and UVB rays. SPF 15 is recommended for daily use. However, if you plan to spend the day outside in the sun, purchase sunscreen with SPF 30. Waterproof sunscreen is a good idea for those participating in swimming, exercise or work. In general, waterproof sunscreen should be reapplied every 40-80 minutes. Make sure to get all areas of sun exposed skin and apply an adequate amount. Sunscreen will help prevent against the immediate pain from a sunburn, as well as skin cancers directly related to sun exposure.

3. Consider bug spray! Mosquitos, spiders and ticks often become quite worrisome in the warmer months. While most bug bites are only a nuisance, some can cause more serious disease such as West Nile, Zika and Lyme Disease. If traveling, be aware of the diseases endemic to that area. For instance, mosquitos in Nebraska may carry West Nile but not Zika. Choose an Environmental Protection Agency registered repellent that has DEET, picaridin, IR 3535, oil of lemon eucalyptus, paramenthane-diol or 2-undecanone as the active ingredient. If using both sunscreen and bug repellent, apply the sunscreen first. Do not use insect repellent on infants younger than 2 years of age. Be sure to keep repellent out of the eyes, nose and mouth. To that end, do not apply bug repellent on children’s palms and clean your hands after applying. Do not apply repellent under clothes. The Environmental Protection Agency provides a search tool for consumers looking to purchase the appropriate bug repellant-https://www

By Julie Wiekamp, MPAS, PA-C
Fad diets are everywhere. You can’t turn on the TV, flip through a magazine or even have a friendly conversation without hearing about the “latest and greatest” way to lose weight. From fasting to gluten free, the marketplace is full of messages on what we “should” or “shouldn’t” eat. So what exactly is a “good diet?” A good diet plan needs to be specialized to an individual with regard to not only their medical conditions, but also their cultural practices. A good diet plan should be one that you can follow indefinitely with an emphasis on healthy food choices over a lifetime. The Mediterranean diet is a wonderful example of a time tested diet plan that can be easily adjusted. The Mediterranean diet is known to decrease cardiovascular mortality and has also been linked to better Type 2 Diabetes outcomes and certain types of cancer prevention.

The Mediterranean diet emphasizes fresh fruits and vegetables. A strong base of fresh fruits and vegetables provides the body with a boost of vitamins, minerals, fiber and antioxidants. Fresh produce retains more vitamins, minerals and antioxidants. So, whenever possible, seek out the fresh options. Frozen vegetables are usually second best.

Whole grains are consumed within the Mediterranean diet. Rid your diet of processed, white bread. Instead, seek out whole grain choices high in fiber.

Olive oil is the primary fat consumed. Very little saturated fat(animal fat) is eaten. Instead, meals are prepared and flavored with olive oil. Olive oil is a monounsaturated fat, useful in lowering total cholesterol and LDL cholesterol. Bear in mind, any oil is high in calories. So, olive oil, like any fat, should be consumed in moderation.

The amount and type of meat consumed in the Mediterranean diet is often very different than the average Nebraskan diet. Fatty fish, such as salmon, is readily consumed. Salmon provides benefits for both the brain and the heart, as it is high in omega 3 fatty acids. Admittedly, finding good fish in Nebraska may prove challenging. But, numerous grocery stores are offering a wider variety of fresh and frozen fish in the area. Poultry is consumed a few times per week. Finally, red meats are consumed in smaller quantities and less frequently.

Low fat dairy is a useful way to increase your protein and keep your cholesterol in check. Search for low fat cheeses, skim milks, Greek yogurt and cottage cheese.

Instead of reaching for the salt, reach for herbs and spices. This practice will give your foods more flavor and keep your blood pressures in check.

No diet plan is right for all. However, following the Mediterranean diet may be easily used by most individuals and families. It is not a step by step meal plan, but instead a framework for viewing food and choosing healthy options that work for you and your household.

To see a copy of the Mediterranean diet pyramid: https://oldwayspt.org/traditional-diets/mediterranean-diet

By Julie Wiekamp, MPAS, PA-C
If you live in Nebraska, it is nearly impossible to escape the hype and excitement that comes with Husker football. Every fall, Memorial Stadium is full of passionate fans, ready to cheer on their favorite player. On game day, the fans at Memorial Stadium are heard from miles around. Yet, nothing quiets the stadium like a bad head injury.

Traumatic brain injuries are most often caused by some type of accident. Motor vehicular accidents and falls are the most common causes. However, athletes in recreational sports such as football, hockey, soccer, and boxing are especially prone to head injuries. Sports related concussion is found to affect somewhere between 1.6-3.8 million athletes annually.

Concussion is just one type of traumatic brain injury. Concussion most often occurs through a direct blow to the head. One does NOT have to lose consciousness to have a concussion. Loss of consciousness may be a symptom of concussion, but many concussions go unrealized because the individual did not lose consciousness. Concussion symptoms include confusion, loss of memory, mood changes, difficulty concentrating, poor coordination, stumbling and slurred speech. Anyone suspected of concussion should be evaluated by a health care provider. Acute bleeds to the brain and skull fracture must be ruled out first. Imaging, such as CT, may be necessary for some injuries.

Several sideline tools have been developed to aid in the diagnosis of concussion. The SCAT5 may be used by licensed health care professionals to evaluate concussions. Athletes are usually tested before the season, and again if a concussion is suspected.

In general, all athletes with concussion must be removed from play until given clearance to return by a health care provider. A step-wise return to play protocol is initiated. First, athletes should be symptom free off medication and able to return to schoolwork without problem. Neurological testing(SCAT5) should be back at baseline. Only then, may athletes begin to participate in light aerobic exercise followed by a gradual return to full play. A minimum of 5 days is required before even considering a return to play.

It is very important that athletes return to play slowly and per protocol. Athletes who have not fully recovered from concussion are at a much higher risk of sustaining a second concussion. A second injury to the brain, when it is not fully healed, may result in long term or even fatal consequences.
Most individuals with concussion go on to do quite well long term. Most high school athletes are able to return to play within a few weeks.

For more information regarding concussions and return to play:
https://www.cdc.gov/headsup/index.html

By Julie Wiekamp, MPAS, PA-C

Breast cancer affects many homes in the United States. Chances are, most of us have a relative or a friend that has been diagnosed with breast cancer. In fact, it is the most common type of non-skin cancer for women in the US. Early cancer detection leads to better outcomes. Thus, it is very important to discuss cancer risk and breast cancer screening with your provider.

Screening is very different based upon your individual risk factors. Women at high risk for developing breast cancer are those with a prior history of breast cancer, ovarian cancer, a genetic predisposition (ie, BRCA gene) or radiotherapy to the chest between ages 10-30. These women must undergo more rigorous screening, and the screening is often begun at a much earlier age.

Mammography is still the best imaging method to screen for breast cancer. Mammograms use xray technology to view changes in the breast that can not be appreciated on breast exam. They are effective for early cancer detection.

For the average woman, mammography begins some time between ages 40-50. The American Cancer Society(ACS) recommends women discuss mammography with their provider at age 40. Based upon risk factors, some may choose to start screening at that time. The ACS recommends yearly mammography between the ages of 45-55. At age 55, women of average risk may discuss the risks and benefits of screening mammography every 1-2 years. The US Preventative Task Force Services and American College of Gynecologists have slightly different recommendations. If there is a strong family history of breast cancer, sometimes screening may even begin earlier than age 40.

What about self breast exam? In general, women need to be familiar with their own breasts. It is important to be able to recognize new lumps or masses within your breasts. Breast cancer may cause the skin along your breast to become irritated, red, scaly, orange or even dimply. Nipple discharge, retraction and tenderness may also be a sign of cancer.

Yearly well woman physicals are very important! Physicals are a perfect time to discuss risk factors, perform breast exam, schedule mammograms and discuss any other preventative care that may be needed. If you have any concerns regarding changes in your breasts, make sure to schedule a check up.

By Julie Wiekamp, MPAS, PA-C
Over 1 million Americans experience a shingles outbreak each year! In fact, the CDC estimates that 1 out of every 3 individuals will experience shingles over their lifetime. Routine vaccination decreases the possibility of shingles, while timely diagnosis and treatment help reduce complications.

Shingles is caused by the same virus that causes the chicken pox. After one has cleared their initial infection with chicken pox, the virus will lie dormant in the nerve roots. Under the right circumstances, the virus will reactivate along one nerve root, thereby causing the classic shingles rash.

One of the greatest risk factors for developing shingles is age. 20% of shingles cases will occur from ages 50-59, while 40% will occur in those aged 60 or older. Anyone with a suppressed immune system is also at increased risk of disease.

The shingles rash will usually contain several raised blisters atop a patch of reddened skin. The rash will typically follow a single nerve root distribution and is usually unilateral- meaning that it does not cross midline. The rash is contagious and may cause chicken pox in one who has not had the disease or been vaccinated. Once the lesions have crusted over, the risk of transmission is gone. The rash is usually accompanied by itchy, burning, tingly skin.

Sometimes shingles will cause fever, fatigue or other more severe conditions. A painful, burning sensation in the distribution of the rash may linger long after the blisters have disappeared. Sometimes, the pain, or postherpetic neuralgia, will persist for months. Reactivation of the shingles virus in the distribution of the eye is also very serious and requires urgent attention and referral to opthamology.
Antivirals are the mainstay of treatment for shingles, especially if the diagnosis is made within 72 hours of onset. Antivirals are not as beneficial if given 72 hours after onset.

Shingles vaccinations are available. In fact, the CDC recommends healthy adults, ages 50 and older, receive 2 doses of the Shingrix vaccine.

Speak with your health care provider about any concerning rashes. It is best to start treatment for shingles as quickly as possible. Make sure you speak with your provider at your upcoming physical about routine shingles vaccination as well!

By Julie Wiekamp, MPAS, PA-C
A skin abscess is a pocket of infection that lies just below the skin’s surface. It is often caused by a break in the skin where bacteria enter and start to grow. Abscesses initially look much like a pimple, but will enlarge rapidly. They are often very tender and reddened. If left unchecked, they often cause fevers and the adjacent skin to become infected as well. Skin abscesses are best treated in the clinic and often require incision, drainage, packing, wound cultures and antibiotic therapy.
Abscesses are very contagious, and the infection is easily passed from one individual to the next. As with any skin infection, good hand washing is a must and it is best to try and cover the infected area to prevent the spread of drainage and bacteria. Thoroughly cleaning tubs, showers, sheets and clothing is a must. To prevent a skin infection, make sure to clean off gym equipment before use, especially exercise mats!

By Julie Wiekamp, MPAS, PA-C
Much confusion exists surrounding the adult pneumococcal vaccines. Currently, there are two types of pneumococcal vaccines on the market and both are quite good at preventing one of the most common types of bacterial pneumonia. The CDC recommends all adults over the age of 65 receive both vaccines, while adults with other medical conditions may receive the vaccinations earlier.

Pneumonia is inflammation or infection of the lungs. It is caused by many types of viruses and bacteria. Symptoms include fever, chills, fatigue, productive cough and shortness of breath. Patients may even become nauseated or wheezy. If taken, chest xrays will often show consolidation or infiltrates. Treatment depends on the type of virus or bacteria causing the pneumonia, as well as the general health of the patient. Sometimes, patients may need to be hospitalized to clear the infection.

The pneumococcal vaccinations specifically provide immunity against certain strains of the Streptococcus pneumoniae bacteria. Streptococcus pneumoniae causes pneumonia, sinus infections, ear infections and meningitis. The pneumococcal vaccinations do NOT provide immunity against viral pneumonias or pneumonias cauesd by other types of bacteria.

Two types of pneumococcal vaccines are currently available. Pneumococcal polysaccharide vaccine(Pneumovax 23) and pneumococcal conjugate vaccine(Prevnar 13) are both given to adults. Pneumovax 23 protects against 23 different types of Streptococcal pneumoniae bacteria. It is not effective for children. Prevnar 13 is given to both children and adults and provides excellent immunity.
The CDC recommends all adults over the age of 65 receive the Prevnar 13 vaccination, as well as the Pneumovax vaccination. Adults ages 19-64 may receive 1 dose of Pneumovax before age 65 if they have chronic heart disease, lung disease, diabetes or smoke cigarettes. Immunocompromised individuals ages 19-64 are also eligible for both Prevnar 13 and Pneumovax. Many adults will require a booster.

The vaccines are quite effective at preventing pneumococcal pneumonia. However, many eligible adults are simply not receiving their vaccines! Talk with your provider about your vaccination status!

Gluten free diets are very popular. Gluten is a structural protein found in several grains. Most people can consume gluten without problem. However, some individuals become very sick eating gluten and must avoid all foods containing it. Despite the large number of people eating gluten free, a lot of confusion remains about the diet and why it may be right to stop eating gluten altogether.

Who should be on a gluten free diet? Anyone with Celiac Disease must take gluten out of their diet completely. Celiac Disease is often described as an “allergic” reaction. When a genetically prone individual is fed gluten, antibodies are made that actually attack the body’s own small intestine. Celiac disease can be diagnosed by testing for these antibodies in the blood and biopsying the small intestine. Once a diagnosis is made, the patient is restricted to a gluten free diet. Symptoms of classic Celiac Disease are diarrhea, poor absorption of nutrients, and weight loss. Poor absorption of key vitamins and minerals may lead to unhealthy bones, anemia and fatigue- just to name a few. Once gluten is taken out of the diet, symptoms tend to resolve. The severity of Celiac Disease can vary quite a bit based upon the immune system response. If only a few autoantibodies are made, more mild symptoms are seen.

Gluten free diets are limiting, although more and more resources are available to help accommodate the restriction. Gluten is found in wheat, barely and rye. These grains must be strictly avoided. Oats also contain gluten, although the autoimmune response to oats does not appear to be as troublesome. For those with a more mild version of Celiac Disease, or those in remission, it is possible to trial small portions of oats. Studies are ongoing as to how much, and who may be able to safely consume oats. Gluten is commonly used as an additive. Check food labels. Beer and ales should be avoided as well. Grains considered safe for Celiac Disease patients include corn, rice, buckwheat, soybean and potatoes. Thankfully, food companies are providing more and more alternatives for those striving to remain gluten free.

Finally, some individuals are choosing to take gluten out of their diet because they simply feel better while not eating it. For these individuals, a diagnosis of Celiac Disease has not been found, but their intestinal symptoms seem to improve upon limiting gluten. It is interesting to note that barely, wheat and rye also contain a large number fructans. Fructans are known to cause abdominal bloating and gas. Studies continue to search out whether it is the gluten, or the fructans, in the barely, wheat and rye that cause stomach discomfort in this subset of patients.

Make sure to discuss your abdominal symptoms with your provider. A firm diagnosis of Celiac Disease is useful, and many resources are available for the patient looking to restrict gluten.

Unfortunately, there has been a lot of conflicting information regarding masks. We recommend wearing a mask when out in public. COVID-19 is primarily spread through the air. When you stand in close proximity to someone infected with COVID-19, you inhale the viral particles. COVID-19 viral particles often aerosolize, or suspend in the air for long periods of time. Health care workers caring for COVID-19 patients must wear certain masks, often termed N95s. But why is wearing a mask recommended outside of the hospital or clinic setting? As we learn more about COVID-19, we have found that there are large numbers of infected individuals who either never show symptoms or are presymptomatic. These asymptomatic individuals may stand unknowingly by you at the store, church or farmer’s market, silently spreading the disease. However, when both parties wear a mask, the risk of transmission decreases significantly!!!! True, most masks are not as effective as the N95s required of health care workers. But, cloth and surgical masks do help stop the spread of larger respiratory droplets. Wearing a mask to work or run errands may seem uncomfortable. But, by wearing a mask you are protecting others around you. Please be kind.