Parenting | DrPullen.com – Medical and Health Blog

Category Archives: Parenting

How Safe is Oral Sex?

December 12, 2011 Dr. Pullen

Bill Clinton didn’t consider it sex. Lots of teens today consider oral sex a safe alternative to intercourse. Headlines like on ABC news in 2009 cry out, “Oral Sex is the New Goodnight Kiss.” Data suggests that oral sex is becoming more common practice in teens than vaginal intercourse, a major change from a generation ago. In 2002 up to 24% of males and 22% of females teens who had never had vaginal intercourse reported having had oral sex with an opposite sex partner (1). In addition gay men want the real truth, is oral sex a safe alternative to more risky behaviors? The answers seem to all be relative. There are few absolutes in life, but one of the truths is that the only way to completely avoid risk of an STD is to avoid any type of sex. That said, how safe, or alternatively how dangerous, is oral sex?

Let’s look at the evidence for transmission of the various STDs by oral-genital contact.

HIV: Human Immunodeficiency Virus, the cause of AIDS, is the STD many fear most. It can be transmitted when a body fluid containing the virus gains access to another person’s mucous membranes or bloodstream. Unquestionably HIV is transmitted by anal and vaginal intercourse. There are at least a few cases where it is believed that the HIV virus was transmitted to the receptive partner after oral sex with ejaculation. Oral sex without ejaculation into the mouth is theoretically possible, but is felt to be extraordinarily unlikely. The risk of contracting HIV from a single incidence of anal intercourse with with ejaculation and no condom use with an HIV infected male has been estimated at 1:100. Extensive study has been done in trying to find out what the incidence of contracting HIV from oral sex with ejaculation with an HIV infected male, but these studies all have confounding variables. The real problem is that all of these studies have been in gay male populations, and a low percentage of the men had only oral sex. On second and subsequent interviews many times the history changed, and made other routes of transmission more likely. In one study it was estimated that there were zero cases of conversion in a population after over 35,000 incidences of oral sex. All said, although it is possible to contact HIV from oral sex, the chances are very low. Low enough that if oral sex is a behavior that replaces anal intercourse in gay men the benefit of avoiding the high risk behavior likely greatly outweighs the risks of oral sex in this situation.

Herpes Simplex: This may be the most common STD transmitted by oral sex. Up to 70% of teens are estimate d to have been infected with the herpes simplex 1 virus, the cause of >90% of oral herpes cases. Many others, and many of the same people also have been infected with the herpes simplex 2 virus, the cause of >90% of genital herpes. The problem with herpes simplex is that despite popular belief, an infected person can shed the herpes virus at times when they have no symptoms or visible evidence of infection. It is believed to be fairly common to transmit the herpes simplex virus either from the mouth to the genitalia, or from the genitalia to the mouth during oral sex. The incidence of HSV transmission by oral sex is not well studied.

Gonorrhea: Gonorrhea, caused by the bacteria Nisseria gonococcus, is an STD that typically causes painful urination and a discharge of pus from the urethra in men. In women it can be asymptomatic, can cause a vaginal or cervical discharge, or can cause more serious infection of the fallopian tubes and or ovaries, called Pelvic Inflammatory Disease (PID). Gonorrhea can also infect the throat or tonsils. The route of this infection appears to be oral sex, generally receptive oral sex with the penis in the mouth. It is less clear whether cunnilingus can transmit gonorrhea although it is felt that this is very rare if it ever happens. Men likely only contact gonococcus from vaginal or anal intercourse or from an infected partner during receptive oral sex.

Chlamydia: There is less data about transmission of Chlamydia by oral sex. It is generally felt to be possible to transmit Chlamydia both as the person performing and the person receiving fellatio. The incidence of this is just not known.

Syphilis: Syphilis is fairly uncommon in the US, but transmission of syphilis during oral sex is relatively easy, and is felt to be a relatively common cause of transmission, possibly up to 15% of cases in some areas of the US.

HPV: HPV is probably the most prevalent STD in the world today. The HPV virus can be transmitted to the throat or mouth during oral sex. The incidence of this is poorly understood, but there is an increasing rate of HPV positive head and neck cancers in the last 30 years. Many experts feel that this correlates to increasing acceptance of oral sex. Oral cancer has historically been primarily a disease of older adults with a long history of smoking and drinking, or in younger persons who use oral tobacco. In recent years the incidence in younger non-tobacco users has increased, and many of these cancers are HPV positive on testing.

Hepatitis: There is debate whether hepatitis B can be transmitted by oral sex, but if possible it is felt to be very unlikely. Hepatitis A can clearly be transmitted by oral-anal sex, and is much more common in the gay male population than in the heterosexual population.

In summary oral sex is not safe sex, but it is far less risky than either vaginal or anal intercourse regarding STD transmission. In addition the risk of pregnancy in heterosexual oral sex is near zero. Avoiding receiving ejaculate in the mouth greatly lowers the risk of transmission of HIV, though probably not the risk of herpes, gonorrhea, or HPV. Condom use for men, or use of a dental dam in women seems effective in markedly reducing the risk of most STDs with oral sex, but may not be common practice.

Psychological Issues: Oral sex is clearly an intimate act. Most psychologists agree that sex, either oral sex or sexual intercourse, brings a relationship to a different level. How this type of intimacy affects a relationship, the self esteem of the participants, and future feelings about relationships and intimacy are subjects worthy of consideration, but I know of no research into this topic.

So, “How safe is oral sex?” What do you want to tell your children about oral sex as a part of their sex education? You can decide now based on the discussion above and whether it involves men having sex with other men (MSM) vs. heterosexual oral sex. One risk of labeling oral sex a high-risk behavior in MSM is that it may leave gay men feeling that its risk is equal to anal intercourse, which is far from the truth. If oral sex is an alternative to anal intercourse for MSM then it greatly reduces the risk of HIV transmission.

1 Comment - Leave a comment!

The Gluten Free Marketplace Explodes

December 5, 2011 Dr. Pullen

The Gluten Free Marketplace Explodes

Gluten Enteropathy, or celiac disease (sometimes called celiac sprue), is a condition where the lining of the small bowel is damaged by antibodies to gluten found in wheat, rye, barley, malt and some other grains. When people who are gluten sensitive eat food containing gluten their small bowel becomes inflamed, the villi that contain enzymes to help digest foods to allow their absorption become atrophic and dysfunctional, and they lose weight, become ill and just feel terrible. For many years it was felt that gluten enteropathy was rare in the United States, and was primarily a European problem. As late as 1999 the teaching in U.S. medical schools was that only 1:10,000 Americans had gluten enteropathy. Beginning in the early 1990’s research began to show that the incidence was much higher, and it is now estimated that as many as 1:100 Americans has gluten sensitivity. This for unknown reasons seems to be a real increase in the last half century, and not be just a product of increased awareness and better testing.

Gluten sensitivity can be dramatic or subtle, and difficult to diagnose. A battery of blood tests often including Anti-tissue Transglutaminase Antibodies(Anti-tTG) IgA, Anti-tG IgG, Anti-Gliadin Antibodies, Anti-Endomysial andibodies, or other antibody tests if positive can suggest the diagnosis. A negative test has a higher predictive value at ruling out celiac disease than a positive test has at confirming the diagnosis (the tests are more highly sensitive than they are specific). To confirm the diagnosis requires a small bowel biopsy that is usually obtained by upper GI endoscopic exam.

Once diagnosed with celiac disease a person has to learn how to eat a gluten free diet in a society where wheat and other gluten containing food is nearly everywhere. Fortunately more and more prepared foodstuffs are being marketed all the time, and more recipes, support groups, and nutritional advice is available than ever before.

I just read a very interesting article in the N.Y Times by Keith O’Brien that nicely outlines the history of the emergence of gluten enteropathy in the U.S., and the market leadership by General Foods in bringing gluten free food products to market to capitalize on the growing market for gluten free products. You may enjoy reading:

Should We All Go Gluten Free?

By Keith O’Brien November 25, 2011.

My guess is that you know someone dealing with the need to eat gluten free. Fortunately as awareness grows and resources become more easily available providing a gluten free meal is less onerous than it was just a decade ago.

I am also learning more about various nutritional deficiencies that can accompany celiac disease. The malabsorptive condition seen in patients with celiac disease can lead to several well documented vitamin deficiencies that are uncommon otherwise. Deficiencies in almost all of the fat soluble vitamins and B vitamins are more common in celiac patients than in the general population. I recently saw a 17 year old girl in the office with known celiac disease who had been well controlled on a gluten free diet for several years. She was found to be both vitamin B12 and folic acid deficient when evaluated for anemia and fatigue.

As a medical community we have become more aware and educated about celiac disease in recent years, and it is good to see that the marketplace is stepping up to meet the demand for gluten free products and make existence easier for this significant minority of Americans with gluten sensitivity.

What do you think? - Leave a comment!

Sequenom™ brings MaterniT21™ and a Whole New Set of Difficult Choices

October 22, 2011 Dr. Pullen

Coming to 20 major U.S. metropolitan areas this week will be a test called MaterniT21™ from Sequenom™. Over the past 25 years we’ve gone from alpha-fetoprotein testing, to adding 2, 3 and more recently 4 tests as “penta” screen to try to improve the estimation of a woman’s risk for having a trisomy-21, or Down’s syndrome pregnancy without actually obtaining fetal cells, but all they have really done is improve statistical prediction capability. Up to this point in order to tell if a woman is carrying a Down’s Syndrome baby required amniocentesis to obtain amniotic fluid at about 16-18 weeks gestation, or the arguably higher risk chorioamniotic villous sampling at 10-12 weeks gestation. Both of these tests ran low (estimated 1/350) but real risks of fetal injury and miscarriage. Now from a company named Sequenom™ comes a test on fetal cells obtained by a venous blood sample of the pregnant women’s blood as early as 10 weeks gestation that can do genetic screening for Down’s Syndrome without more invasive ways to obtain fetal cells. The initial study of 212 women showed a >99% accuracy rate. (1 false positive, 2 false negatives in 212 women tested).

This is both exciting and frightening. It raises huge questions including who if anyone should get this testing. Here is a list of some of the issues that come to my mind as we start the process of figuring out the role of this new technology:

Increased Abortions and Earlier Abortions of Down’s Syndrome Pregnancies: One consequence of a more accurate test for Down ’s syndrome if it leads to more widespread testing or women for this condition is that more women will face the decision of abortion or not. Now women first face the question, “Would I abort my pregnancy if I knew I had Down’s syndrome, and if so am I willing to undergo a test that could cause miscarriage to get that information.” With the Sequenom™ MaterniT21™ test women will be able to get much more definitive information without a test that puts their fetus at risk from the test itself. This may lead to more women choosing to be tested. Putting aside the whole “pro-life vs. pro-choice” debate, the opportunity for earlier diagnosis will make technically easier and less physically traumatic abortions possible in women who have a Down’s Syndrome pregnancy.
Who should be Eligible for the Test?: Although the risk of Down ’s syndrome rises with increasing maternal age many Down’s Syndrome babies have young Moms. With a more accurate and less dangerous test available should all or more women be offered the test?
Who should pay for the testing?: This is a very complicated question. This test is not going to be inexpensive. On the Sequenom™ press release they suggest that the cost will approximate the cost of amniocentesis testing. They do not make it clear if this means the cost of the amniocentesis test itself, the cost of the genetic testing of the cells obtained, or both. If the test is done it will lead to higher costs for prenatal care as the test itself will significantly increase the overall cost of prenatal care. On the other hand the cost of having a Down ’s syndrome baby is not inconsequential. Down ’s syndrome children sometimes have major other congenital deformities, and the long term cost of education, support as adults, and associated family and societal costs are real and significant. A comprehensive cost-benefit analysis of this process will be interesting to see when it becomes available. These issues themselves will lead to ethical and moral choices.
Lower Incidence of Down’s Syndrome: If this tests becomes widely used, and if more women choose to abort pregnancies with Down’s Syndrome fetuses, the incidence of Down’s Syndrome could significantly decline. While many may consider this the desired outcome, some Down’s Syndrome supporters fear that this may lead to reduced support and reduced research into drugs and other techniques to help Down’s children.

I’m sure I’ve only touched the surface of the ethical, emotional, medical, moral and financial issues this new MaterniT21™ test from Sequenom™ and likely others to follow will bring. It seems a near certainty that with the ability to sample fetal cells from maternal blood other genetic tests like tests for cystic fibrosis, sickle cell disease, and many others will follow.

Don’t miss a post, subscribe using the email subscription in the right sidebar.

Which Argument Shoots Down Your Excuse for Not Getting a Flu Shot.

September 16, 2011 Dr. Pullen

Got My Flu Shot Today

I really don’t like the term “flu” or “flu shot” because the term flu should not be used interchangeably with “viral illness.” Influenza is a specific, often very severe and even deadly viral illness and influenza vaccine is a very specific vaccine. Still the term flu shot is so integral to our everyday language that I’ll us the term, and encourage all of you to GET YOUR FLU SHOT. I hear excuses every day during the fall and early winter when I offer influenza vaccine to my patients. Here are some of the most common excuses (explanations?) I hear and my explanation (argument?) of the folly in that line of reasoning.

“I never get the flu. I don’t need a flu shot.” – Most people only get influenza once every several years. It is not unusual for any given individual to go 10-15 years without contacting influenza. Influenza is a severe illness much of the time and it is worth getting a flu shot every year to prevent one case of influenza every 10-20 years.
“The last time I got a flu shot I got the flu.” – This is just not true. An influenza vaccine simply does not cause influenza. Since the influenza vaccine contains a killed virus, it is not possible for it to cause influenza.During the season when we give flu shots minor illnesses are common. It is not unusual to become ill during the time shortly after getting a flu shot. Also a small percentage of people who get a flu shot may have some minor aching, low grade fever or malaise. This is not even close to as severe a problem as a real case of influenza, and is no reason not to get a flu shot.
“I just don’t like shots,” or “I hate needles,” or “Shots hurt.” – Nobody likes getting shots, or being stuck with a needle. The benefits of influenza vaccine, both for yourself and for those you care about are important enough to suffer through an injection. Just get it over with.
“I heard the flu shot this year is just the same as last year so I don’t need another shot.” – I heard this today from a medical student at the office. They should know better, and I tried to set them straight. It is true, that in 2011 the components of the influenza vaccine are the same as they were in 2010. I suspect that this student was just trying to find an excuse not to get a shot. It is good news that the vaccine has not changed this year. First it means that no new and very different influenza virus lurking and ready to cause a severe influenza pandemic was discovered. Getting a second vaccine will be the equivalent of a booster shot, making you even more immune to these strains of influenza, whereas the remaining immunization from last year’s flu vaccine are not adequate to provide immunity sufficient to prevent contacting influenza this year.
“I’m healthy and if I get the flu I won’t get all that sick.” — I’m happy that you are a healthy person who takes good care of yourself. Now get a flu shot and stay healthy, because influenza can be very severe or even lethal for even the strongest and healthiest of us. In addition if you catch influenza you will be putting others at risk. You’ll be sick enough that someone will need to take care of you, and they will be at risk needlessly because you chose not to be immunized. This is especially true if you are around the elderly, the very young, pregnant women, or persons with chronic disease. Respect yourself and those around you and get a flu shot.
“I want to leave my immune system alone so I will develop good immunity naturally. If I get a flu shot I weaken my immune system.” – - This is just faulty reasoning. There is no evidence to suggest that getting an influenza vaccination reduces your immunity against other germs. It simply provides antibodies against certain strains of influenza A and B. This immunity likely is increased by annual flu shots, so that by getting a flu shot annually you develop better influenza immunity each year.

Last year I posted on The Social and Moral Responsibility of Immunizations for health care workers, teachers and others in positions where others at high risk may be exposed to them if they contact influenza. I wrote earlier this year on the Flu Season. This health blog also links to an AFP article on The 12 Basic Rules of Influenza and I wrote on how to Avoid Getting Sick. I hopt that all of these are informative, but if I could accomplish one thing with this blogging effort, I’d convince every one of my patients and readers (except the uncommon patients with severe egg allergy or other valid reason to need to rely on the herd immunity that could occur if the rest of us got immunized) to get an influenza vaccination every year. If I could do that I’d feel that I’d have made a real difference in the tiny part of the world that I touch.

8 Comments - Leave a comment!

Rohypnol: What You Should Know About the Date Rape Drug

August 8, 2011 Dr. Pullen

Rohypnol, or roofies, is the name for what is more commonly called the date rape drug. Rohypnol has become notorious because of its potent amnestic and hypnotic effects which can lead a person given a dose of Rohypnol to have short term amnesia. This has led to its popularity as a “Club Drug” along with Ketamine, MDMA (Ecstasy) and GHB. Rohypnol has not been approved for use by the U.S. FDA and is considered an illegal drug in the U.S. Rohypnol is in the benzodiazepine class of medications along with more well known and commonly used drugs like diazepam: read diazepam side effects (Valium), alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonapin) and many others.

Rohypnol (chemical name flunitrazepam) is the most potent of the benzodiazepines on a mg-for-mg basis and is very fast acting, making it potentially useful in severe refractory insomnia, mostly in patients in the hospital. For the same reasons it is notorious for its abuse as a date rape drug. Rape by someone well known to the victim, often date rape, is unfortunately very common. Rohypnol has been found to be involved in a very small percentage of date rape, probably less than 1% of cases, but it undeniably is abused for that purpose. The much more common drug involved in date rape is simply ethanol, the alcohol in all alcoholic beverages which can also lead to blackouts, amnesia and vulnerability to sexual abuse.

This said, how should a woman avoid becoming a victim of date rape associated with Rohypnol? Probably the key is to avoid situations where heavy drinking and drug use is expected. In addition trying not to leave a drink unattended and then picking it back up to drink may be considered. Still if going to a dance club and drinking while there, if you dance you are likely to want to put your drink down. This issue makes nearly eveyone at a dance club who drinks alcohol at some risk for having their drink spiked with Rohypnol. This means other than completely avoiding dance clubs and drinking we need to depend on our friends to watch out for each other. That said the real issue is with the societal issues that lead to use of drugs like this in the first place.

That issue is with the perpetrator of the crime giving the drug to the victim. As a society we need to watch out for each other. We need to teach our sons and daughters that if they even suspect this type of behavior may be happening or going to happen that they take action to avoid being involved and if possible to stop the perpetrator of the crime. It is far too easy to explain away the odd behavior of a friend as just having had too much to drink, or to not want to interfere or embarrass their friend or themselves by taking action to intervene. We need to have the courage to step up and take actions to intervene when suspicious behavior is noted. Given that alcohol is probably the most frequent drug involved in date rape and other mishaps of intoxication thinking that behavior may be “just alcohol” is flawed thinking.

One helpful thing may be to recognize the effects of Rohypnol on someone around you. If a friend starts to look odd, dazed or confused we should take measures to protect them. Typical symptoms of ingestion of Rohypnol include confusion, uncoordination and sedation. These effects can come on quite quickly, and may look much like alcohol intoxication. Alcohol does in fact clearly increase the sedative and central nervous system depressant effects of all benzodiazepines. All told the best way to reduce the chances of being given Rohypnol is to avoid situations where heavy drinking and drug use is prevalent.

Rohypnol is also used recreationally, especially in conjunction with stimulants and heroin. Stimulants like cocaine and methamphetamine lead to severe insomnia and Rohypnol is sometimes used to “soften” the so-called crash from these stimulants. It is also used to achieve profound intoxication, and when combined with alcohol this can lead to fatal overdoses. Rohypnol has many street names including roofies, forget-me-pill, Mexican Valium, and many others.

Rohypnol has also been documented in Europe as an adjunct to robbery, with victims given Rohypnol and then robbed. This is a type of abuse of Rohyphol that also takes advantage of the potent amnesia that those who are under the influence of Rohypnol experience. In Europe where Rohypnol is available as a prescription drug the potential for misuse is certainly higher than in the U.S.

Rohypnol has no legitimate role in U.S. medicine, and is a drug of abuse. Rohypnol in the U.S. is imported from abroad where its use is apparently even more widespread. I pray that you as a parent or as a young person never have any first hand experiences with this drug, and that the word Rohypnol is something you only read about in places like this.

What do you think? - Leave a comment!

Molluscum Contagiosum: Common in Children and as an STD

June 3, 2011 Dr. Pullen

Despite the name which sounds like a terrible disease molluscum contagiosum is arguably the least serious and concerning of all warts and all STDs. Warts, STD’s, children, not serious? Has Dr. Pullen gone nuts? Hear me out. It all makes sense really if you read on.

Molluscum contagiosum is a viral skin infection that causes small, usually 2-5 mm size raised skin colored to pinkish bumps on the skin that usually have a small dimple in the center, so we call them umbilicated in appearance (like an umbilicus in the middle). They are almost always painless, and unless you scratch or dig at them they resolve without scarring usually. So what’s with the descriptive terms above:

Least Serious Warts: These are often called water warts, but are really not closely related to most other human warts. They are not in the human papilloma virus family with genital warts, plantar warts, flat warts, etc. but rather are caused by a member of the pox virus family. Molluscum lesions painless and almost always resolve on their own faster than most other types of viral warts. The typical total course of molluscum contagiosum in any one individual usually ranges from 6-18 months, although it can be longer in a small minority of people. Any one molluscum contagiosum lesion itself tends to go away sooner, often in 2-3 months. These lesions, unlike genital warts which are clearly associated with cervical, penile and tonsil cancer, are not felt to be associated with any serious or long term consequences.

Molluscum Contagiosum as an STD: Although in practice we mostly see molluscum contagiosum in children, they are also a sexually transmitted disease in older adolescents and adults. Molluscum contagiosum gets its name because it is fairly contagious. You tend to get the infection by skin-to-skin contact with another person with an infection, or contact with a fomite carrying the virus. A fomite is an inanimate object like a towel, clothing, toys, or any other object that has the virus attached to it. In sexually active persons the skin to skin contact tends to be on the genitalia, the torso and the proximal extremities. In children they are seen virtually anywhere except the palms and soles, although in my experience they are not common on the face.

Diagonsis: The diagnosis of molluscum contagiosum is usually easy for an experienced practitioner. The appearance is so typical we can often at a glance know with a high degree of certainty the diagnosis. If in doubt we can simply squeeze one of the lesions after using a small needle or scalpel blade to nick the roof of the lesion and express a cheesy whitish material that is very unique and confirms the diagnosis. In really odd appearing lesions a punch biopsy can be done to send for pathologic exam, but this is almost never necessary.

Treatment: In children I try to convince the parent to just wait out the course of the molluscum. Any treatments involve some sort of discomfort to the child, and unfortunately often even a thorough search for lesions and careful destruction of all the apparent lesions is fruitless as new lesions usually pop up shortly after the treatment requiring returning for another round or treatment. If I can convince Mom or Dad to just leave these alone, knowing they may get worse before they get better, they are happy to see them resolve after a few months or a year or two. In older children, adolescents or adults who really want to get rid of these they can be treated by many types of destructive therapy. Liquid nitrogen cryotherapy is effective. Simply unroofing each lesion and expressing the core works well. For this I use a larger needle, about 20 gauge, to nick the top, and gloved thumbs to pinch out the core between my thumbnails. Blistering agents can also be used.

Molluscum contagiosum in an adolescent or adult is a clue to discuss STDs, consider screening for other STDs, and if a severe case a reason to question immunity. In HIV patients or others with a suppressed immune system molluscum contagiosum can develop rapidly spreading and severe cases.

Overall molluscum contagiosum is usually an easy diagnosis where in children the biggest task is to assure the parents have realistic expectations and ideally the patience to just wait out the course. Unless there is undue anxiety or parental concern, this is a reassuring diagnosis to many parents if presented calmly and with confident reassurance. At least it’s usually easy to be confident of the diagnosis.

10 Comments - Leave a comment!

Enterobius Vermicularis and the Scotch Tape Test

April 20, 2011 Dr. Pullen

The scotch tape test for Enterobius vermicularis, the common pinworm, is one of the really simple, inexpensive and just plain cool tests used in primary care. In addition the life cycle of the pinworm is well understood and is quite unique (not to mention disgusting) in that it depends completely on humans eating feces repeatedly.

To understand why the scotch tape test work works we need to first review the interesting life cycle of the pinworm. Enterobius vermicularis is known as the pinworm because it is about the size of a common pin. It lives in the human small intestine and proximal colon. After living a few weeks the female worm migrates down the colon, exits the anus and lays its eggs on the skin of the perianal area at night. The female dies after laying her eggs. The worm and the eggs seem to lead to itching, which initiates scratching which helps facilitate the eggs getting on the fingers and then reingested. The infection is most common in children who have less concern about putting their hands in their mouth after scratching or touching their anal area, and self-inoculate themselves. The ingested eggs then hatch in the duodenum, the males and females mate, the male dies and the female moves to the distal small bowel after molting twice as she passes through the bowel, and the process is repeated.

This sounds disgusting but the fecal-oral route of spread is a common way that infections are spread. The unique thing about the pinworm is that it’s probably the only common human infestation that depends on people perpetuating and sustaining the infestation by repeatedly ingesting more eggs over and over. If no eggs were reingested the infestation would die out as the worms die after laying their eggs.

All this sounds terrible, but there are a few good things about pinworms. The first is that the infection is almost harmless. Infection tends to either be asymptomatic, or just cause perianal itching. In girls it can sometimes cause a vaginal itch if the organisms inadvertently crawl into the vagina instead of the rectum after coming out to lay their eggs.

The second good thing is that pinworms are easily diagnosed. When I see a child I suspect of having pinworms I have their parent wake them about 2-3 AM and look at their anus with a flashlight. Often the worms can be seen on the outside. Sometimes they are also seen in the diaper or the toilet after a bowel movement. If not seen the scotch tape test is done by taking a piece of scotch tape, applying the sticky side to the child’s anus on awakening in the morning, and sticking the piece of tape to a microscope slide. I just give a few microscope slides to the parent to collect the specimens at home on two or three mornings, and have them bring the slides in for me to examine. The pinworm eggs are easy to see under the microscope, and a diagnosis is made if eggs are noted.

The third good thing about pinworms is that treatment is very easy and effective. A single dose of mebendazole, a 100 mg chewable tablet, is effective in most cases. We do routinely treat the whole family at once to eradicate the organism from any unsuspecting family members and increase the chance of long term cure.

Unfortunately reinfection is common, especially in children in daycare or when they originally contacted the organism from another child who remains undiagnosed. If your child contacts pinworms, don’t be overly concerned. It’s common, easily treated and not at all serious.

What do you think? - Leave a comment!

How Contagious is Mono

December 20, 2010 Dr. Pullen

How contagious is mono you ask? The short answer is only moderately contagious. Unlike many common illnesses infectious mononucleosis (mono) is spread by ingesting the causative Epstein Barr Virus (EBV) shed in another person’s saliva, hence the “kissing disease” nickname. Other than kissing you can spread mono by sharing eating or drinking utensils or by touching something contaminated by mono and then putting your hand in your mouth. Also limiting spread is the fact that many infants and young children contact mono as an asymptomatic minor illness and so already have immunity. This lends a degree of “herd immunity” to the population and holds down rapid spread of the disease.

The Epstein-Barr Virus is a member of the Herpes family of viruses. The typical presentation of mono is in a teenager who develops a severe sore throat and fever. Keep in mind that the usual office blood test for mono, the “mono spot” test, is often negative until up to 10 days of symptoms. The presentation can be clinically indistinguishable from strep throat initially, and up to 50% of patients with mono have positive throat cultures or rapid strep tests. Pair this with the 20-30% false negative rates of the office rapid strep tests, and the initial diagnosis is often not made until a second or third office visit when it becomes apparent that the child is not responding to treatment for strep throat and the mono test becomes positive. If treated with amoxicillin a patient with mono will often develop a reddish macular rash all over, and this can be mistaken as a penicillin allergy; see amoxicillin side effects for a nice resource. Still the classic thick white exudate on the tonsils of a child or teen with mono can be very suspicious to an experienced examiner, and if paired with really big 3-5 cm anterior or posterior cervical lymph nodes or an enlarged spleen we can often suspect the diagnosis on the initial visit even if it’s too early to confirm the diagnosis with lab tests.

Because of the wide variety of symptoms that mono can cause, and the wide variety of severity of illness, it is the disease that comes to my mind first when I hear the old med school adage, “Uncommon manifestations of common problems are much more common than common manifestations of uncommon problems.” Despite its peak incidence in children and young adults, mono is seen at all ages. Presentation in young children is often quite subtle, and not diagnosed. In older adults it often presents with sore throat, enlarged tonsils with a thick white exudate, and swollen cervical nodes like in teens, but can also present with florid hepatitis, simple fatigue, or abdominal pain from hepatosplenomegaly. Rare presentations include aseptic meningitis and leukocytosis found on a routine CBC.

One of the frustrating aspects of mono is the long duration of fatigue some patients get. This can be very debilitating, and mono is one of the few diagnoses where rest is especially important. Listening to your body and not trying to push yourself to your limit and allow the symptoms to resolve more quickly than if you try to push yourself to exhaustion every day. Half days of school, with naps and focus on the key subjects can allow students to stay on course throughout the course of the illness. Antiviral medications are not helpful in mono. In severe acute presentations a short course of prednisone can quickly shrink the tonsils and allow the patient to eat and drink enough to stay hydrated and nourished. Fever can persist for several weeks in some cases. (See prednisone side effects)

The relationship between EBV and chronic fatigue syndrome is not clear, and although I believe chronic fatigue syndrome is a real condition, I don’t believe it has been shown to be related to EBV. Some recent research suggests a virus called XMRV as a cause of chronic fatigue syndrome, although this is very controversial. Most patients with EBV can get back to school or work within a few weeks. Management of athletes in contact sports has been better defined in recent years. Most sports medicine experts allow participation in contact sports after the fatigue has resolved if absence of hepatosplenomegaly can be documented with ultrasound. In past years we insisted on at least 8 weeks time after diagnosis prior to contact sports. The newer approach seems more appropriate, and allows both individualization of advice, and gives confidence to the physician who does need to keep a young athlete out of competition.

For a graphic look at a goofy teen with mono and a flashlight see this video. Note the very white exudate on the very large tonsils. Thanks kid.

2 Comments - Leave a comment!

5 Mistakes Your Children Should Make

December 18, 2010 Dr. Pullen

In this age of helicopter parenting and parenting as a competitive endeavor, it’s important to remember that there is no better way to learn than from our own mistakes. If we don’t allow our children the opportunity to fail, the chance to make mistakes for which the consequences are modest, then we cheat them out of important learning opportunities.

Here are 5 of the best mistakes you owe your child the opportunity to endure:

Forgetting their lunch. Seems really simple, but no child ever died of starvation from missing lunch at school a couple of times. All of our lives we will need to be responsible for remembering tasks. Forgetting to bring lunch to school is a nice simple mistake with predictable and acceptable consequences that every child can afford to make. This counts not just for lunch. It can include homework, sporting equipment to a practice session etc. You can fill in the blank here.
Spending their money and not having enough left for something they want. Children at a young, and not-so-young age can benefit from learning to budget for the things they want. If we simply allow ourselves to be the piggy-bank for every desire we don’t give our child the chance to learn to make financial decisions as they mature.
Learn to calm themself: As an adult having the ability to calm ourselves when things are not going our way is an important skill. As parents of infants, toddlers and youth it is tempting to quickly step in and help comfort our child when they are upset. Sometimes this is mandatory and appropriate. Other times giving the child the chance to help themself by thoughtful ignoring or casual observation for a bit first, and allowing them to develop self-quieting skills can be an early step in helping them to acquire this key life skill. Nonverbal touch is a good parenting skill to learn to help with this in your young child.
Fail at Business: Lots of kids want to start a business of some sort. It may be selling lemonade, mowing lawns, delivering newspapers or collecting sports cards. Unless the endeavor is one that your family values just cannot allow strongly consider allowing your child to try and succeed or fail on the merits of the business. If they want to sell lemonade help them buy the ingredients, a good lesson in credit here if you loan them the money to buy the materials, and in business planning If they price he lemonade too low, they will lose money, too high may lead to no customers. Many great entrepreneurs have failed at early business ventures. Why not get the first one or two under their belt before Jr. High?
Pay the consequences: If you child makes a mistake, it’s important to be very selective in the times you choose to protect them from the consequence s of a mistake. If they learn that there are natural consequences of behaviors, and that Mom or Dad is not going to bail them out from every situation they find themselves in as a result of poor choices, they learn to make good choices. If they learn that they are immune to natural consequences because a parent rescues them consistently then they are likely to make choices as an older child or adult where we cannot escalate our interventions to the level needed to avoid more serious consequences. If you refuse to wear mittens when you go out to play your hands get cold. If you spend your money on candy you don’t have money to buy the comic book you want. Later in life if you don’t use condoms you get an STD or pregnancy. Learn from the little mistakes so you choose not to make the big ones.

What do you think? - Leave a comment!

Social and Moral Responsibility and Immunizations

September 27, 2010 Dr. Pullen

This topic comes to mind now that we finally have our influenza vaccination at our office. Don’t get me going about how the giant pharmaceutical companies choose to provide their influenza product to giant customers, i.e. retail pharmacies before they supply physician offices. Every year I try to be first in line at our office for my influenza vaccination. I take seriously the mantra that as health care providers we have a responsibility to first do no harm. It’s hard to imagine doing more harm than seeing a patient with influenza on Monday, and on Wednesday, the day before I get sick, sneezing and passing the influenza germ to one of my vulnerable older patients, or a pregnant woman, or a young baby who then dies from influenza. This scenario is just inexcusable given that I could have avoided harming the patient if I had received the recommended and easily available influenza vaccination. It would be immoral and irresponsible to put my patients at that type of risk unnecessarily. I encourage, coax, tease, and everything short of intimidate my employees and fellow physicians to get their influenza vaccination also. School teachers, emergency workers, and others in close contact with the public should similarly feel morally compelled to get influenza vaccination.

I also got a Tdap vaccination this year also, even though it’s several years until I was due a tetanus shot. See Dr. Pullen Gets His Tetanus Booster Shot Years Early! My thinking was the same, try to avoid a pertussis infection, and not put my patients at risk.

It’s a small step from discussing health care workers and influenza and pertussis vaccination, to talking about parents and childhood vaccinations. The parent who chooses not to vaccinate their children against measles and pertussis puts not only their own child, but other children in the community and the school who may be at particular risk for complications from these infections in danger. These children at high risk may catch these infections from these unimmunizd children. As a parent I’d feel terrible if my child died or became brain injured from measles, but I’d also feel horrible if my child passed Pertussis or measles on to a child with leukemia, or HIV because I chose to not immunize my child. I appreciate that this is a free society, and we can make our own personal choices about health care including immunizations. It’s not illegal to decline recommended immunizations, but in many cases it is irresponsible and immoral. Parents who choose not to immunize their children and take advantage of the herd immunity of the majority of children whose parents responsibly immunize their kids are just ignorantly selfish. They think they are protecting their children from risks of immunizations, though a great mass of evidence refutes this point of view. In fact they are putting both their own child, and other children who lack immunity through no choice of their own or their parents at risk.

I’m anticipating a rash of angry comments calling me a mouthpiece of the brainwashed physicians of organized medicine. Don’t believe them.

See these references on the safety of childhood immuinzations.

Prenatal and Infant Exposure to Thimerosal From Vaccines and Immunoglobulins and Risk of Autism i.e. NOT.

Data Fail to Support Thimerosal-Autism Link

The end of the autism/vaccine debate?

Book Is Rallying Resistance to the Antivaccine Crusade

2 Comments - Leave a comment!