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David Katzman, MD & Jennifer DeLaney, MD
Internal Medicine Specialists

Dear Friend, 
The busy holiday season is behind us and we are off to a brand new year! February is heart health month so let's try to build a healthy relationship with our heart and make it one of our top New Year's resolutions. There are many ways to start leading a healthier life. For starters, make that appointment with your doctor for your annual physical and check-off some items on your worry list! Know your numbers such as your blood pressure, cholesterol, blood sugar and your weight. Knowing these numbers can help you see areas that need improvement and help you strive for goals to a healthier lifestyle. Hippocrates once said "walking is man's best medicine". This one simple exercise could be a great way to start improving your heart health! Experts say that walking for just 21 minutes a day can cut your risk of heart disease by 30%. No excuses...the groundhog has spoken and Spring is on it's way! 

Zika Virus:  Should You Be Concerned?
David Katzman, MD
The Zika Virus, an emerging infection in South and Central America, has been making front page news. This is a mosquito-transmitted virus that has been associated with a devastating birth defect called microcephaly, where an infant exposed to the virus during pregnancy is born with a small head and developmental problems. The Zika virus has been present for some time in Africa, India and the Pacific Islands, but didn’t spread to the Western Hemisphere until travelers brought the infection during the 2014 World Cup to Brazil. The World Health Organization (WHO) estimates that as many as 4 million people in South and Central America may become infected by the end of the year.
The virus can be spread by blood and other body fluid exposure, including semen. The typical way it is transmitted is through the bite of an infected mosquito. Mothers who are infected can spread it to their unborn child. The virus can also be transmitted sexually through infected body fluids. The virus has already been detected in the United States in returning travelers, but has not been widespread given our better sanitation and mosquito control. The virus can also be detected in urine and saliva, but it is unclear if these fluids can spread the infection.
Most people who become infected have no symptoms and no long term problems from infection. Only 1 in 5 will develop symptoms such as fever, pink eye, body aches and a rash. Symptoms typically begin several days after the mosquito bite and can last a few days. More serious complications are rare. There has been an association between this virus and the development of a temporary paralysis, called guillain barre. This syndrome has not been proven to be caused by Zika and is under investigation.
The biggest concern of health authorities stems from the association of Zika with microcephaly, developmental problems and fetal loss. There have been over 4,000 births in Brazil with microcephaly, a 20-fold increase from the previous year. In January, the CDC has advised pregnant women to consider postponing travel to areas where Zika transmission occurs due to the potential risks to their unborn child. It is also advisable for all premenapausal women to abstain from sex or use a condom with a partner who has been in an endemic area for several months after they return. In addition, the CDC now asks people who have travelled to areas where the virus is common to refrain from donating blood for a month after they return.
As with all mosquito-borne illness, preventing bites is the key. Wearing long sleeves and pants (especially coated with Permethrin), using insect repellant that contains DEET, and staying indoors in screened or air conditioned buildings are ways to avoid contracting the virus if you travel to the Caribbean, South America or Central America. The infection is not yet spreading in the US. The mosquitos that have the ability to carry this virus are found in 11 Southern states. It is unclear if the Tiger mosquito, which is the mosquito in Missouri, can transmit this virus.
Jennifer DeLaney, MD
Tossing and turning all night in bed can be a misery, as can the fatigue from a previous night’s poor sleep. I think we all agree that getting a good night’s sleep is important to wellbeing.  Few people sleep as well as they would like. It is unrealistic to expect 8 hours of uninterrupted sleep. Most people awaken multiple times and have 2-3 blocks of deeper sleep in between. Most people underestimate the amount of sleep they are getting.
Improving sleep begins with changing your daytime habits.  “Sleep Hygiene”--having a regular bedtime and wake up time, avoiding caffeine after noon, avoiding naps, keeping your worries away from bedtime, avoiding alcohol, cigarettes, and blue light exposure from computer and phone screens--can help.
Treating medical conditions that disrupt sleep can also improve your sleep. If heartburn, frequent urination, pain, sleep apnea, menopausal symptoms, restless legs or anxiety and depression are interrupting your sleep, treating them may lead to you feeling more rested.
So what should you do if you are doing all the right things and are still not falling asleep? Cognitive behavioral therapy has been shown to be as effective as sleeping pills for getting an adequate night’s sleep. 8 out of 10 people will find that these techniques are sufficient to get adequate rest. This discipline emphasizes stress reduction, relaxation techniques and limiting time in bed to 20 minutes if you cannot drift off. A psychologist who specializes in sleep medicine can help you learn the techniques needed to help make your sleep more restorative. Another useful method to consolidate sleep and fall asleep more easily is sleep restriction. In sleep restriction, you limit the number of hours in bed to 5-6 a night, until you are sleeping 85% of the time. Then sleep time is gradually increased. This restriction leads to uninterrupted sleep, which is more restorative.
People often desire medicine to help them sleep. Medications for insomnia have not been approved for long term use (>6 weeks.) After 6 weeks, most people become tolerant to the sedatives and dependent on them to sleep. The use of sedatives such as Ambien, Lunesta, or Temazepam is associated with a doubling in your risk of death, a 2-5 fold increase in cognitive problems, and a significant increase in the risk of car accidents, falls and fractures. 25% of women who take these medications are impaired on driving tests the next morning. The ideal situation is to use sedatives as only a short term bridge until sleep hygiene, sleep restriction and cognitive behavioral techniques allow you to achieve restful sleep without them.
Follow these tips for insomnia from Wolters Kluwer UpToDate
Sleep Hygiene: Basic rules for a good night's sleep
*Sleep only as much as you need to feel rested and then get out of bed
*Keep a regular sleep schedule
*Avoid forcing sleep
*Exercise regularly for at least 20 minutes, preferably 4-5 hours before bedtime
*Avoid caffeinated beverages after lunch
*Avoid alcohol near bedtime: no "night cap"
*Avoid smoking, especially in the evening
*Do not go to bed hungry
*Adjust bedroom environment
*Avoid prolonged use of light-emitting screens before bedtime
*Deal with your worries before bedtime
Stimulus control therapy rules
*Go to bed only when sleepy
*Do not watch television, read, eat, or worry while in bed. Use bed only for sleep and sex
*Get out of bed if unable to fall asleep within 20 minutes and go to another room. Return to bed only when sleepy. Repeat this step as many times as necessary throughout the night
*Set an alarm clock to wake up at a fixed time each morning, including weekends
*Do not take a nap during the day
Sleep restriction rules
*Determine the patient's average sleep time from a sleep diary
*Use this average sleep time as the new time allowed in bed each night
*Set a consistent wake time based upon the type of insomnia and patient need
*Have patient avoid daytime naps
*If sleep efficiency increases above 90 percent (85 percent for patients over 65 years of age), then increase time in bed by 15 to 30 minutes
*If sleep efficiency decreases below 85 percent (80 percent for patients over 65 years of age), then decrease time in bed by 15 to 30 minutes. 

Those Pesky Nocturnal Leg Cramps
David Katzman, MD
Most adults have been awoken by painful nighttime leg cramps, or charley horses. 50% of the population over 50 have had muscle cramps, and their frequency increases with age. Cramps consist of a sudden, painful sensation with muscle tightening. They most often affect the foot or leg. They can often be relieved by forceful stretching of the cramped muscles. Although the pain can be quite severe, it is not a sign of a progressive illness. The cramps can be debilitating due to the pain they cause and the associated sleep disruption from them.
The vast majority of leg cramps have no known cause. They are more common in those taking diuretics, in the summer, and when people are dehydrated due to inadequate fluid intake. Some feel that structural disorders of the feet, prolonged sitting or standing on hard surfaces may predispose to cramps. Sometimes they can be seen in association with a pinched nerve, neuropathy, or circulation disorders.
Stretching can not only relieve a cramp after it has occurred, it can also prevent cramps from happening in the first place. Stretching your calves and hamstrings or riding a stationary bicycle for a few minutes prior to retiring can help keep cramps at bay. Preventing toe pointing by keeping the bed covers loose at the foot of the bed can also help. Avoiding dehydration, and stopping diuretics when medically feasible can lead to impressive benefits. I was once told by a patient to place a bar of soap at your feet when you sleep, and anecdotally some people note this to be effective.
If conservative measures fail, and the cramps are problematic given their frequency, I will sometimes try medications. Quinine had been used for many years quite effectively but was removed from the market due to potential serious side effects including cardiac arrhythmias and major blood problems. 6 ounces of Schweppe’s tonic water prior to bedtime will provide a small, safe and possibly effective amount of quinine. B-Complex vitamins taken three times daily may be effective. Taking an electrolyte supplement prior to sleep has also been effective. One that I like is called Salt Stick and can be purchased online or at REI.
However, please check with Dr. DeLaney or me prior to starting this.
Office News
*Drug Recall
Voluntary recall on two lots of Ventolin HFA (Albuterol Sulfate). this includes lot number 5ZP1708, which expires 12/2016, and lot number 5ZP1951 which expires 02/2017. The products have been found to have a defective delivery system, as some canisters may not contain enough propellant to deliver the correct dosage. Please return the medication to your pharmacy and you will be issued a new canister. 
*Welcome the Newest Member of Our Team: 
Please welcome Tracy Smith, RN, BSN who will be working part time in the office with Dr. Katzman and Dr. DeLaney. Tracy has 23 years experience in the nursing field and has worked in home health, kidney transplant, and roles in management and teaching. 
*Patient Portal Coming Soon:
The office will be mailing the Patient Portal enrollment information to your home over the next few months. This will take place of unprotected personal email and will give you access to your personal medical history and allow you to make medication renewal requests. This enrollment is voluntary, but encouraged to protect your private information and to comply with HIPPA laws. 
*Please E-mail Instead of Texting For Medical Q
Dr. Katzman and Dr. DeLaney would prefer to be emailed instead of using text messages over the phone for relaying any medical questions. This is for your privacy and personal information protection. 
*Reminder on Insurance Card Updates
The office will be asking to see your insurance cards at your next visit. PLEASE call us if you have a new insurance card so we can update your information! We apologize for the inconvenience, but it is necessary to have the correct and updated information so we can get approval for your medications and diagnostic testing in a timely matter. 
*Be Careful in Choosing Your Individually Purchased Insurance
If you are in an HMO or have purchased an HMO based Medicare plan such as Medicare Complete through a private insurance carrier we may not be able to order any diagnostic testing or refer you to a specialist. Only the primary care physician assigned by your HMO can manage those services needed. This can be very frustrating and time consuming for all parties involved. Please check with your insurance carrier if you have any concerns. 
*Billing Questions
Please Contact Tonya for any questions concerning your account. She will be available to return your calls on Wednesdays and can also be reached via e-mail
*Office Website
Please visit our website if you missed last month's newsletter! The newsletter archives can be found by hovering your mouse over the Medical Links tab. You will also find here links to several reputable websites with the latest medical news and health information. 

Healthy Tidbit
Cocoa Raspberry Muffins 
1/2 cup all-purpose flour
1/3 cup cocoa powder, unsweetened                   1/3 cup applesauce
1/3 cup sugar                                                       1/4 cup raspberry jam
1/2 tsp baking soda                                              3 egg whites
1/2 tsp baking powder                                         1 tsp vanilla flavoring

Blend the first 5 ingredients in a mixing bowl; In a separate bowl blend the remaining ingredients. Combine ingredients from both bowls and mix well. Spoon into 8 lined muffin cups and bake at 350 degrees for 18-20 minutes (or until muffins spring back when tapped).

Makes 8 muffins: 104 calories each. 3 grams protein, 7 grams fat, 23 grams carbs, 2 grams fiber, 128 mg sodium
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