Sam was studying for his bar exam when he woke up with a red scaly patch over his abdomen. He thought at first it was just a rash, but when the scaliness and itching got worse and started to spread, he saw a dermatologist.

The diagnosis was psoriasis and, at the time, he thought of it as just another embarrassing skin problem, like the acne he had suffered when he was in high school. As stressful as that was to handle, he now knows that psoriasis is an even more serious and persistent disease that can affect virtually all areas of health.

The skin part is bad enough. Red patches covered with silvery scales that itch or burn can occur anywhere on the body, even the genitals or the inside of the mouth. In some cases, the skin can crack and bleed. On the scalp or even on the forearms, the patches may appear to be a bad case of dandruff. They are, in fact, much more persistent and difficult to treat.

Dealing with any skin problem can become extremely stressful. But with psoriasis the stress works both ways. Sam’s doctor believed that his psoriasis might have developed as a result of emotional stress he was experiencing while studying for the bar.

A Systemic Disease

Psoriasis is a disease of the immune system that can cause an inflammatory response anywhere in the body. There is no cure, and it’s a lifelong disorder, although ordinarily with periods of flare and remission.

When the immune system starts to re-produce excess quantities of TNF-alpha and interleukin-12 and 23, skin cells start to produce rapidly, resulting in the raised, red areas of plaque. These flare-ups are often associated with emotional stress, injury to the skin, infections or even reactions to certain drugs.

Sometimes, the reaction is confined to the skin, but it can also cause inflammatory changes elsewhere in the body.

Nail psoriasis affects fingernails and toenails, causing ridges, pitting, discoloration and separation of the nail from the nail bed. Dead skin may build up under the nail.

About 15 percent of psoriasis patients develop psoriatic arthritis. This may occur 12 to 20 years after the skin symptoms; or, in a few cases, several years before any sign of a skin disorder. In the latter case, diagnosis is difficult and is usually best made by a rheumatologist.

Like the skin manifestations, the inflammation in the joints varies widely in severity and has flare/remission cycles that may or may not coincide with the flares of the skin disorder.

The disease is chronic, however, and gets worse over time. It’s important to get diagnosis and treatment early in order to avoid permanent damage to joints and significant disability.

One common sign is painful sausage-like swelling of the fingers. The arthritis may also affect one or both knees or elbows or the joints in the back, hip or neck. Sometimes pain and stiffness occur at the place where tendons and ligaments attach to bones–such as at the back of the heel or the sole of the foot.

Since 40 percent of patients with psoriatic arthritis have a family member with psoriasis, heredity is believed to play a role, as it does with other manifestations of psoriasis.

Moderate to severe psoriasis is also associated with a number of cardiometabolic conditions, including diabetes, obesity, hypertension and high cholesterol. Psoriasis patients frequently have high levels of c-reactive protein (CRP) , a marker of inflammation that has been linked to heart disease. Compared to similar individuals the same age, a patient with moderate to severe psoriasis has a significantly higher risk of suffering a heart attack.

Knowledge about the systemic risks of psoriasis has grown rapidly over the past decade or so; yet the National Psoriasis Foundation estimates that 39 percent of Americans with severe disease are not in treatment while many more are undertreated.

For mild psoriasis confined to the skin, topical treatments, similar to those used for other skin disorders, are usually sufficient. Probably the most effective treatment uses ultraviolet light–either 5 to 10 unprotected minutes in the mid-day sun three times a week or ultraviolet light therapy indoors.

For psoriatic arthritis, NSAIDs such as ibuprofen or naproxen are usually the initial prescription to control pain and inflammation, although these have risks and can make psoriasitic flares on the skin worse.

In most cases, disease-modifying antirheumatic drugs (DMARDs) such as methotrexate are eventually needed to limit joint damage. Immunosuppressant medications such as azathioprine, cyclosporine and leflunomide work by suppressing the immune system. Both of these treatments have side effects, sometimes serious. And immunosuppressants leave the body vulnerable to other attacks such as infections.

The newest drugs are known as biologics. They work by blocking the action of specific substances that are involved in the inflammatory response. These include proteins such as tumor necrosis factor-alpha (TNF-alpha) and interleukins 12 and 23. Because they target selectively, there is less risk of shutting down beneficial parts of the immune system.

Enbrel, Humira, Remicade and Simponi are recently introduced drugs that block TNF-alpha. Stelara selectively targets interleukin-12 and interleukin-13. The first biologic was introduced as recently as 2003, and these medications are still being studied for long-term safety. All are taken by injection or intravenous infusion.

Biologics are typically prescribed for patients with moderate to severe psoriasis or psoriatic arthritis who have not responded to other treatments or have suffered serious side effects.

When started early enough, these drugs offer the potential to prevent permanent damage to joints and head off the serious complications involving metabolism and the cardiovascular system. Unfortunately, for one reason or another, only about one percent of psoriasis patients are now taking a biologic medication.

Many experts believe there is significant undertreatment of the disease, primarily because of the perception, among doctors as well as patients, that it is primarily a cosmetic, dermatological problem. Even long-term patients may fail to connect their joint, cardiovascular and other problems to the systemic inflammation that brought on the scaly red patches on their skin.

Increased knowledge has brought better treatments, and these treatments have the potential to lessen the considerable burden of psoriasis.

REFERENCES:

American Academy of Dermatology, “Psoriatic arthritis.”American College of Rheumatology, “Psoriatic arthritis,” updated September, 2012.

“Biologic drugs: fact sheets,” Psoriasis.org, National Psoriasis Foundation, 2013.

T.W. Chu and T.F. Tsai, “Psoriasis and cardiovascular comorbidities with emphasis in Asia,” G. Ital Dermatol Venereol, April, 2012.

H.J.A. Hunter, C.E.M. Griffiths and C.E. Kleyn, “Does psychosocial stress play a role in the exacerbation of psoriasis?” The British Journal of Dermatology, 20-13;169(5):965-974.

Mariana J. Kaplan, “Cardiometabolic risk in psoriasis: differential effects of biologic agents,” Vascular Health and Risk Management, December, 2008.

Erine A. Kupetsky, D.O., M.Sc, and Matthew Keller, M.D., “Psoriasis vulgaris: an evidence-based guide for primary care,” Journal of the American Board of Family Medicine, 2013;26(6):787-801.

National Psoriasis Foundation, “Systemic medications for psoriasis and psoriatic arthritis including biologics.”

NIH, “Questions and answers about psoriasis,” updated August, 2013.

N. Onumah and L.H. Kircik, “Psoriasis and its comorbidities,” Journal of Drugs in Dermatology, May, 2012.

“Psoriasis,” MedlinePlus, updated November 20, 2012.

“Psoriasis–topic overview,” WebMD, last updated January13, 2010.

“Psoriatic arthritis,” MedicineNet.com, Medically reviewed October 2, 2013.

“Psoriasis is a systemic disease: an expert interview with Alan Menter, M.D.,” Medscape Dermatology,

02/20/2014

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At two years of age, Malcolm loves sports. When he stands on the pitching mound, his windup is a mirror image of those he has seen his parents use. It doesn’t matter that his pitch sometimes goes to second base rather than home plate.

Malcolm loves to imitate the form and style that he sees in adults around him, and he is gaining considerable strength and coordination while he has a good time. He passes up his own child-size bat and struggles only a litte as he picks up a heavy adult bat that is almost as long as he is tall, swings it through the air (sometimes hitting the ball) and then triumphantly rounds the bases–sometimes in reverse order.

Some parents nurture fantasies of seeing their children become highly paid professional athletes, pushing them relentlessly from a young age. But only a small number have that ability, and children rarely thrive under that kind of pressure. Yet sports activity can and should be a healthy part of every child’s development.

Physical activity is crucial for good health and maintaining a normal weight. And individual and team sports teach children an array of skills and personal qualities. Hard work, discipline, motivation, commitment, cooperation, leadership, teamwork–these are qualities that are useful not only on the athletic field but on the job, in the community and at home.

CHILDREN UNDER SIX are not really ready to follow rules and understand the cause and effect relationships of team sports. Activities at this age should be fun and easy going with parents offering a lot of support and praise.

Malcolm is good at throwing, catching and putting a ball into a hoop, but that doesn’t mean he is a future star. Some children are not as coordinated nor as interested, and introducing them to these activities early and often is not necessarily going to make them proficient.

Expecting too much, too early is only going to cause them frustration. Children at this age are looking for fun and adult praise. Save the coaching for later.

Pre-schoolers generally thrive on any activities that include tumbling, jumping, running or dancing.

AT AGES 6 TO 9, a child has a longer attention span and is better able to follow directions and learn some rules. She may be ready to join an organized activity such as T-ball or soccer, but, again, the emphasis should be on fun and allowing the child to develop at her own pace.

Contact sports such as football are generally not recommended at these ages since most children have not had time to develop the proper skills and may be at risk from those who are bigger and have developed better skills. Pediatricians have noted an increase in head injuries among youth football players at this age level.

AT AGES 10 TO 12, a child has usually developed mature vision and is able to take on sports that require complex skills–basketball, hockey, volleyball and football. Particularly at these ages, the focus should be on sportsmanship and team play. And each child should have a chance to participate.

The choice of sport is probably less important than the approach of a program. Coaches and volunteers should have experience working with children and, preferably, some training in education or child development. But parent coaches and volunteers can also be good at working with kids. Talk to other parents to get an idea of how teams and coaches operate.

Puberty may create dramatic growth spurts that can be misleading. A child is suddenly almost as big as an adult but has not yet developed proper coordination and balance.

Parents sometimes squabble between themselves about whether a child should play football. There are some serious risks involved, particularly concussions and head injuries. Take into consideration the child’s age, size and maturity compared to those he or she will be playing against. Most important: does the child want to play?

WHICH SPORT? Overzealous parents often push their child into specializing too early in one sport. This should come no earlier than age 12; and, then, only if the child is particularly enthused about that sport.

Before that, children should be encouraged to try out a number of activities, choosing those that click with his or her personality and developmental level.

Some sports such as tennis, golf, swimming, gymnastics, ice skating, skiing and snow boarding are done individually, although often in a group or team setting (such as a school tennis team). Team sports include soccer, hockey, baseball, softball, basketball, volleyball, lacrosse and field hockey. Some advise parents to encourage their children to participate in one team and one individual sport each year, at least at first.

Each sport can teach a unique set of skills, attitudes and strategies.

SOCCER, with constant running, builds cardiovascular endurance and gives a child training in balance and foot dexterity. Football teaches hard work, intensity and team discipline.

Basketball is a great sport for gaining hand/eye coordination plus running and jumping skills. Like soccer, there is almost constant movement to build cardiovascular fitness.

Lacrosse builds toughness and confidence even though the game is not as rough as it seems. The hard collisions that occur in hockey and football–and are notorious for causing concussions–are relatively rare in lacrosse.

Finally, baseball requires focus, patience and close attention. Like basketball, it is good for hand/eye coordination, but most of the running comes in short, intense spurts.

As children get older and more accomplished in one or more sports, the risk of injury escalates. A 2007 report of the American Academy of Pediatrics Council found that more than half of pediatric injuries involved overuse syndrome. Bad enough for adults, overuse injuries are particularly risky for young persons with growing bones. It’s important for them not to ignore pain or try to “work through it.”

The report recommends that youth have at least one day off each week from organized physical activity and two to three months away from their particular sports.

Children who are talented enough and choose to take their activity to another level, playing on school, travel or AAU teams, should be applauded and supported. It’s important, though, that the major impetus for doing so comes from the child.

REFERENCES:

Sandy Alexander, “All in good time: the importance of age-appropriate sports,” Baltimore’s Child, April, 2011.

Linda Wasmer Andrews, “Finding your child’s inner athlete,” WebMD Feature, reviewed by Daniel S.Kirschenbaum, Ph.D., November 21, 2011.

Meredith Cohn, “Playing youth sports contributes to long-term health,” Baltimore Sun, January 8, 2014.

Marianne Engle, Ph.D., “The best sports for your child,” NYU Child Study Center ParentLetter, October, 2008.

“Finding the right team sport for your child,” Parenting.com.

“How can sports help to promote youth employment?” HuffPost Sports, January 8, 2014.

Mayo Clinic Staff, “Children and sports: choices for all ages,” MayoClinic.com.

“Signing kids up for sports,” KidsHealth.

“Teach your child to love a sport,” Parents Magazine, September, 2010.

03/20/2014

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You may have seen the billboard: “Born from 1945 to 1965? CDC recommends you get tested for hepatitis C.”

If you were born between those dates, you belong, of course, to the group referred to by the media as baby boomers–children born after the end of World War II. But why is the Centers for Disease Control advising you to get tested for hepatitis C? Here are some answers.

Of the 3.9 million Americans infected with hepatitis C, 75 percent were born between 1945 to 1965. The disease is five times more prevalent among that age group than among other Americans. And most of these individuals have no idea that they are infected until they suddenly develop severe liver problems, often leading to liver failure. That’s good reason to heed the message on the billboards.

The Centers for Disease Control made this recommendation in August of 2012 following a survey of about five thousand patients at four U.S. health care systems between 2006 and 2010. The survey confirmed a high percentage of undiagnosed hepatitis C infections among those born between 1945 and 1965.

Hepatitis C is one of several hepatitis viruses that enter the body through various routes and attack the liver. The hepatitis C virus (HCV) is passed through contact with the blood of a person infected with this virus.

As a result, previous CDC recommendations focused on high-risk groups such as

• intravenous drug users,

• dialysis patients,

• anyone who received a blood transfusion prior to 1992 (when screening of blood for this virus was initiated) and

• health care workers who have been exposed to the virus, usually through needle stick injuries.

Also at risk are persons who received tattoos or body piercings under non-sterile conditions and children born to mothers who are infected. Transmission can also occur through sexual activities that result in exposure to contaminated blood.

In third world countries, some of which have infection rates as high as five percent, transmission often comes from injections or procedures with improperly sterilized equipment.

Why Baby Boomers?

The CDC does not know why baby boomers comprise such a high proportion of infected Americans. One reason is that birth rates before and after those dates were significantly lower. As a result, baby boomers are comprising an increasingly large portion of the total population.

It’s also possible that a higher than average number of persons in this age group experimented briefly–or more extensively–with IV drugs. Many of these persons may be reluctant to reveal they are at high risk because of past drug use.

Some baby boomers were also adults during the period when blood transfusions were more likely to be contaminated.

Another reason the CDC made the recommendation is that there is generally a lack of awareness of hepatitis C, even though it now kills more Americans than HIV and poses serious, life threatening complications.

Infections are common, but the patient may experience no symptoms for many years. When symptoms do occur, they tend to be mild and vague–decreased appetite, fatigue, joint and muscle pain, nausea and weight loss. Yellowing of the skin and eyes (jaundice) should not be ignored as it is a sign of liver problems, whether hepatitis C is involved or not.

About three quarters of persons infected develop chronic hepatitis, and 60 to 70 percent of these develop chronic liver disease.

Over a period of 20 to 30 years, scarring (cirrhosis) of the liver starts to occur, making it difficult for the liver to function effectively. As many as five percent of persons with a chronic hepatitis C infection die of liver failure or liver cancer.

Although liver cirrhosis is commonly associated with alcohol abuse, hepatitis is actually a more frequent cause. The combination of hepatitis C and alcohol use can be a potent threat to the liver.

The CDC recommendation for screening was made in part to protect adults from living unknowingly with a silent infection for 20 or 30 years, then being suddenly faced with liver failure or liver cancer.

If detected before serious liver damage occurs, hepatitis C can be treated. And, as the CDC pointed out in its recommendation, new treatments have become available.

The goal of treatment is SVR–sustained virological response, meaning the virus cannot be found in the blood six months after treatment. For many patients, combination therapy with interferon and ribavirin results in cure rates of about 60 percent. Interferon must be injected, however, and has some serious side effects.

New antiviral drugs are emerging that are expected to be more effective and better tolerated. The U.S. Food and Drug Administration recently approved [December, 2013] sofosbuvir (Sovaldi), a nucleotide analog inhibitor that can be used in combination with ribavarin and/or interferon.

Some patients cannot tolerate interferon, and sofosbuvir is the first all-oral, non-inteferon medication approved for the disease. In six studies involving 1,947 patients, the drug was found effective in clearing 89 to 95 percent of genotype 2 and 61 to 63 percent of genotype 3 after only 12 weeks of treatment.

Two weeks earlier, the FDA approved simeprevir (Olysio), a protease inhibitor that blocks a protein needed for the hepatitis C virus to reproduce. In five clinical studies involving more than two thousand patients, 80 percent of treatment-naive subjects given simeprevir plus interferon and ribavirin had sustained virologic response compared to 50 percent of subjects given interferon and ribavirin alone. Other protease inhibitors approved in 2011 are boceprevir and telaprevir.

There are other potential HCV drugs now being tested, and it is believed they may prove to be even more effective. Noting the improved chances for successful treatment, the Centers for Disease Control believes more widespread screening is needed for a disease that otherwise might go undetected.

The CDC estimates that more than 800,000 Americans with hepatitis C might be discovered through one-time screening of this age group. And, with early detection, most would be able to avoid the severe liver damage that comes with advanced disease.

REFERENCES:

“All patients born between 1945 and 1965 should have hepC screening, says CDC,” Medical News Today, August 20, 2012.

Centers for Disease Control, “Hepatitis C testing for anyone born during 1945-1965: new CDC recommendations,” last reviewed and updated October 1, 2012.

Centers for Disease Control, “Hepatitis C information for the public,” last updated May 6, 2013.

Vincent K. Dhawan, M..D., “Hepatitis C,” Medscape Medical Reference, updated December 31, 2013.

Mayo Clinic Staff, “Hepatitis C,” MayoClinic.com, August 13, 2013.

Steven Reinberg, “Baby boomers need hepatitis C test, CDC study confirms,” WebMD News from HealthDay, August 15, 2012.

U.S. Food and Drug Administration, “FDA approves new treatment for hepatitis C virus,” FDA Press Release, November 22, 2013.

World Health Organization, “Hepatitis C: Fact sheet No. 164,” updated July, 2013.

3/20/2014

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SELF-ENROLL

STAFF-ENROLL

04/11/2014

For more information, sample newsletters or to get on our mailing list contact:

        Community Relations
        West River Regional Medical Center
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