Monday, July 14, 2014

What is Juvenile Arthritis?

Blog contributed by Kathleen
Zimmerman, MD
Pediatrician
It is estimated that about 300,000 children in the U.S. have some form of juvenile arthritis.  Most people have heard of Juvenile Rheumatoid arthritis, or JRA.  But there are other forms of arthritis as well, including Juvenile Idiopathic Arthritis (JIA), which is the most common form in children.

Most forms of Juvenile Arthritis are autoimmune.  This means that the child’s immune system is attacking their healthy cells.  It is thought that this autoimmune attack may be triggered by a virus and in some cases children have a genetic risk if arthritis is in the family.

Arthritis in children can have different symptoms and these symptoms can come and go for long periods of time.  The most common symptom is constant joint swelling, joint pain, and stiffness.  This may be in one joint or in multiple joints.  Some children are limping or clumsy because of the joint pains.  The pain is often worse in the mornings.  Other symptoms may be high fevers or skin rashes that don’t have another cause.   Children may also have eye inflammation and growth problems.

There is not a single test for Juvenile Arthritis.  Your child’s doctor may suspect arthritis if they have the symptoms above and they do not have an explanation (no recent injury or recent illness) and also if the symptoms do not go away on their own.  If your child was suspected to have Juvenile arthritis they would need a thorough exam of the joints as well as bloodwork. Referral to a Rheumatologist (specialist in arthritis) is typically recommended to help with the diagnosis and treatment. 

Juvenile Arthritis is a chronic illness that comes and goes.  During a “flare”, children may need medication to help control their symptoms. Physical therapy is helpful as well.  If the pain is severe or difficult to treat, stronger medications that suppress the immune system are used to calm the symptoms down and allow the child to live a more normal life.  The goal is for the child to remain active and to have long periods of “remission”, where the symptoms are gone for months to years.   Children with juvenile arthritis may also have “silent” problems with the eyes or growth (without symptoms).  Therefore, it is also important to have regular eye exams and checkups even if they have no symptoms. 

Researchers are working on finding causes of Juvenile arthritis and also researching better medications with fewer side effects.  To learn more about Juvenile Arthritis and the most recent science on these diseases you can go the National Institute of Health site: www.niams.nih.gov and the Arthritis Foundation site: www.arthritis.org






Tuesday, May 27, 2014

May is national Osteoporosis (OP) month

Blog contributed by Renu Joshi, MD,  Endocrinology

Osteo means bones and porosis means holes. As the name suggests we have bone loss which can lead to Bone fractures.

It is a silent disease and does not cause any pain until Fracture occurs.

Did you know that 50-65% of women between 50-75 suffer from Osteopenia / osteoporosis and 50 % of white women will suffer from Fracture due to Osteoporosis.  25 % of patients with hip Fracture will die within the first year. Incidence of Hip fracture is higher than combined Breast cancer, Heart attack and stroke in Females.


Men can also suffer through OP but it starts at age 70 or higher.

While we all get screening for other things the screening for OP still remains very low. A 5-minute screening test for OP is the U/S of the heel, which almost picks up > 70 % cases of OP and it is free.

We as women are always taking care of others but we can be better care taker if we take care of ourselves
SO Be In charge of your health!!!

You can prevent OP by these simple things:
  1. Take 1000 -1500 mg calcium  (diet and supplement combined) daily
  2. Vitamin D at least 800 units daily
  3. Exercise both aerobic and Muscle strengthening (by lifting weights) at least 3 times weekly 
  4. Drink < 3 caffeine beverages (including Coffee and sodas)
  5. Getting screened early after Menopause so treatment can be given appropriately 

  Let’s do it together so we can save Fractures!!!

Monday, May 12, 2014

How to Eat Healthy at Home and at Work


Patients typically tell me about one struggle or the other: “I have a hard time eating healthy at home” or “I have a hard time eating healthy at work”. With obesity on the rise, as a whole we have got to learn to do better at both! I believe the keys to healthy eating are knowledge, discipline and preparation.

Knowledge. Being educated. Being an aware consumer. Knowing how many calories are in food items. Knowing what are healthy choices and what are not.

Discipline. Being determined to eat healthy the majority of the time. Being able to say no to junk food the majority of the time. Choosing unsweetened drinks over sweetened ones.

Preparation. Planning ahead for meals and snacks. Having a list before you go to the grocery store. Not allowing yourself to become too hungry, resulting in binge eating. Having water on hand.

I feel like most people get the first two points, it’s more a matter of applying them. The third point, preparation, is what I want to focus on. Being prepared sets one up for success. Start with a list. What are healthy food items you would like to purchase on your next trip to the grocery store? This list must include variety, snacks, and meals. As far as meals go: The internet holds a plethora of recipes (do people use cook books anymore?! Ok…kidding, but seriously). Try to avoid recipes with white flour/pasta, the word “fried”, and cream sauces/a lot of cheese.  And when you find those tasty, healthy recipes…make extras! Then you have leftovers for work! I try to avoid casseroles and make soups (broth-based) or stir-fries instead.
When you get home from the grocery store, rinse and prepare whatever you can. Cut celery sticks. Wash lettuce and prepare veggies for easy salads. Cut up fruits that need it. Put snack items into baggies/containers. Hard-boil eggs. Get the junk food out of the house. If it’s not there, it can’t be consumed!

Get your lunch/snacks ready for work the night before. If you plan for your meals, you are less likely to grab unhealthy food on a whim. May I suggest salads in a jar: dressing on the bottom, other items such as low-fat cheese/egg/chicken/nuts/seeds/fruit/other veggies next, then lettuce on the top. When you are ready to eat, just turn it onto a plate and the dressing is on the top and nothing is soggy. Another idea is  fruit and yogurt parfaits with plain yogurt (check out how many grams of sugar are in flavored yogurt!). Use fruit as your sweetener and add some low-sugar granola, oats, or nuts. Be careful of cereal, flavored oatmeal and bars, as they often contain high amounts of sugar!

At home, I make a baked oatmeal, bran muffins or quiche weekly. That way there is always something in the fridge to grab for breakfast that is healthy. I use very little to no sugar in my recipes and add lots of extras: fruit, cinnamon, nuts, etc. I load up the quiche with veggies and omit the crust. These are also good options for lunch or a snack at work.  It is also helpful to have nuts, carrot sticks, or an apple in the car to keep you from making a stop for some less-nutritious choices.


And one last point: choose foods that will fill you and not leave you hungry soon after. Protein and healthy fats (like nuts and avocados) can really help with satisfaction. 

Friday, May 2, 2014

Why are we seeing Measles again?

Blog contributed by Kathleen Zimmerman, MD,  Pediatrician

In recent news there have been a multitude of stories on increasing outbreaks of measles.   Measles was almost eradicated by the year 2000, so why are we seeing measles again?

Measles is spread by a very contagious virus.  The virus is spread as easily as influenza virus.  Therefore once a case comes into a community, it quickly spreads to those who have not been vaccinated. Widespread vaccination against measles creates “ herd immunity”.   This is the best protection a community can have from measles outbreaks.  Herd immunity stops isolated cases of measles from spreading into an epidemic.

Vaccination rates have declined in certain areas of the United States and these are the areas that have “holes” in the herd immunity and these are the communities that are having increasing outbreaks of measles.   California’s cases went up from 4 last year to 58 as of this month (and will be higher by the time you see this blog).

Vaccination refusal and delays are most commonly due to misconceptions about vaccine safety.  Also many young parents have never seen measles before and they do not understand that just 50 years ago there were 500,000 Americans infected with measles per year with 48,000 hospitalizations and 500 deaths each year.   The near eradication of this deadly disease 14 years ago was achieved by vaccination.  The return of this disease in exponential numbers is occurring because of vaccine refusal.

It’s important for parents to realize that when they refuse or delay vaccines for their child, they are not only putting their own child at risk, but also their whole community.   This couldn't be exemplified more clearly than in what we are seeing unfold in our country with the current measles outbreaks.




Monday, April 14, 2014

Child Abuse Prevention

Blog contributed by Andrea Burks, DO, Heritage Pediatrics, PinnacleHealth Medical Group



April is child abuse prevention month.  In the United States of America there are approximately 3 million reports of child abuse and neglect each year involving 6 million children. 686,000 children were determined to be victims of abuse and neglect in 2012 and of those 1,640 resulted in death. That is greater than 4 child abuse related deaths per day. There are likely many more cases that are not reported. Child abuse and neglect happens at every socioeconomic level, across ethnic and cultural lines, within all regions and levels of education. Boys and girls are maltreated in equal numbers.  Children less than 4 years old are at greatest risk for severe injury and death from abuse. The most common abusers are parents, other family members, or an unmarried partner of a parent. Children who suffer maltreatment are at higher risk for cognitive delays, emotional difficulties, harm to development of nervous and immune systems, and health problems as adults. It is important to recognize, help prevent and report suspected child abuse and neglect because its lasting effects can impact us all. Small acts from everyone in a community can help save a child from harm.

The first step is to recognize child abuse. Child abuse can be physical, emotional, sexual, or involve neglect of a child by someone who has responsibility for the child. It is common for more than one type of abuse to occur at a time. It is important to note a single sign does not mean maltreatment has occurred but if signs appear repeatedly or in combination a closer look at the situation may be warranted.


  • Physical abuse involves non accidental physical injury including but not limited to hitting, kicking, biting, burning, choking, shaking, and throwing. It often leaves bruising at different levels of healing, marks on body consistent with objects or hand prints, or unexplained bruises, black eyes, or broken bones. The physically abused child may wear clothing inappropriate for weather (e.g. long sleeves in hot weather to hide bruising). They may also be reluctant to go home or fearful of parents.
  • Emotional abuse involves with holding love, support or guidance from a child. Emotional abuse is as strong a predictor of subsequent impairment in child development as physical abuse. Emotional abuse may include ignoring, rejecting, isolating, verbal assault, threatening, blame, belittling, or shaming the child in a persistent chronic pattern. The caregiver may appear unconcerned about the child. The child may show overly compliant or demanding behavior, be extremely passive or aggressive. They may speak of attempting suicide or they may report lack of attachment to parent.
  • Sexual Abuse can involve engaging a child in sexual acts, exposing a child to sexual activities, indecent exposure, or exploitation of a child through pornographic material. Effects of sexual abuse extend beyond childhood. These children often have loss of trust and feelings of guilt. The child may show signs of regression such as bedwetting, rocking, head banging, stranger anxiety, withdrawal from family and friends, suddenly refuse to change clothes in gym, or refusal to participate in physical activities. The adults may appear extremely protective and limit contact of the child with other children.
  • Neglect is failing to provide the basic needs for a child including food, clothing, shelter, proper hygiene, education, and medical attention. Neglect can also involve abandoning a child or putting a child in unsupervised or dangerous situations. The child may miss a lot of school, beg or steal from classmates or friends, or lack medical/dental care. They may have dirty clothes or clothing inappropriate for weather.


Prevention of child abuse and neglect is a community effort. Individuals in the community can play a role in helping families find the strength to raise safe, healthy, and productive children.  A majority of parents don't want to harm their children. Abusers are more likely to have been abused themselves and don't know other ways to parent. They may suffer from mental or chronic health problems, struggle with substance abuse, and commonly have high stress and lack of support. Parenting is one of the toughest and most important jobs. We all have a stake in ensuring parents have access to the support they need to be successful parents. You can start by getting to know your neighbors. Help a family under stress by offering to give them a break and babysit for a few hours, help run errands, help a parent with a small child get through checkout line at the grocery store, or reach out to children in the community. If a child discloses they are victims of abuse, first believe them, listen, and don't be critical or negative of child or parent. Assure the child they are not to blame and report the incident.

It is the right and responsibility of everyone in the community to report suspected child abuse or neglect. You can make a report by contacting your local child protective service agency or police department. You do not need to have evidence or actual knowledge of abuse to make a report. You should have reasonable cause, heightened concerns, or belief based on observation. Reporters can be anonymous but giving your name may help the investigation. Good Faith Laws protect the reporters from legal liability. Trust your instincts. Reporting your suspicions may protect the child and get help for a family who needs it.

If you are a parent under stress find ways to regain control. Try counting to 10, take deep breaths, call a friend, put your child in a safe place and take a few minutes to calm down and relax. Never be afraid to apologize to your child if you lose your temper and say something in anger that wasn't meant to be said. Reach out to community centers, church, schools, and physicians for guidance on positive parenting skills. It is often helpful to learn good communication skills, appropriate discipline, and how to respond to children's physical, developmental and emotional needs. Understanding appropriate developmental milestones may help you set reasonable expectations for a child. Creating social connections with family, friends and the community gives encouragement and can help improve parent child relationships. There is also concrete community support that assists with food, clothing, housing and access to healthcare.  You can contact you physician for information about these services.

In Pennsylvania report concerns for child abuse and neglect to ChildLine 1-800-932-0313

Wednesday, April 9, 2014

March is National Nutrition Month

Blog contributed by Tina Metropoulos, DO, Primary Care Physician

In primary care, we often counsel patients about healthy dietary habits. 
I’m frequently asked about what foods are healthy.  Another common question is whether a fad diet is safe, effective, or advisable – “How about Atkins?”, “Is South Beach okay?”, and should I go “Paleo?". Sometimes the goal is weight loss, and sometimes it is to improve lifestyle. Specifically, patients are often concerned about their heart health and providers often discuss diet as a means to reduce risk for heart disease.

Recently, the American Heart Association updated their healthy nutrition guidelines.  I read through them, after their release in 12/2013.  The overall focus is on a balanced, moderate, diet with limited processed food intake.  An important recommendation is to have a diet rich in fruits and vegetable – with an average of 9-10 servings a day for an adult.  There are other guidelines and diets which focus on fresh fruits and vegetables, such as the DASH diet and the Mediterranean diet.  This may seem as hard as climbing Mt. Everest, especially if you count an occasional side salad as your token veggie for the week.  However, I try to help patients realize how easy it can be to include healthful, and flavorful, fruits and vegetables in their daily meals.

First, it’s important to understand how much “a serving” is.  A serving of fresh fruit is equal to 1 medium fruit, ½ cup cooked, chopped, or canned fruit, ¼ cup dried, or ½ cup juice (easy to get when you add some dried cranberries to some mixed nuts!).  A serving of fresh or cooked vegetables is roughly ½ cup; vegetable juice is ½ cup, while 1 cup constitutes a serving of raw leafy greens.

So, if you chop up some tomatoes, peppers, cucumbers in your lunchtime green salad (or if you are feeling adventurous, some artichokes or asparagus), you’d have at least 3 servings to put toward your daily quota.  Add some sliced berries to your AM bowl of Wheaties and you have another serving.  Snack on hummus and carrot or celery sticks (much better for your afternoon slump than a double mocha) and you’ve added another serving or two – more than half-way there!  And, we haven’t even counted dinner yet.

Now that spring is in full swing we will soon have an abundance of fresh fruits and vegetables available!  By visiting your local farmer’s market or grocery store you can stock up on colorful, visually appealing, and delicious produce.  Eat up!

What is a serving size?

Recipe Ideas:



Monday, February 24, 2014

Does My Child Have an Eating Disorder?


Blog contributed by Kathleen Zimmerman, MD,  Pediatrician

If you are asking this question, then your child needs to be seen by his or her provider.  Over the past decade the United States and other parts of the world have seen steady increases in the incidence of anorexia (nervosa) and bulimia for both females and males.  There is also an increasing trend for younger children to develop eating disorders as well as teens.  Eating disorders present with many different signs and symptoms.  Sometimes these are difficult to detect if your child is hiding them.   Here are a few that should raise a flag and prompt you to bring your child to the office:

  1. Constantly worried about their size or weight
  2. Not eating as much food as they used to but insisting they ate when you weren't around
  3. Binge eating large amounts of foods 
  4. Menstrual period is becoming irregular or skipping months
  5. Intense exercise more than 1-2  hours per day and they are very stressed if they miss a workout
  6. Symptoms: cold intolerance, dizziness,  abdominal pain, constipation, diarrhea, muscle cramps, looks pale and weak
  7. Either parent has a history of eating disorder

Your provider will measure height, weight, BMI and get a thorough diet and exercise history.  They may need to talk with your child alone.  Follow up appointments will be important to track the weight.

Early detection of eating disorders is important to prevent serious consequences.  So, even if your child denies there is a problem, it is important to have your provider evaluate any concerning eating behaviors or weight changes.