#Lyme Disease after Treatment

Lyme Disease

Lyme disease is increasing in the U.S. due to warmer temperatures and an increase in the deer population (deer tics spread the disease). Cases doubled between 1991 to 2018.

Lyme disease is caused by bacteria. The initial infection presents with fever, headache, fatigue, muscle and joint aches, enlarged lymph glands, and a red rash (may look like a bull’s eye in some cases).

Diagnosis initially depends on a history of a tic bite in someone with a rash and/or the symptoms described. Blood tests can confirm the diagnosis, but they do not become positive for 4-8 weeks after the tic bite occurs.

Most patients recover completely after a course of antibiotics, but about 10-20% develop a post treatment Lyme disease syndrome (PTLDS).

After initial symptoms have gone away, patients with PTLDS have new symptoms such as fatigue, joint pain, memory loss, poor focus, and dizziness with elevated heart rate when standing up. It can last for months to years.

Why? No one knows for sure but possibilities include the bacteria or parts of it remains in the body after antibiotic treatment or an immune reaction to the bacteria results in autoantibodies (antibodies that attack certain tissues in the person’s body, e.g., the brain).

Although there is some disagreement about PTLDS, there is evidence for it from lab and imaging studies. For example, special brain scans show widespread brain inflammation and changes in the front part of the brain.

Also, two different autoantibodies are often found in these patients. There may also be increased blood levels of a protein found with inflammation.

Currently, there is no specific treatment for PTLDS. Experts say that providing a second round of antibiotics does not help. Instead, doctors try to treat the symptoms to improve patient comfort.

There is new research attempting to find preventive measures such as a vaccine or an oral medicine that kills the tic before it can cause an infection (the tic needs to be on the person’s body for at least 36 hours before introducing the bacteria into the patient).

This blog is based on an article on this topic by Anita Slomski in JAMA Network 2023; 330(12): 1124-1126.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Depression and #Processed Foods

Depressed

Research shows that eating ultra-processed foods can increase the risk of depression. Ultra-processed foods are “energy-dense, palatable, and ready-to-eat items.”

Research was primarily done on non-Hispanic white women ages 42-62 in the Nurses Health Study II.

Women in the study who ate large quantities of ultra-processed foods had high rates of increased BMI, more smoking, and more co-morbid health conditions such as diabetes, high blood pressure, and high cholesterol; they also exercised less.

Women who ate the most ultra-processed foods had increased rates of depression. However, “… only artificially sweetened beverages and artificial sweeteners were associated with a greater risk of depression …”

Those women, who started in the highest risk group and reduced their intake of ultra-processed foods by 3 or more servings per day, were able to reduce their risk of depression over a 4 year timeframe.

The researchers noted in their paper that artificial sweeteners can alter a brain function that is thought to be involved with depression.

My suggestion is to avoid food and drinks with artificial sweeteners. Typically, people hope to reduce weight gain by choosing these products. However, research shows they are usually ineffective for that purpose and may actually cause more weight gain.

The research referenced in this blog is from a paper by Samuthpongtorn and colleagues titled “Consumption of Ultra-processed Food and Risk of Depression” published in JAMA Network Open September 20, 2023; 6(9): e2334770.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Psilocybin for #Depression

Depressed

Recently, psilocybin has been used along with psychological support to treat Major Depressive Disorder. Research published in JAMA in August 2023 showed that psilocybin 25 mg with psychological support was more effective than placebo (nicotine 100 mg) and psychological support in treating depression in adults (age 21-65).

Improvement was shown at 8 weeks and improvement was sustained until at least day 43. All patients in the study had at least a moderate degree of depression.

To be chosen to participate in the study, patients were not allowed to have taken an antidepressant for 2 weeks or longer, had no suicidal thoughts, no substance use, and no family history of psychosis.

Other studies have supported the use of psilocybin with psychological support to treat Major Depressive Disorder. In Germany, psychiatrists with appropriate training and psychotherapy skills can treat depressed patients with psilocybin.

Australia recently has approved the use of psilocybin for treating depression. They also approved it for use in patients with PTSD.

Now, it appears that it may be a helpful treatment for depression and other mental disorders, e.g., PTSD. It is not intended to be used alone but only along with psychological therapy.

Psilocybin is a psychedelic derived from psilocybe mushrooms. It affects multiple types of serotonin receptors. Many standard antidepressants increase the availability of serotonin.

Psilocybin can affect all of the senses and can cause hallucinations. It has been used as a street drug for many years.

Stay tuned.

Blog partially based on research by Raison CC et al. Single-dose psilocybin treatment for major depressive disorder: A randomized clinical trial. JAMA. 2023 Aug 31, 2023; e2314530.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

A Reluctant Leader

Do you see yourself as a leader?

Being a Leader

Do I see myself as a leader? Actually, I consider myself to be a reluctant leader. Why? I am an introvert and a typical middle child so I never sought leadership positions.

However, leadership positions found me throughout my life. That began when I was a 12-year-old boy scout who was invited to be the senior patrol leader for my troop.

This became a pattern for the rest of my life. I did not seek leadership positions but was regularly asked to take them on.

The last one before retirement was being asked to assume the role of Vice President of Medical Affairs (head doctor) for a large teaching hospital.

The reason I wrote this brief essay is because I want to let introverts know that they can become a leader and do well. Do not assume that you have to be an extrovert, seek leadership positions, and be special to become a successful leader.

There is a desperate need for leaders and relatively few people willing to lead when needed. This is true for membership on the Board of a condo development, being on your church council, or running a department where you work.

You don’t have to be a born leader. There are many excellent books and videos on how to become a successful leader. Find a mentor who has been in leadership positions and done well; ask him or her to give you some guidance.

If you are willing to lead (even reluctantly), there will be many opportunities throughout your life. Go for it!

Peter M. Hartmann, MD

The Modern Inquisition

Burned at Stake

What personality trait in people raises a red flag with you?

I am concerned when someone appears possessed by an ideology. When someone is deeply convinced their worldview is right and the only valid moral stance, they are at risk of using force to achieve compliance from others.

An extreme example from the past is the Spanish Inquisition. Jews were required to convert or be burned at the stake. Thousands died.

Today, ideologues tend to use less extreme measures. When an institution is possessed by an ideology, people can lose their job for believing the wrong thing. People in all walks of life can be subject to being bullied on the internet. Invited speakers can be canceled at universities because they think the “wrong” things.

I still believe in freedom of speech, civil discourse, and being humble about what we think we know.

I am reasonably sure that those who burned others at the stake truly believed they were acting morally.

Be careful.

Peter M. Hartmann, MD

Oral Nasal #Decongestant Use

Runny Nose

For many years pseudoephedrine was available as an over-the-counter treatment for a congested nose from allergies or the common cold. However, it was moved behind the counter when it was misused to make an addicting drug.

That meant that phenylephrine was the only medication available over-the-counter for the oral treatment of nasal congestion.

Phenylephrine is effective when used directly into the nose (intranasal). It has also been available in an oral form.

Recently, the FDA reviewed research on the safety and effectiveness of the oral form. They have concluded that it is safe if taken at approved doses.

However, the FDA also concluded that multiple studies show that it is INEFFECTIVE. That is, it does not reduce nasal congestion any more than a placebo (an inactive ingredient for comparison with the medicine being tested).

If they are correct, then purchasing an over-the-counter oral decongestant with phenylephrine would not be helpful.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

What Does It Mean?

If you had to give up one word that you use regularly, what would it be?

Confused

The word I would give up is “literally.” It’s definition was “a word or phrase meaning just what it says and is not a simile or a metaphor.” So, if I said, “That boxer had hands of stone,” I was probably using a metaphor, i.e., his hands were actually human skin and bones, but he hit so hard it was as if he had stones for hands.

On the other hand, if the boxer had his hands amputated and replaced with stones, I would have meant it literally when I said, “He had hands of stone.”

However, in the last couple of decades literally has been used as a form of emphasis. For example, after missing the beginning of the Super Bowl one year, the speaker said, “It was literally the worst day of my life.”

However, it wasn’t the worst day of his life; the day his 6-year-old son was killed in an auto accident was. The speaker knew that but just wanted to emphasize that he was extremely upset about missing part of the game. He did not literally mean it was the worst day of his life (yet, that was the word he used for emphasis).

Given this change in the use of the word, if I use it, the listener does not know if I am using it just for emphasis or I mean it to be understood as being literal and not as a simile or metaphor.

It seems strange even to me that I am disturbed (a little) that a word I used for years to explain something now cannot be used without a real risk of being misunderstood.

So, the word I would be willing to eliminate from my vocabulary is “literally.” 🤔

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Transgender #Surgery

Surgery

An article in JAMA Network Open on August 23, 2023 addressed how often gender-affirming surgery (GAS) was performed in the U.S. from 2016 to 2019. During that timeframe the number of surgeries almost tripled.

In 2019 there were 13,011 procedures performed. The greatest number were in patients ages 19 to 30 (52.3%). Patients ages 31 to 40 represented 21.8% of surgeries. Patients ages 12 to 18 represented 7.7% of cases.

Breast and chest surgeries were the most common ones performed (56.6%). Genital reconstruction was performed mainly in older patients (35.1%). Facial and other cosmetic procedures were the least common (13.9%).

The authors believed that the significant increase in rates of surgery was due largely to greater insurance coverage for these procedures.

They also stated that the procedures have an “acceptable morbidity and reasonable rates of perioperative complications.” That is, in the U.S. such procedures are reasonably safe.

The authors did not address concerns about the quality of prior studies. One paper from 2022 was a review of a large number of studies on patient satisfaction with GAS. Those authors noted that 68.7% of studies addressed “patient-centered outcomes,” but “only 1.0% used metrics validated in the transgender population.” However, overall the reports indicated “high patient satisfaction.”

The paper also addressed patient satisfaction, which was based on prior studies. Generally, those papers indicate good patient satisfaction, improved quality of life, and a decrease in gender dysphoria.

Some authorities recommend caution since individual studies include only a small number of patients compared to the number of surgeries performed. Also, in a number of cases the follow-up was as short as 6 months after the procedure.

Also, in one study cited by the JAMA article, 38% of the patients “would change their experience with GAS.” This could be anything from difficulties in arranging for the surgery to untoward outcomes; they were not listed.

Despite these reservations, it does appear that patient satisfaction is generally high after GAS, at least for a period of time. Once there is a larger number of individuals with GAS tested with standardized questionnaires several years post-op, we will have a more definitive answer to the question of whether patient satisfaction with GAS persists in the long run.

Peter M. Hartmann, MD

Family Medicine & Psychiatry