Sunscreens may act either:

• Chemically: absorb a specific portion of the spectrum thus preventing harmful rays from hitting the skins surface. Most sunscreens contain combinations of 2 or 3 of chemicals to prevent sunburn.
• Physically: provide a physical barrier to UV radiation and scatter or reflect the harmful rays.
• Examples: Zinc oxide, red petrolatum. Titanium dioxide.
• DONT FORGET: Hats, long sleeve shirts, and long lightweight pants.

APPLICATION and GENERAL INFORMATION- SUNSCREENS

• Cover all exposed areas evenly and liberally. Figure 1 oz per adult application in a swimsuit.
• Optimally apply 30 minutes BEFORE sun exposure for penetration and binding.
• Water resistant: the formula retains SPF after 40 minutes of activity in water, sweating or perspiring.
• VERY Water resistant: the formula retains SPF after 80 minutes of activity in water, sweating or perspiring.
• An SPF of at least 15 is recommended for most people by the Skin Cancer Foundation. HOWEVER...
• Products with SPF over 30 only block UVB slightly more than those of SPF=30. The higher concentration of chemicals increases potential for adverse effects, such as skin rashes. An SPF of 30 blocks 97% of the UVB rays. An SPF of 15 blocks 93% of UVB rays.

We have been having blazing hot sun in Fayette County, and lots of our patients have questions about sunburn treatment and prevention. We have people that say they “never burn” to those who say they “get fried” in a manner of minutes. We all have different skin tones, which make us susceptible to the harmful rays of the sun. The U.S. Food and Drug Administration and the American Academy of Dermatology recognize six skin-type categories.

Click here to read more about the skin-types.

Skin Protection Factor (SPF) : how the efficacy of a sunscreen is expressed. It is a ratio of the time required to produce minimal redness with a sunscreen, to the time to produce minimal redness without a sunscreen. An SPF of 15 will allow a person to remain in the sun without burning 15 times longer, than if the skin was unprotected. However, application needs to happen frequently during sun exposure due to sand, swimming or towel drying.

If you encounter that evil weed, poison ivy and were not able to get the urushiol washed off in time, you will begin to see the rash. It appears as red patches, that eventually blister and after a couple of weeks dry up and resolve. At Nickman’s we see lots of cases of this bothersome rash, here are our recommendations. Sometimes you will need to call on your physician for appropriate prescription treatment, based on the extent of the rash.

You need to see a doctor when:

• Over 25% of body surface area is contaminated, or if any sign of infection.
• Limited but disabling involvement (hands, face, area around mouth/eyes, or genitals)
• If you have a history of severe reactions

Treatment of poison ivy-needs to be treated at least 14 days!

• Oral prednisone: 0.5 to 2mg/ kg / day tapered over 14 to 21 day period. Usually start with 60mg per day, and taper down over 14-21day period. Using a 21-day regimen will decrease the likelihood of rebound dermatitis.
• Medrol dosepak (6-day therapy) is not long enough of duration. This treatment is not long enough and may cause rebound symptoms.

Last week we discussed the basics of Poison Ivy and its identification. Here is what happens when you run into this problematic plant:

Here is what happens:

• Urushiol, which is an oleoresin (lacquer) oozes from the broken leaf and stems, causing the characteristic black dots which is oxidized urushiol (due to the enzyme laccase found in the oleoresin) and can be found on plant leaves within 10 minutes of its exposure to oxygen. Urushiol can be transmitted to the patient by contact with the plant, or pets, tools, gloves, shoes and clothing for months. Washing clothes in regular laundry detergent will decontaminate fabrics. Poison Ivy should NEVER be burned, as it vaporizes the oil, causing lung damage. The allergic reactions can occur years after the plant dies.
• The characteristic wheals and blisters of poison ivy contain serum, and NOT the urushiol. Poison ivy and other poison plant rashes can't be spread from person to person. But it is possible to pick up the rash from plant oil that may have stuck to clothing, pets, garden tools, and other items that have come in contact with these plants.

When contacted:

Poison ivy (click for photo example) are all members of the Anacardiaceae family of plants. The Toxicodendron (“means poisonous tree”) genus of plants causes more contact dermatitis than all other causes combined. Ten to fifty million Americans develop allergic contact dermatitis to a Toxicodendron annually. In one study 10% of all occupational injuries among seasonal farm, workers in PA and NY were due to poison ivy contact. The genus/species names are as follows:

• common or northern poison ivy (Toxicodendron radicans)

• western poison ivy (Toxicodendron rydbergii)

• eastern poison oak (Toxicodendron toxicarium)

• western poison oak (Toxicodendron diversilobum)

• poison sumac (Toxicodendron vernix)

Regardless of the species name all the treatment protocols are the same. Allergic Contact Dermatitis (ACD) has 2 distinct phases.

• A sensitization phase where a specific hypersensitivity to the allergen is acquired.

Iron is a necessary part of hemoglobin, a protein which carries oxygen from our lungs throughout our bodies. Iron is also part of many other proteins and enzymes. Iron deficiency anemia is the most common type of anemia, and it occurs when your body does not have enough of the mineral iron. Iron deficiency anemia will appear as weakness and even shortness of breath.

If your physician recommends iron therapy, your Nickman’s pharmacist can help you get the most out of iron therapy.

INITIATE THERAPY WITH: ORAL IRON

• Ferrous sulfate 325mg (5grain) yields 65mg elemental iron ( 20%)
• Ferrous gluconate 300mg yields 35mg iron (12%)
• Ferrous fumarate 300mg yields 99mg iron (33%)

Start with: Ferrous sulfate 325mg one tablet daily usually at bedtime, increasing up to three times daily.

• NOTE: Take 1 or 2 hours before a meal
• Food can decrease absorption by 50%
• Extended-release or enteric-coated formulations have been found to transport iron past the duodenum and proximal jejunum, thereby reducing the absorption of iron. Vitamin C is added to some products to enhance iron absorption.
• Orange juice (Vitamin-C) can double the absorption. About 200 of Vitamin-C mg is needed to increase absorption of 30 mg of elemental iron.
• Take 1 hour before or 3 hours after antacids.
• IF stomach upset occurs, may take with small snack such as crackers. NO milk or tea.
• Iron therapy can cause black or dark green stools. Iron therapy might mask the symptoms of a stomach or intestinal bleed.

Vitamin B-12 (cyanocobalamin)—the pharmacist's favorite supplement.

Source of B12: muscle meats, liver & dairy products. Not found in vegetables. Vegetarians are at risk.

Function: involved in cell division and rapidly growing cells in the body. This includes the blood forming system, gastrointestinal tract, and nervous system.

Deficiency:

• Large blood cell anemia.
• Untreated Vitamin B12 deficiency may cause neuropathy. Remember that large doses of folic acid will correct the anemia but will allow nervous system damage to progress.

Vitamin B12 is bound to protein in meats and dairy products and is released by the activity of stomach acid. When synthetic vitamin B12 is added to fortified foods and dietary supplements, it is already in free form and does not require this separation step. Decreased vitamin B12 absorption can be due to reduction in stomach size, as in bariatric surgery.

Causes of Vitamin B12 deficiency

• Dietary deficiency of Vitamin B-12 is rare. Noticeable symptoms of a vitamin B12 deficiency can take years to develop. Irritability, weakness, numbness, anemia, loss of appetite, headache, personality changes, and confusion are some of the signs and symptoms associated with very low levels of vitamin B12.
• True vegans need to supplement B12, however fortified breakfast cereals are a readily available source of vitamin B12 with high bioavailability.
• Many patients have trouble absorbing B12 from food due to reduced gastric acidity from drugs that suppress stomach acid such as Prilosec, Nexium, Pepcid and others. Oral supplements can be used since about 1% of oral supplements will be absorbed, without gastric acid.
• Metformin long term will deplete vitamin B12 levels. The challenge becomes that Vitamin B12 deficiency may look like diabetic peripheral neuropathy, with numbness and tingling in the feet and hands. Patients may have a B12 deficiency, and not neuropathy!

Mechanism: Folic acid is important for formation of red blood cells, create new proteins as well as DNA synthesis.

Dietary sources: Folate is found naturally in a wide variety of foods, such dark green leafy vegetables, fruits and fruit juices, nuts, beans, peas, dairy products, poultry and meat, eggs, seafood, and grains. Spinach, liver, yeast, asparagus, and Brussels sprouts are among the foods with the highest levels of folate. By FDA requirement, manufacturers add folic acid to enriched breads, cereals, flours, corn meals, pastas, rice, and other grain products, since 1998. This accounts for 100-180mcg per day.

Pregnancy: decreased incidence of Spina bifida (opening of the spine) and anencephaly (failure of the brain to develop). Because of its role in the synthesis of DNA and other critical cell components, folate is especially important during phases of rapid cell growth. Supplement 400-800mcg before pregnancy occurs since the neural tube closes between day 21 and 28 after conception. If high risk for spina bifida, may use up to 4mg (4000mcg). All women of childbearing capability should be taking supplemental folic acid of at least 400mcg. Since 1998, when the mandatory folic acid fortification program took effect in the United States, spinal bifida and anencephaly rates have declined by 25% to 30%. Keep in mind that half of pregnancies in the United States are unplanned, adequate folate status is especially important even before conception (planned or unplanned) occurs.

Pyridoxine (B6)

Sources: meat, fish, legumes (beans), dry yeast, potatoes and other starchy vegetables and non-citrus fruits.

Function: as an enzyme for a variety of essential reactions in the metabolism of certain amino & fatty acids. Vitamin B6 in coenzyme forms performs a wide variety of functions in the body and is extremely versatile, with involvement in more than 100 enzyme reactions, mostly concerned with protein metabolism.

Deficiency States: may lead to anemia, convulsions in infants, cheilosis (cracked lips), seborrhea like skin reactions and neuropathy. As with riboflavin, the deficiency state consists of rather diffuse symptoms. Dialysis patients, and those deficient in other B-vitamins are more likely to express symptoms of Vitamin-B-6 deficiency.

Possible health benefits: may alleviate PMS (premenstrual syndrome) symptoms, improves mood, decreases risk of heart disease, and stimulates immune system. Possibly decrease nausea of pregnancy.

Treatment of Nausea of Pregnancy:

Diclegis®: is a prescription drug for treatment of nausea of pregnancy, also known as morning sickness. Its cost: almost $600.00/ 100 tablets. Diclegis® contains Vitamin B-6 and Pyridoxine, both which are available over the counter. Always consult your obstetrician before taking any over the counter meds.

Niacin deficiency was common in the southern United States in the early 1900’s due to diets being heavy in corn-based products. United States Surgeon General Joseph Goldberger observed the link in pellagra and orphanages and mental hospitals. In 1926 he established a diet that supplemented Brewer’s yeast to correct this deficiency. Pellagra can also occur in populations that are homeless, alcoholic, or psychiatric patients who refuse food.

Dietary sources: meat, fish, legumes, whole grains. Grains are supplemented with micronutrients such as thiamin, riboflavin, niacin, iron and folic acid.

Function: converts carbohydrates into glucose, metabolizing fats and proteins, and keeping the nervous system working properly

Deficiency states are rare, due to the presence in most of the foods we ear. Niacin deficiency causes Pellagra “translation: rough skin”. Primary symptoms involve the 3 D’s of Pellagra: Dermatitis, Diarrhea, Dementia.

Adverse effects: flushing of the top layers of the skin, stomach upset, and may increase blood sugar levels. The “flushing” is like a hot flash, which can be blocked by taking an Aspirin 325mg tablet one hour before the dose of niacin. Acetaminophen (Tylenol) does NOT work.

Function of riboflavin: Function: central component in a number of enzyme systems, especially in the lungs.

Dietary sources: milk and eggs, meats, fish, green vegetables, yeast, and enriched foods such as fortified cereals and breads. Grains have been fortified with B vitamins since the 1950’s. Because riboflavin is light sensitive, milk is usually commercially sold in an opaque container.

Deficiency States: Riboflavin deficiency is extremely rare in the United States. In addition to inadequate intake, causes of riboflavin deficiency can include endocrine abnormalities (such as thyroid hormone insufficiency) and some diseases.

· Inflamed lips cracks and sores at corners of the mouth

· Inflammation of the inside of the mouth

· Eye conditions such as dimness of vision without detectable lesions of eye

· Sebaceous dermatosis

Potential riboflavin deficiency states:

· Patients with anorexia nervosa

· Very rarely, inborn errors in metabolism of riboflavin dependent enzymes

· celiac disease due to poor absorption

Vitamin B-1 (Thiamine) (also spelled “thiamin”)

Function of Thiamine: works to help break down carbohydrates and plays a role in nerve conduction.

Deficiency States: Also associated with malabsorption, dialysis, and protein-calorie under nutrition. In addition to insufficient intakes of thiamin from the diet, the causes of thiamin deficiency include lower absorption or higher excretion rates than normal due, for example, to certain conditions (such as alcohol dependence or HIV/AIDS) or use of some medications.

• Dry beriberi: affects the nervous system and may cause psychiatric disturbances.
• Wet beriberi: may cause heart problems and leads to overall weakness.

Alcoholics: Most thiamine deficiencies in the US are due to alcoholism. Chronic alcohol use disorders appear to be the most common cause of thiamin deficiency. Up to 80% of people with chronic alcoholism develop thiamin deficiency because alcohol intake reduces gastrointestinal absorption of thiamin, thiamin stores in the liver, and thiamin metabolism.

People with alcoholism tend to have poor nutritional intake and therefore inadequate intakes of essential nutrients, including thiamin. Wernicke-Korsakoff syndrome is one of the most severe psychiatric symptoms of alcohol abuse. All patients with alcohol abuse should be supplemented with thiamine.

The last fat-soluble vitamin we need to mention is Vitamin-K. We get plenty from the food we eat, and what we make in our bowels. All though Vitamin-K is fat soluble, we accumulate very little. We have at most 7 days of storage.

Sources for Vitamin K: leafy vegetables, vegetable oils, liver, & synthesis by what we make in our intestines. Phylloquinone (Vitamin K-1) is present primarily in green leafy vegetables and is the main dietary form of vitamin K. Menaquinones (Vitamin K-2), especially long-chain menaquinones, are produced by bacteria in the human gut.

Vitamin-K is necessary for activation of clotting factors.

Deficiency States: Can be due to:

• Excessive antibiotic use. Newborns & preemies are at increased risk.

• Cystic fibrosis patients because of fat malabsorption and broad-spectrum antibiotic use (that kills off bacteria that produces Vitamin-K) should be supplemented with Vitamin-K

• Vitamin-K stores are small- deficiency may develop in a week.

Interactions: warfarin, a 60-year-old drug for thinning the blood opposes Vitamin K in the clotting cascade. Warfarin patients need to be aware of food interactions with this drug.

Vitamin-E: more useful for women than men!

Vitamin E (tocopherol) is a fat-soluble vitamin with antioxidant properties; it protects cell membranes from oxidation and destruction. A few decades ago, it was widely touted for everything, however lately its use has fallen out of favor. As an antioxidant, it protects cells from the damage caused by free radicals. Free radicals are produced from the conversion of food to energy. People are also exposed to free radicals in the environment from cigarette smoke, air pollution, and ultraviolet light from the sun.

• Source: there are 8 naturally tocopherols. The most active is d-alpha-tocopherol.

• Dietary sources: Vegetable oils, wheat germ, leafy vegetables, egg yolk, margarine, legumes.

Cancer: The Selenium and Vitamin E Cancer Prevention Trial (SELECT) was published in October 16, 2011 edition of The Journal of the American Medical Association.

• 400 IUs (360mg) /day & over significantly increased the risk of prostate cancer among healthy men when compared with healthy men taking placebo.

• The researchers found that the increased risk means that there will be 1 to 2 more prostate cancers per 1000 patients who took the high dose vitamin E for one year. Interestingly, in men who received both vitamin E and selenium, there was no increased rate of prostate cancer.

Melatonin is classified as a “dietary supplement” by the FDA, even though most of us look at melatonin as drug product.

Our body makes melatonin and is secreted by the pineal gland in the brain to regulate sleep-wake cycles or circadian rhythms. Melatonin is synthesized from the amino acid tryptophan. Melatonin secretion begins around the third or fourth month of life, peaks in pediatric years, and lessens as we age. A 70-year-old has about ¼ of the melatonin secretion as young adults do. Supplementation of melatonin seems to be a reasonable option for sleep induction.

• USE: May be useful may help to regulate sleep disturbances that occur with insomnia, jet lag, rotating shiftwork, depression, chronic kidney disease.
• Jet lag: Melatonin can improve some symptoms of jet lag, such as alertness and psychomotor performance, may also be useful for daytime sleepiness and fatigue.

Might not be effective for helping you fall asleep quicker..

• DOSE: 0.3—1 mg produces normal melatonin levels in the circulation; Suggest higher doses of (2—6 mg) which are needed to obtain beneficial effects. Maximum: 10 mg/day.
• Doses over 10mg may produce excess concentrations of melatonin which can produce numerous biological effects. Daytime sleepiness, impaired mental and physical performance, hypothermia, and hyperprolactinemia can be caused by excessive melatonin doses. These effects are not observed with normal concentrations of melatonin.

What it does: Vitamin A is the name of a group of fat-soluble retinoids, which are involved in immune function, vision, reproduction, and cellular communication. Vitamin A is critical for function in the retinal receptors, as well as for the outer surface of the eye. Vitamin A also supports cell growth playing a critical role in the normal formation and maintenance of the heart, lungs, kidneys, and other organs.

• Dietary sources: fish liver oils, egg yolks, green leafy, orange & yellow vegetables.

Deficiency States:

• Night blindness: early sign of Vitamin-A deficiency. May progress to xerophthalmia, which is dryness & ulceration of the cornea. May progress to blindness.

• See decrease in heath and integrity of skin.

• Deficiency is rare. Cystic fibrosis patients need supplementation.

Adverse effects: dry mucus membranes, cracked lips, yellowing of skin, fatigue, nausea, hair loss, headache, dizziness, blurred vision, birth defects, loss of muscular coordination, dry scaly skin.

• Multivitamin supplements typically contain 2,500–10,000 IU vitamin A, often in the form of both retinol and beta-carotene.

Which Calcium is best?

In the last Clinicians Corner, we discussed Vitamin-D supplementation. Although Vitamin-D is helpful in immune system functioning, its primary role is in maintaining calcium regulation in the body. Vitamin-D is necessary for calcium absorption to occur out of our gastrointestinal tract.

Many of our patients, because they are elderly or take acid suppressing drugs, have limited stomach acid. Calcium carbonate, which is made from oyster shells, requires acid for dissolution and absorption. With many of our patients taking acid suppressing therapy, Calcium citrate which does not require acid for dissolution, is a better option for this group.

Calcium carbonate: (Os-Cal-500)

· Contains 40% Calcium (500mg Calcium per tablet)

· Should be taken with a meal. Optimal absorption occurs in the presence of gastric acid.

· May cause constipation, divided dosing and adequate fluids should alleviate its occurrence.

· Must divide doses. Approximately 500mg can be absorbed at a single time.

· Keep in mind that “Tums®” antacid is calcium carbonate in a chewable form. It is a lot less expensive than the chewable calcium supplements. Generic Tums® Ultra is 1000mg of Calcium carbonate, that releases 400mg calcium. Ask your Nickman’s pharmacist to help you save money!

With 41% of the population being vitamin D deficient, especially in these latitudes, we need to be recommending this Vitamin a whole lot more. In a study done in 2011, the overall prevalence rate of vitamin D deficiency was 41.6%, with the highest rate seen in blacks (82.1%), followed by Hispanics (69.2%). Drinking milk and sun exposure is not the answer to correcting this wide scale deficiency. People low in vitamin D who take a supplement may be less likely to fall. That makes sense, given that vitamin D plays a key role in keeping bones and muscles strong.

Do I have to swallow a capsule, what about drinking milk, or exposure to sunshine?

Dairy Products: It takes about 5 quarts (3000kcal) of milk, to equal 2000iu (50mcg) in a capsule…. not to mention over 2750 calories!

Sun Exposure: Sun Exposure (Ultraviolet-B) 2 to 3 times a week during mid-day. Bare arms & legs for 10-15 minutes per session is usually adequate. The effect of sunlight exposure and vitamin D synthesis is reduced in individuals with darker skin pigment. Effective use of a sunscreen does block the synthesis of Vitamin-D in the dermis. Middle aged and elderly persons who use sunscreens daily have significantly lower serum concentrations of 25-Hydroxyvitamin D3. However, the benefits of using a sunscreen, far outweigh the disadvantages of a decrease in Vitamin-D. A local dermatologist told me “it is easier to treat Vitamin-D deficiency than it is to treat skin cancer...so use a sunscreen.”

Lots of our patients take Metformin, which is the first line therapy for Type-2 diabetes. Metformin is a safe drug for initial treatment of Type-2 diabetes, as it helps the body use its own insulin more efficiently without causing hypoglycemia (low blood sugar). Untreated high blood sugars can lead to diabetic peripheral neuropathy, which begins as tingling and burning in the hands and feet. Vitamin B-12 levels that are too low can also cause tingling and burning in the hands and feet. Sometimes these two conditions (diabetic peripheral neuropathy and Vitamin B-12 deficiency) can have the same symptoms and can be confused.

WATCH for Metformin induced Vitamin B12 deficiency

· Up to 30% of patients on metformin have reduced B12 absorption which could eventually lead to B12 deficiency. Besides anemia, Vitamin-B12 deficiency can cause peripheral nerve damage, which can be mistaken for Diabetic Peripheral Neuropathy (DPN).

· Check B12 levels if new diabetic peripheral neuropathy occurs or neuropathy gets worse. The lower B12 levels may cause an increased risk of peripheral neuropathy.

· Treatment: Injectable B-12 usually not necessary, oral B12 (1000mcg PO daily) is sufficient. Do not stop metformin, just treat the B12 deficiency.

Everyone is excited that the Pfizer COVID-19 vaccine was approved by the FDA and is now being distributed. Patients have lots of questions and your Nickman’s pharmacist wants to provide you with the most updated information.

SAFETY

Pfizer said that no serious safety concerns related to the vaccine were reported in its study, which included 43,661 volunteers. This would fill Heinz Field to 63% capacity.

Keep in mind that GSK studied Shingrix (shingles vaccine) in 30,000 people! And this vaccine is given ONLY to patients over 50 years of age.

Side effects do occur with any vaccine injections, here is what to expect:

• Injection site reaction (redness, swelling, some pain)
• Some fatigue (tiredness)
• Headache
• Muscle and joint pain
• fever

Keep in mind, this vaccine cannot give someone COVID-19, because it is a messenger RNA (mRNA) based vaccine. There are no active virus particles in the injection.

EFFICACY

How did they get this vaccine so fast? Lots of money, lots of companies, lots of scientist’s laser focused in developing a safe and effective vaccine. Government financial support allowed these drug companies to make a full-fledged effort to develop this life saving vaccine. Pfizer did not accept any development money but will sell 100 million doses to the U.S. government in exchange for $1.9 billion ($19 per dose). Moderna received about $1 billion in federal funds to support its vaccine development and has agreed to provide 100 million doses to the U.S. for $1.5 billion ($15 per dose). So far Pfizer and Moderna’s vaccine is showing about 95% efficacy, when compared to the seasonal influenza vaccine which is around 45% effective.

There has been a 40% decrease in Emergency Department visits due to the COVID-19 pandemic. Patients are concerned about going to the Emergency Department due to the potential of being around all those “sick people.”

There are times however that patients MUST go to the emergency department for serious illness. If you are exhibiting any of the following signs, SEEK EMERGENCY CARE IMMEDIATELY.

Signs and Symptoms of Pulmonary Embolism (PE)

A pulmonary embolism is a blood clot in the lung. If left untreated 30% of the patients will die. If you experience the following symptoms seek emergency care immediately.

• Dyspnea: Difficulty breathing or shortness of breath. Usually sudden and severe.
• Hemoptysis: Coughing up blood.
• Diaphoresis: Abnormal sweating.
• Cyanosis: Nails or lips turning blue.
• Tachycardia: Rapid heartbeat
• Pain: Unexplained sharp, severe pain in the chest and/or back.
• Syncope: Loss of consciousness.

Signs and Symptoms of Deep Vein Thrombus (DVT)

There has been a 40% decrease in Emergency Department visits due to the COVID-19 pandemic. Patients are concerned about going to the Emergency Department due to the potential of being around all those “sick people.”

There are times however that patients MUST go to the emergency department for serious illness. If you are exhibiting any of the following signs, SEEK EMERGENCY CARE IMMEDIATELY.

The best way to describe a stroke is a “brain attack”, where the brain gets deprived of blood supply. If a patient exhibits the signs and symptoms listed below, call immediately for emergency care. Once a patient gets to the hospital, one hour is needed to determine whether the interruption in blood supply is due to a blood clot (occlusive) or a ruptured blood vessel (hemorrhagic). For hemorrhagic strokes up to 50% of people can die in the first year.

Occlusive strokes can be treated with a “clot buster” to unplug the vessel and restore circulation. However, the clot buster can only be administered within 3 hours of the onset of symptoms. Therefore, it is urgent to seek emergency care immediately.

• B -Balance: sudden loss of balance, headache, or dizziness
• E -Eyes: trouble seeing out of one or both eyes
• F -Face: Uneven smile or expression, facial droop, or numbness in the face
• A -Arms: weakness, numbness, one arm drifts down
• S -Speech: slurred, mute, inappropriate words, or strange speech
• T- Time: seek help immediately. Immediately call 9-1-1.

Let’s assume that you bought your hygrometer (humidity monitor) and your child is congested and you want to run a humidifier in your kid’s bedroom. Your Nickman’s Pharmacist can help make the best and safest selection and provide tips to care for your humidifier.

TYPES of HUMIDIFIERS

“Cool Mist” These two types of humidifiers generally appear to produce the greatest dispersions of both bacteria and minerals.

• Ultrasonic, which create a cool mist by means of ultrasonic sound vibrations.
• Impeller, or "cool mist," which produces a cool mist by means of a high-speed rotating disk.

Two additional types of humidifiers can allow for growth of bacteria and fungus if they are equipped with a tank that holds standing water, but generally disperse less, if any, of these pollutants into the air. These are:

• Evaporative: transmits moisture into the air invisibly by using a fan to blow air through a moistened absorbent material, such as a belt, wick, or filter.
• Steam vaporizer: which create steam by heating water with an electrical heating element or electrodes. "Warm mist" humidifiers are a type of steam vaporizer humidifier in which the steam is cooled before exiting the machine. The American Academy of Pediatrics does not recommend warm steam vaporizers.

HUMIDIFIERS, what you need to know!

We pharmacists frequently get questions about choosing a humidifier. Your Nickman’s Pharmacist can help you make that decision but here is some pertinent information.

· Every homeowner should own a hygrometer that measures temperature and relative humidity. The ideal relative humidity for health and comfort is about 40-50%. Most allergists recommend, “before you recommend a humidifier, recommend a hygrometer first!”

· In the winter months, it may have to be lower than 40% relative humidity to avoid condensation on the windows

· If a parent wants a cool mist humidifier for a child who is congested or has a runny nose, keep in mind that it may make their allergies worse, especially if they are allergic to dust mites and mold.

· Dust mites and mold like high humidity levels, so a humidifier will increase humidity and make allergies worse. Mites contain about 70% to 75% water by weight and must maintain this to reproduce. Their primary source of water for dust mites is ambient water vapor

· For dust mite control, you want to keep humidity levels low. An air conditioner or dehumidifier can help to keep humidity levels low -below 50% if possible. (30% is adequate)

Pete Kreckel

Who should get the flu vaccine?

That’s easy… virtually everyone from age six months and up, regardless of pregnancy status. Patients with laboratory confirmed COVID 19 infection, symptomatic or not, should not get the influenza vaccination until they are no longer acutely and do not require isolation. On average about 45% of the United States citizens get their annual flu shot.

Efficacy of last year’s vaccine: was estimated to be 45% with 50% accuracy for the Influenza-B and 37% for Influenza-A

Flu vaccines for our patients over age 65:

• Fluzone High-Dose Quadrivalent® contains four times the amount of antigen as the standard-dose inactivated flu vaccine, producing better protection in the elderly population. In a NEJM study Fluzone High Dose was found to be 24% more effective in preventing flu in adults 65 years and older relative to a standard-dose vaccine.
• FLUAD® Influenza Vaccine, Adjuvanted: For active immunization of persons 65 years of age and older against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine. (Source: fda.com) Medicare beneficiaries 65 years and older found that trivalent FLUAD provided greater protection against flu-related hospitalizations than standard-dose, egg-based flu vaccine.

Let’s assume you didn’t adequately follow our prevention tips. We can cover two scenarios. The first we will discuss when you find a tick on your skin, and remove it. Then we can discuss treatment when the characteristic rash appears.

Pharmacological Prevention of Lyme disease:

The Infectious Disease Society of America recommends antibiotics for prevention of a tick bite only when:

· Attached tick identified as an adult or nymphal deer tick (Ixodes scapularis)

· Tick is estimated to have been attached for 36 + hours

· The antibiotic can be given within 72 hours of tick removal

· The local rate of tick infection with B. burgdorferi is ≥20 percent. (we certainly have that in Central Pennsylvania)

· Doxycycline is safe to be given. Not for patients that are pregnant, nursing or a pediatric patient.

Recommended dose: Doxycycline 100mg (2) tablets daily as a single dose with food.

Pharmacological Treatment of Lyme disease

The first sign of infection is usually a circular rash called erythema migrans (bullseye rash). This rash occurs in approximately 70-80% of infected persons and begins at the site of a tick bite after a delay of 3-30 days. (So, 20-30% of the time is does NOT occur)

LYME DISEASE #1

Pennsylvania, for many years has led the nation in number cases of Lyme disease. Now that hunting season is underway on our state, everyone is headed to the great outdoors either a day of hunting or staying home and doing yeardwork! Many of our patients are coming to Nickman’s Drug with questions about Lyme disease. Your Nickman’s pharmacist should be consulted with your questions about Lyme disease.

CAUSE: by the bacterium Borrelia burgdorferi and is transmitted to humans by the bite of infected blacklegged ticks (Ixodes scapularis) more commonly referred to as the “deer tick”. SYMPTOMS: include fever, headache, fatigue, and a characteristic skin rash called erythema migrans, which occurs 3-30 days after the tick bite. The rash is sometimes called a “bulls-eye” rash.

THE RASH

· May occur anywhere on the body, and appears in approximately 70 to 80 percent of infected persons—(so unfortunately 20-30% of the time it does NOT appear)

· Begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days)

· Expands gradually over a period of days reaching up to 12 inches or more (30 cm) across