Toenail Fungus

Unattractive toenails are common but have many causes, including fungus, trauma and autoimmune disease. Athletes can develop dystrophic toenails from repeated sudden-stop trauma associated with basketball, soccer and tennis. The great toes are most often involved in fungal disease and trauma-related dystrophy but exclusive little toe involvement is likely related to trauma.

The diagnosis of toenail fungal infection should be confirmed by laboratory diagnosis. Treatment courses are long and can be expensive, failure rates are high and recurrences are common.

FDA has approved efinaconazole topical solution, or Jublia, for the treatment of toenail onychomycosis (toenail fungus). This is applied like nail polish daily for 48 weeks and the manufacturer claims a 25% cure rate. A product already on the market, ciclopiox (Penlac) has a 7% cure rate after 48 weeks.

Oral medications, such as Lamisil (terbinafine), are usually the treatment of choice since the initial cure rate is as high as 76%. Liver toxicity is a concern and blood tests are needed during treatment. Medication is taken for twelve weeks but it may take a year to assess.

Preventing infection is best: Keep feet clean and dry, avoid sharing nail tools such as clippers and scissors and wear flip-flops or other footwear in the gym shower or locker room.

More information, including a discussion on non-prescription treatments.

Vitamin D

Today is the start of winter, the day with the fewest hours of daylight. It’s also the coldest time of year with the least amount of skin exposed. Consequently, skin production of vitamin D ceases in in cold climates. Many adults require vitamin D supplements, especially in the winter when stores can go to zero by spring. Vitamin D deficiency is associated with osteoporosis as well as the health of the immune and cardiovascular systems.

The prevalence of low vitamin D is increasing globally and is more common in South Asia and the Middle East. Black Americans have lower measured vitamin D levels, but have better bone density and fewer fractures. Ironically, almost all research on vitamin D supplements have been done on white patients but black women will increase levels after supplements at the same rate as white women.

Vitamin D supplements are inexpensive and widely available. For patients with normal vitamin D levels, as daily supplement of at least 800 IU is adequate. Higher doses are needed to treat deficiency. For high risk patients, prescription strength dosing of 50,000 IU once weekly may be needed followed by daily supplements.

All patients should maintain a daily total calcium intake (diet plus supplement) of 1000 mg (for ages 19 to 70 years) to 1200 mg (for women ages 51 through 70 years and all adults 71 years and older).

Pneumonia Shot

The pneumonia shot is recommended for all adults older than age 65. More than ninety different types of pneumococcus bacteria have been identified and it is impossible to immunize against all of them. Vaccines have been developed against the most common types.

The traditional pneumonia shot given to older adults protects against the twenty-three strains that cause 80-90% of disease. This is the vaccine that has been used for decades. Recently, guidelines recommend adding a second shot that protects against thirteen additional strains. This second shot had previously been given to children and adults who had underlying medical conditions that reduced their immunity.

The latest recommendation from United States Advisory Committee on Immunization Practices (ACIP) is that at age 65 every adult have the PCV 13 shot followed by the PCV 23 six to twelve months later. Adults older than 65 who already had the PCV 23 should have the PCV 13 one or more years later. 

Either form of the pneumonia shot can be given at the same time as another vaccine. It takes the body about two weeks to start producing antibodies (which is how the vaccine works). The most common side-effects are pain, swelling and redness at the injection site – these typically last fewer than 48 hours.

More information about PCV 23 and PCV 13.

Medicare and many insurance companies will pay for these shots - but be sure to check with your carrier. 

Brown or White?

Egg farmers produce a wide variety of eggs to meet consumer demand. Brown eggs are preferred primarily in the Northeast United States, while white eggs are preferred across the rest of the country. Shell color has no effect on nutrient content as nutrient content is determined by the hen’s feed. The only difference is white-feathered hens lay white eggs and red-feathered hens lay brown eggs. Brown and white eggs have virtually identical nutrient profiles, but studies show consumers perceive brown eggs to be more nutritious, have greater flavor and fat content, and believe they come from less conventional farm practices. Hens that lay brown eggs are larger and require more feed; as a result, brown eggs may be more expensive.

America’s egg farmers produce eggs using a variety of production methods. Consumers may recognize USDA-defined terms such as “cage-free” or “free-roaming” eggs laid by hens in indoor floor operations; and “free-range” eggs that are laid by hens with access to the outdoors in accordance with weather, environmental or state laws. Studies have been conducted to determine if housing and production methods affect nutrient quality. The findings indicate that housing type had no effect on cholesterol, vitamin A or vitamin E content. Fatty acid composition, however, did vary between housing types: eggs from the free range production system had slightly higher total fat, monounsaturated fat, and polyunsaturated fat than eggs produced by caged hens. The research suggests that these differences in fatty acid composition reflect the free range hens’ access to wild seeds and insects. There is little nutritional difference between certified organic and conventional eggs.

While people will always have their own egg preferences, the preponderance of current research suggests that all types of hen-laid eggs offer high-quality protein with varying amounts of 13 essential vitamins and minerals. Let your conscience (and pocketbook) be your guide.

More information (sponsored by the egg industry - keep that in mind).

Kidney Stones

There is universal agreement: kidney stones are the most painful experiences known. Once someone has a kidney stone he will make all efforts to prevent it from happening again. There are some current recommendations lending scientific credence to widely held beliefs.

Drinking more fluid to increase urination may decrease the risk of recurrence of kidney stones. Patients who have had kidney stones should drink enough to produce at least two liters of urine daily.

Researchers reviewed published literature from 1948 to March 2014 to create the evidence-based guideline, which appeared in the Nov. 4 Annals of Internal Medicine. 

Stone recurrence may also be prevented by reducing dietary oxalate, such as that found in chocolate, beets, nuts, rhubarb, spinach, strawberries, tea, and wheat bran; reducing dietary animal protein and purines; and maintaining normal dietary calcium, according to the guideline.

The evidence also showed that patients who decreased intake of soda that was acidified by phosphoric acid had reduced kidney stone recurrence. The benefit was limited to patients who drank soda that was acidified by phosphoric acid (typically colas) rather than those acidified by citric acid (typically fruit-flavored sodas).  Even though colas are the bad actors in these studies, there doesn’t appear to be any role for any type of soda in the diet.