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Summer is a great time to enjoy outdoor activities but it’s also in the middle of tick season, which can pose a danger to your health. Keystone Infectious Disease’s Medical Director, Dr. Raghavendra Tirupathi, and medical students studying under him, Rutvi Patel, Namrata Gajjala and Aparajitha Rajkumar answer common questions about Lyme disease and other tick-borne diseases in today’s Take Care article.

What Is Lyme Disease?

Lyme Disease is the most common tick-borne illness found in the United States and Europe. It is caused by a bacterium called Borrelia burgdorferi, which is transmitted through the bite of infected deer ticks, also known as blacklegged ticks.

Where Are the High-Risk Areas For Lyme Disease In The US?

It is only possible to get Lyme disease from ticks which carry the bacteria. In high-risk areas, about 10–50% of deer ticks carry the bacteria. These include Eastern states, The Great Lakes Region, Northern Midwestern states and the West Coast. Each year, the Centers for Disease Control and Prevention (CDC) receives approximately 30,000 reports of Lyme disease from state health departments, but some data suggests as many as 476,000 people could have the disease each year. Pennsylvania leads the US in Lyme disease cases, with as many as 30% of all reported cases occurring in the state.

How Is Lyme Disease Transmitted?

Lyme disease is transmitted by deer tick bites, with the risk depending on geographic location, season, tick type and attachment duration. Ticks must be attached for more than 24 hours and need to feed for over 36 hours to become engorged with blood and capable of transmitting the disease. Moreover, the risk of transmission is higher after 72 hours. An unattached tick poses no risk of transmission. Lyme disease is not spread person-to-person through touching, kissing or sexual contact.

The risk of acquiring Lyme disease from a tick bite is 1-3% in prevalent areas and is more common during late spring and summer months, peaking in June and July. Prompt tick removal reduces this risk. As you can see below, tick bites are most common from April to September, peaking in June and July, but can happen all year round.

What Should I Do If I Get A Tick Bite?

If you get a tick bite, it’s best to remove the tick as soon as possible using a three-step method. First, use curved tweezers to grasp the tick as close to the skin surface as possible. Avoid using a cigarette, petroleum jelly or liquid soap to remove the tick, as these substances may irritate the tick and cause it to behave like a syringe, injecting its bodily fluids into the wound. Next, pull the tweezers with the tick backward, gently and firmly. Do not jerk, twist, squeeze, crush or puncture the tick’s body, as its bodily fluids may contain infection-causing organisms.

If any mouth parts of the tick remain in the skin, leave them alone; they will be expelled naturally. Attempts to remove these parts may result in significant skin trauma. However, if more than half of the tick remains or if you’re unsuccessful in removing it, seek medical attention for expert removal.

Lastly, after removing the tick, wash the skin and hands thoroughly with soap and water. It’s advisable to note the appearance of the tick, as only the deer tick can transmit Lyme disease. Observe the bite area for up to 30 days following the tick bite. Look for the development of a circular rash called a “bull’s-eye.” If a rash develops, contact your healthcare provider promptly.

What Are The Symptoms And When Should I Seek Medical Care?

If you experience any rash or flu-like symptoms such as fever, headache, fatigue or joint pain, it is best to seek healthcare advice. While a small bump at the bite site is typical, if the bite site becomes painful, swollen or oozing, it may indicate infection and require immediate attention. A rash that resembles a bull’s-eye, with central paleness and a circle of redness, is highly indicative of Lyme disease. Rarely, weakness and uncoordinated movement can accompany the rash, which is concerning.

How Is Lyme Disease Diagnosed?

Lyme disease is primarily diagnosed clinically. Specific signs, such as the characteristic rash, weakness or arthritis, along with a history of exposure to ticks or tick bites (especially the deer tick), can help narrow down the diagnosis of Lyme disease compared to other similar viral illnesses. However, a blood test can be used to check for Lyme disease antibodies, which may only test positive after 6 weeks. An early test is likely to be negative.

Should I Get The Tick Tested?

The CDC strongly discourages using tick test results to make decisions about antibiotics, as the results may not be reliable due to variations in quality standards across different laboratories. However, it is advisable to consult with your healthcare provider or a local lab for tick testing. The presence of germs in a tick does not necessarily indicate that the person is infected. Negative results can also be misleading, as another infected tick may have bitten the person unknowingly. Check out the Pennsylvania state DOH website for details about the tick testing laboratories.

Can Lyme Disease Be Treated?

Yes, Lyme disease is treated if symptoms develop and/or tests come back positive. Early diagnosis and treatment help prevent complications such as facial nerve palsy, meningitis, cardiac issues, chronic arthritis and progressive encephalomyelitis (inflammation of the brain and spinal cord). Oral antibiotics like doxycycline, amoxicillin or cefuroxime axetil are effective, while intravenous antibiotics are necessary for severe symptoms.

Can Lyme Disease Be Prevented?

To prevent Lyme disease, avoiding tick bites is essential. Ticks are commonly found in grassy, brushy or wooded areas, so it’s best to steer clear of such environments. When spending time outdoors, sticking to the center of trails helps minimize contact with ticks. Caution should be exercised with pets and outdoor activities, as ticks can also be found on animals. Even in your own yard, steps should be taken to maintain a clean environment and reduce tick exposure.

After outdoor activities, check clothing for ticks before entering the home. Tumble-drying clothes on high heat for 10 minutes kills ticks on dry clothing. Showering with hot water within two hours of coming indoors reduces tick-borne disease risk and helps wash off unattached ticks. Conduct a full body check, including hard-to-reach areas, after returning from tick-infested areas. Check pets for ticks too; finding a crawling tick suggests others may be present.

Can I Use A Tick Repellent?

For effective tick repellent, consider using products containing active ingredients like DEET, picaridin or IR3535 (in 20% concentration). However, products with more than 50% DEET do not necessarily provide extra protection against tick bites. These repellents can be applied directly to the skin using creams, sprays or wipes. The United States Environmental Protection Agency website offers a helpful search tool to find the right product for your needs. Additionally, clothing, boots and camping gear can be treated with products containing 0.5% permethrin. Permethrin-treated items remain protective even after several washes. Alternatively, premade permethrin-treated clothing and gear are available.

Do I need Antibiotics Following A Tick Bite? 

The CDC generally does not recommend antibiotics to prevent diseases after tick bites. However, preventive treatment with a single dose of doxycycline within 72 hours is recommended if the attached tick is identified as a deer tick, has been attached for 36 hours or more and the bite occurs in an area where deer ticks are common. Those who are pregnant or are less than 4 years old should not be treated with doxycycline.

Do Ticks Transmit Other Diseases? 

Deer ticks can transmit multiple diseases alongside Lyme disease, resulting in co-infections. Anaplasmosis, caused by A. phagocytophilum bacteria, is spread by deer ticks and is the most common co-infection with Lyme disease. Symptoms include fever, headache, chills and muscle aches. Doxycycline serves as the standard treatment for both Lyme disease and anaplasmosis. Other co-infections, such as babesiosis, Powassan virus disease and hard tick relapsing fever, are less common but still significant.

By taking proper precautions and performing skin checks on yourself, children and pets after spending time outdoors, you can greatly reduce the chances of tick-borne illness.

This article contains general information only and should not be used as a substitute for professional diagnosis, treatment or care by a qualified health care provider.

As we come to the end of the month of May, we also are coming to an end of Mental Health Awareness month. However, this does not mean that we stop worrying about or monitoring our mental health during the rest of the year. In fact, it is important to always be monitoring your mental health to make sure that you are feeling okay emotionally. Trond Harman, Licensed Clinical Social Worker at Keystone Health shares a few ways that you can easily manage your mental health during the year.

The National Institute of Mental Health recommends the following activities to care for your mental health:

• Get regular exercise: Just 30 minutes of walking every day can boost your mood and improve your health. Small amounts of exercise add up, so don’t be discouraged if you can’t do 30 minutes at one time.

• Make sleep a priority: Stick to a schedule, and make sure you’re getting enough sleep. Blue light from devices and screens can make it harder to fall asleep, so reduce blue light exposure from your phone or computer before bedtime.
• Try a relaxing activity: Explore relaxation or wellness programs or apps, which may incorporate meditation, muscle relaxation, or breathing exercises. Schedule regular times for these and other healthy activities you enjoy, such as listening to music, reading, spending time in nature, and engaging in low-stress hobbies.
• Set goals and priorities: Decide what must get done now and what can wait. Learn to say “no” to new tasks if you start to feel like you’re taking on too much. Try to appreciate what you have accomplished at the end of the day. Remember to not make any task too large because not reaching your goal can give you a sense of failure.
• Practice gratitude: Remind yourself daily of things you are grateful for. Be specific. Write them down or replay them in your mind. Try to find three positives in each day, no matter how small.
• Focus on positivity: Identify and challenge your negative and unhelpful thoughts.
• Stay connected: Reach out to friends or family members who can provide emotional support and practical help. (National Institute of Mental Health, 2022)

It is important to remember that self-care looks different for everyone and to find what works best for you. Engaging in self-care can be a matter of trial and error until you find what is best for you.

You should seek professional help if you are experiencing severe or distressing symptoms that have lasted two weeks or more, such as:

• Difficulty sleeping
• Changes in appetite or unplanned weight changes
• Difficulty getting out of bed in the morning because of mood
• Difficulty concentrating
• Loss of interest in things you usually find enjoyable
• Inability to complete usual tasks and activities
• Feelings of irritability, frustration, or restlessness

There are many ways to find professional help, but the best first step is talking to you Primary Care Provider, or if you are in a state of crisis, calling 9-8-8. Remember that mental health is just as important as your physical health, and it is okay to ask for help when you need it.

Get to know Keystone Women’s Care’s newest provider, Certified Registered Nurse Practitioner Caitlin Murray!

What led to you to becoming a CRNP?
Throughout my lifetime, I’ve had exposure to family members having treatment for, or passing from, female-related cancers. I often wished there was something I could do to fix them. These experiences fueled my desire to make changes in the lives of others. I started my nursing career as a CNA at a local nursing home and felt I could do more to help the residents. I attended and graduated from the LPN program through FCCTC. As an LPN, I had the wonderful opportunity to work outpatient clinics at Hershey Medical Center and eventually started working at our local Emergency Department. Again, I felt I needed to do more for the patients I was caring for, so I enrolled in RN school. As an RN I was able to work in two fields I love, emergency medicine and women’s health/labor and delivery. Both were equally rewarding and helped me grow as a nurse and an individual. I again felt I needed to do more and decided to get my MSN as a Family Nurse Practitioner.

What do you like about working in the Women’s Care field?
I feel it is important for young girls and women to feel supported in their medical care and decisions about their health. There are many joyous occasions that are celebrated working in women’s health. And there are also moments when we can support our patients and their families. Much of my Family Nurse Practitioner education included informing patients of the need for preventative care, and this is something many women often put on the back burner. Now I can perform preventative testing for women. I can educate them regarding their gynecologic and obstetric health options, enabling and empowering them to make the best decisions for themselves. I feel it is important to be an advocate for women and women’s healthcare and reproductive rights.

Where did you go to college?
I obtained my Associate of Science in Nursing at Excelsior College, Albany, NY. I obtained my Master of Science in Nursing, Family Nurse Practitioner from Walden University, Minneapolis, MN.

What is your favorite part of your job?
I enjoy caring for patients. I like establishing trusting relationships and helping patients feel supported in their healthcare decisions. I love to teach and educate patients on their healthcare options.

Why did you choose to work at Keystone?
I worked for Keystone Women’s Care as a triage nurse for about three years before starting the clinical portion of my CRNP education. I knew, if given the opportunity, I wanted to return to the organization as a CRNP because my mission and values aligned with those of Keystone Health. As a provider, putting patient care as my focus was a primary goal and Keystone is known for patient care and advocacy. I also knew Women’s Care would be like returning home and it has truly been a wonderful experience.

What are your hobbies and interests outside of work?
Family time is super important to me. With three kids in different activities and juggling schedules, sometimes a meal together is all we get. I am easily distracted by dogs..and cats..and any animal really! I enjoy being in the mountains, either on a Jeep ride with my dogs, scouting for deer and other wildlife, or hiking. I’m an avid reader and usually always have a book with me wherever I go.

Where is your hometown?
I was born and raised in Franklin County.

What’s an interesting fact about yourself or something people might be surprised to know about you?
I am an avid hunter. I enjoy spending this time in the woods with my boyfriend and my dad. There is nothing better than listening to the woodlands wake up on a crisp fall morning or watching the sunset over the mountain ridge. I also enjoy fishing, either surf or lake.

Is there anything else you’d like people to know about you?
I love to teach. I will explain procedures before starting them and fully answer any questions you have. I want every patient to feel safe and comfortable during their visit. I am down to earth and try to be lighthearted and make people smile, while providing you the best care possible. I also feel it is important to advocate for all patients.

 

Welcome back to the Keystone Family, Caitlin!

Keystone Women’s Care is accepting new patients. Click here to learn more!

Depression, or major depressive disorder (MDD), is a mental health condition that affects millions of people all over the world and can be quite debilitating for those who suffer from it. Feelings of melancholy, hopelessness and helplessness are common symptoms of depression. Other symptoms include changes in sleep and eating habits, loss of interest in things that were once enjoyable, decreased focus and decision-making and diminished sexual desire. Fortunately, depression is a disorder that can be treated, and individuals who are struggling with this condition can choose from a variety of treatment options. In this article, Dr. Zeeshan Faruqui, Director of Interventional Psychiatry at Keystone Behavioral Health, discusses some medication and interventional treatment options.

Medication

Medication is one of the most common treatments for MDD, and is often the first option recommended by medical professionals. There are several different types of antidepressants and each work in different ways. Depending on the person being treated and their specific genes, some types of medication may be more successful than others.

The most widely-used antidepressants are selective serotonin reuptake inhibitors (SSRIs), which function by elevating serotonin levels in the brain. Serotonin is a chemical messenger in your brain that helps to regulate mood, and an increase in serotonin has been shown to reduce the severity of depressive symptoms. Examples of this type of antidepressant include: fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro).

Another type of treatment is serotonin-norepinephrine reuptake inhibitors (SNRIs). These medications are similar to SSRIs as they increase serotonin levels. However, in addition to this, they raise the levels of norepinephrine which affects the body’s response to stress and can have an influence on mood. SNRIs include medications such as venlafaxine (Effexor) and duloxetine (Cymbalta).

The tricyclic antidepressants (TCAs) are an older class of antidepressants that raise serotonin and norepinephrine levels. Because of the greater likelihood that they will cause unwanted side effects, they are not prescribed as frequently as SSRIs or SNRIs. Examples are Amitriptyline (Elavil) and nortriptyline (Pamelor).

In addition, there is an earlier class of antidepressants known as MAOIs, which stands for monoamine oxidase inhibitors. Monoamine oxidase is an enzyme that can remove serotonin and norepinephrine from the brain, and this type of medication prevents them from being removed. However, MAOIs are not commonly recommended as there can be dangerous interactions between them and other types of drugs, and even particular foods. Phenelzine (Nardil) and tranylcypromine (Parnate) are two examples of MAOIs.

Antidepressants can be very effective, but there is a risk of unwanted side effects such as nausea, headaches and dizziness. There is also the possibility of more serious effects, such as an elevated suicide risk, especially in younger people like children and young adults. Patients who are taking antidepressants are regularly monitored by medical professionals to ensure that they are responding well to treatment and are not suffering from any negative side effects.

GABA Pathway Medications

Gamma-aminobutyric acid, also known as GABA, is a neurotransmitter that works to maintain a stable mood and reduce anxious feelings. A number of antidepressants work by targeting a particular circuit in the brain called the GABA pathway.

Brexanolone (Zulresso), one of these medications, has been given the go-ahead by the U.S. Food and Drug Administration (FDA) to treat postpartum depression (PPD). It is a steroid that boosts GABA’s activity, and is a synthetic version of allopregnanolone, which is naturally made by the body. Clinical trials show it can quickly reduce depressive symptoms in women who have PPD.

Ketamine is another type of medicine that works by targeting the GABA pathway. It has been used in medical settings for decades, and in recent years has been shown to be an effective treatment for depression. Even in patients who have not had good results from other treatments, clinical trials show ketamine is able to quickly improve their depression symptoms.

Neuroactive Steroids

Neuroactive steroids belong to a class of hormones known for their influence on the central nervous system as well as the brain. They have the potential to impact one’s mood, level of anxiety and response to stress, and certain neuroactive steroids can be useful in the treatment of depression.

Pregnenolone, a hormone that can be found in the GABA pathway, is one example. The body makes its own pregnenolone, but some people may benefit from increasing their levels. It has been proven in controlled clinical trials to be effective at relieving depressive symptoms in patients diagnosed with MDD.

Dehydroepiandrosterone (also known as DHEA) is another neuroactive steroid. DHEA is a hormone that plays an important role in the creation of other hormones, such as testosterone and estrogen amongst others. Studies conducted on both humans and animals have indicated that exposure to DHEA can have an antidepressant impact. Clinical trials show it can alleviate symptoms of depression in patients diagnosed with MDD.

Other Interventional Treatments

We are now in an era of psychology that involves taking action. Interventional psychiatry uses methods that stimulate the brain or fast-acting drugs to treat symptoms that aren’t getting better with regular medication and/or therapy. Clinicians use a lot of different methods to treat patients, but the ones I’m going to talk about below have been approved by the U.S. FDA, which means they are safe and work. These treatments have demonstrated encouraging results in treating depression, postpartum depression, and other conditions.

Transcranial Magnetic Stimulation

Transcranial Magnetic Stimulation (TMS) is a non-invasive treatment that is used when medicines aren’t working well or are causing side effects. TMS is done by putting a magnetic coil on the patient’s head while they are awake and aware. The treatment is not painful, and people can go back to their normal lives right away. Compared to medicines, TMS has very few side effects and most people who do have them say they are mild and only last a short time.

At my practice we currently offer TMS for those with major depressive disorder, but we hope to also offer this treatment for migraines and obsessive-compulsive disorder in the near future. I believe TMS can have a very positive effect on society, because it can treat a variety of disorders that impact many people’s lives. After studies are finished, it may also be available for those with PTSD, tobacco use disorder, alcohol use disorder and opiate use disorder.

Electroconvulsive Therapy

Another treatment is electroconvulsive therapy (ECT), in which the patient is given anesthesia and a small electrical current is then passed through their brain. This procedure is typically reserved for patients who have not reacted well to other therapies or who have severe symptoms. It is a very effective treatment and works quickly, but there can be side effects including memory loss.

This treatment has gotten a lot of bad press in the media and some movies. It is sometimes referred to as “shock therapy” and in the past was done without anesthesia. Today, ECT is much safer and is one of the best ways to help those with severe depression, including those who have psychosis or suicidal thoughts.

Vagus Nerve Stimulation

In this treatment, a device is implanted into the body which sends electrical signals to the vagus nerve – one of the nerves that connects the brain to the rest of the body. These implants are currently FDA-approved to treat epilepsy and sadness. When the device is turned on, it sends electrical signals down the nerve to the brainstem. The brainstem then sends signals to parts of the brain that are involved in sadness. The amount of energy can be changed based on what a patient needs. In Europe, doctors have cleared new devices that stimulate the vagus nerve without surgery. These devices can be used to treat epilepsy, depression and pain. In the United States, cluster headaches can now be treated with a device that triggers the vagus nerve without any surgery.

Neurosurgical Interventions

In the past, surgery was sometimes used for serious and debilitating cases. Today, neurosurgery is being used more and more to help people with mental illnesses. These treatments are much less invasive than those in the past and are also much more focused. Deep brain stimulation is a well-known and FDA-approved treatment for people with movement disorders like refractory epilepsy, essential tremor, Parkinson’s disease and dystonia, as well as for mental conditions like obsessive-compulsive disorder. Even though deep brain stimulation is thought to be safe, there is always a chance that something could go wrong, and stimulating the brain can have its own side effects. Deep brain stimulation includes making small holes in the head to put the electrodes in and surgery to put the battery-powered device under the skin in the chest.

External Trigeminal Nerve Stimulation

External Trigeminal Nerve Stimulation (eTNS) is the most current FDA-approved treatment for ADHD in children ages 7 to 12. This is the first way to treat ADHD without using drugs, and is meant to be done at home while being watched by an adult. It uses a device about the size of a cell phone which sends a low-level electrical pulse through a small patch that sticks to the patient’s forehead. This is not painful and the patient should only feel some tingling of their skin. It uses low-level electrical stimulation to send messages to the parts of the brain thought to be involved in ADHD. Even though we don’t know exactly how eTNS works yet, studies have shown that it boosts activity in parts of the brain that are important for controlling attention, emotions and behavior. For this to be suggested, you should talk to a mental health professional.

Conclusion

Major depressive disorder is a complicated medical illness that needs to be treated using a variety of different strategies. People who are struggling with depression can benefit from effective treatment options including medications, interventional psychiatric methods, medications that target the GABA pathway and neuroactive steroids. Together with their patient, healthcare professionals determine the most appropriate method of treatment by considering the patient’s specific biology, symptoms and treatment preferences. Patients diagnosed with depression have the potential to experience significant improvements in both the severity of their symptoms and their quality of life when given the appropriate treatment.

 

This article contains general information only and should not be used as a substitute for professional diagnosis, treatment or care by a qualified health care provider.

To learn more about Keystone Behavioral Health, call or text us at 717-709-7930 or visit our website.