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With recent frigid temperatures and snow measured in feet instead of inches, emergency departments in cold weather areas of the country are seeing an increasing number of people with frostbite.

Most people bundle up well for winter activities, but what happens when you are unexpectedly facing the bitter cold for prolonged time periods such as if the train is running late and you are waiting for it outdoors, or if your car breaks down? In freezing weather, it is important to be prepared at all times.

Frostbite occurs when cold temperatures kill exposed skin tissue and most noticeably affects fingers, toes, ears, nose, cheeks and chin.

The signs and symptoms start with cold skin and a prickly feeling in the affected area. That may then progress to numbness. Skin may turn red, white, bluish-white, or yellowish-white in color and may become hard or waxy in appearance.

Blistering may occur after rewarming. Superficial frostbite may turn the skin blue and blister up to 24 hours after rewarming. With deep frostbite, the skin may blister up to 48 hours after rewarming. Multiple layers of skin may be damaged, and the condition can cause permanent damage. See a doctor immediately if skin is damaged, blue, or blistered, or if there is numbness after rewarming.

How to avoid frostbite:

• Limit your time outdoors. At 0 degrees Fahrenheit, frostbite can occur in 30 minutes. In -10 below temperatures, it can occur in less than 10 minutes depending on wind chill.

• Dress in loose warm clothing. Air trapped between layers of clothing acts as insulation. Mittens are better than gloves. Be sure to cover ears with a hat or headband. Wear socks and sock liners that fit properly.

• If you are going to be outdoors, don't drink alcohol or smoke cigarettes. Both contribute to frostbite.

• Change out of wet clothing immediately.

• Actively rewarm yourself with a warm, not hot, bath and drink a hot beverage such as coffee, tea or hot chocolate. There may be some pain associated with rewarming as well. This should pass within 30 minutes.

• Eat well and hydrate appropriately.

• Keep moving. Exercise gets blood flow to the extremities.

• Plan well for traveling in your car. Have appropriate clothing (hats, gloves, winter coat) in your car in case you get stranded. Carry extra blankets, water and emergency supplies in the trunk.

--Angelo Pucillo, PA-C, is the assistant chief physician assistant in the emergency department at Hallmark Health System.

Twenty-one physicians affiliated with Hallmark Health System have been named Top Doctors in the Boston Area according to Boston Consumers' CHECKBOOK magazine and . The magazine lists local physicians practicing in 38 specialty fields most frequently recommended in a survey of other doctors.

CHECKBOOK surveyed all actively practicing doctors in the Boston area. Each surveyed doctor was asked to identify physicians he or she "would consider most desirable for care of a loved one." Doctors could recommend one or two specialists in each of the 38 specialty fields. CHECKBOOK reports which physicians were recommended most often, and how many doctors recommended each physician specialist. CHECKBOOK includes only those doctors mentioned enough times by other physicians to be statistically significant.

The Hallmark Health physicians listed are:
Christian Andersen – Orthopedic Surgery
Dennis Begos – Colon & Rectal Surgery
David Bowling – Otolaryngology
Edward Butler – Infectious Disease
Laurence Conway – Cardiology
Anthony Dash – Nephrology
Martha Dyer – Urology
David Gendelman – Ophthalmology
Donald Grande – Dermatology
Suzanne Grevelink – Dermatology
Mark Iafrati – Vascular Surgery
Nasima Khatoon – Hematology/Oncology
Steven Kornbleuth – Dermatology
Robert Pastan – Rheumatology
Khether Raby – Cardiology
David Riester – Allergy/Immunology
David Samenuk – Cardiology
Coralli So – Interventional Radiology
Jeffrey Sobell – Dermatology
Peter Tiffany – Urology
Wayne Wivell – Radiology

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About Hallmark Health
Hallmark Health System is the premier, charitable provider of vital health services to Boston's northern communities. The system includes Lawrence Memorial Hospital of Medford; Melrose Wakefield Hospital, Melrose; Hallmark Health Hematology and Oncology Center, Stoneham; The CHEM Center for MRI, Stoneham; Hallmark Health Medical Center, Reading; Hallmark Health VNA and Hospice; Lawrence Memorial/Regis College Nursing and Radiography Programs, Medford and Hallmark Health Medical Associates, Inc. Hallmark Health is affiliated with Massachusetts General Hospital for cardiology and Tufts Medical Center for neonatology and the Joslin Diabetes Center for diabetes care.

The flu is here. It is nasty and you should be doing everything you can to avoid it.
That is the message from Gary Pransky, MD, a family medicine physician who practices at Hallmark Health Medical Associates in Winthrop. "Without a doubt, the most important thing you can do to prevent the flu, or at least lessen its impact, is to receive a flu vaccination," said Dr. Pransky. "It is not too late to get the shot, as we still have at least a month of heavy flu season."
The most common reason people elect not to get the vaccine is the misconception that it can actually give a person the flu. "That is incorrect," said Dr. Pransky. "The flu vaccine is a 'dead' vaccine, meaning it has no live influenza components, and therefore cannot give someone the flu."
In addition to receiving the vaccination, people should adhere to strict hand-washing routines during flu season, get plenty of rest and exercise, eat a healthy diet and try to avoid stress. "Hand washing is effective when done with soap and water for at least 20 seconds," explained Dr. Pransky. "Hand sanitizers also work well."
If you do end up with the flu, you can do a few things to lessen its impact. "A medication called Tamiflu can help with the symptoms," said Dr. Pransky. "The trick is that you need to take it within 48 hours of showing flu symptoms." The symptoms include fever, muscle aches, nausea, vomiting and cough. "Your physician can run a quick test to tell for sure if you have the flu, which is why it is important to contact your doctor as soon as symptoms begin to set in."
If you miss the 48-hour window, there are still some things you can do to feel better. "Rest and plenty of fluids can help. Anti-inflammatory over-the-counter medications can also help, but you should avoid taking aspirin," added Dr. Pransky. "And we shouldn't dismiss the power of chicken soup and hot fluids in general, as they can help to move the secretions through your system."
Dr. Pransky also reminds us that the flu can be deadly and should not be taken lightly. "It is estimated that in the United States, 5 to 20% of the population gets the flu each year on average and more than 200,000 people are hospitalized from seasonal flu-related complications. Flu is easily spread by coughing and sneezing and individuals are typically contagious for about one week and 24 hours after their fever is gone," he said. "It is crucial to stay home. Don't go to work or school if you suspect that you have the flu. It is too dangerous for people who are at heightened risk, including children under age 2, women who are pregnant or within two weeks postpartum, people on aspirin therapy or who are immune-suppressed, the elderly or those who have chronic diseases."
"I can't stress the importance of getting a flu vaccination," said Dr. Pransky. "There is still time to vaccinate and there is still plenty of vaccine. I would also recommend a pneumonia shot for seniors and those with chronic illness."
Dr. Pransky is a family medicine physician at Hallmark Health Medical Associates, located at 52 Crest Winthrop. He can be reached at 617-846-8622.

Managing your diabetes during New England winters can be full of challenges such as the frigid weather, holiday stress and the cold and flu season. Taking certain precautions at this time of year can help individuals with diabetes stay safe and healthy.
Mike Cheney, NP, a nurse practitioner at the Joslin Diabetes Affiliate and Endocrine Center at Hallmark Health, offered the following tips.
Increased risks for those with diabetes
Winter-time weight gain and inactivity can be added risk factors for patients with diabetes. "There are parties and festivities with all kinds of tempting treats, and sometimes we may not pay as much attention to what we are eating and drinking as we normally do," said Cheney. "Coming off of the winter holidays we sometimes see our patients struggling with their weight."
Cheney points out that talking with your physician and working with your dietitian can help keep you on track and offers the following suggestions to keep your body moving.
• Skip the elevator and take the stairs.
• Find a walking program at a local mall or shopping center.
• Try activities you can do at home, such as stretching.
• This might be the right time to use that gym membership or even work with a personal trainer (programs such as the Hallmark Health System Center for Weight Management and Weight Loss Surgery offer discounted rates to personal trainers).
"Just remember to consult with your physician before you begin any exercise program," reminded Cheney.
Illness impacts blood sugar levels
When you are sick with flu, cold, respiratory infection and other common winter illnesses your blood sugar levels can be affected. You will need to monitor your levels more frequently, and let your provider know of any changes. Cheney suggests the following.
• Prevention is the best medicine
• Get an annual flu shot – its not too late!
• Practice good hand hygiene
• Cover your nose and mouth with a tissue or your elbow when sneezing and coughing

The cold's affect on circulation
One of the complications of diabetes is that temperature sensation in your legs and feet can be affected. "We see people trying warm up with hot water bottles or electric blankets. This can result in burns. Also, if you are stepping into a hot bath to warm up, be sure to test the water with your hands first to get a true gauge of the water temperature."
"When you're going outside, the best way to stay warm is to dress in layers and to make sure that your head, hands and feet are well protected," said Cheney. "But individuals with diabetes need to think about other important items being kept warm as well. Your insulin, glucose meter, and test strips are sensitive to the cold. Be sure not to leave them in your car or exposed to the cold for long periods of time as their effectiveness can be diminished."
Hydrate and Moisturize
Dry winter air can lead to dehydration, which can raise blood glucose levels and dry out skin. "During the cold weather months many people don't realize just how much water they lose over the course of a day," said Cheney. "Remember to drink fluids and to use a thick moisturizer regularly on your skin (thin ones tend to evaporate quickly). Take good care of your feet, but don't use moisturizer between your toes, as it could lead to fungal growth."
Final Thought
"The most important thing anyone, with or without diabetes, can do to improve their health is to quit smoking if you still smoke," added Cheney. "Beyond that, individuals with diabetes should work closely with their doctors and health team, be conscious of their food choices, and try to lead an active lifestyle."
The Joslin Diabetes Affiliate and Endocrine Program at Hallmark Health offers the latest advances for treating diabetes and its complications as well as patient education and support services. Hallmark Health is one of 47 national and two international Affiliate locations and the only Joslin Affiliate in Boston's northern suburbs.

Michael V. Sack, FACHE, president and chief executive officer of Hallmark Health System, Inc., announced today that he intends to retire this month.

Mr. Sack said, "I have enjoyed my time and all of the wonderful people I have worked with over the last twelve years. I am proud of all that we have accomplished and I have tremendous confidence in the entire Hallmark Health organization's ability to succeed – now and into the future."

James Herrington, chair of Hallmark Health System's Board of Trustees, said, "The Board thanks Michael Sack for his twelve years of exceptional service and commitment to the organization and its communities. He has ably led Hallmark Health through a period of tremendous and fundamental change, and his skills, experience and wisdom will be missed."

The organization's accomplishments under Mr. Sack's leadership include:

• Advancing the quality and safety of care by promoting transparency and adopting technologies such as the eICU to help reduce mortality of the most critical patients, and introducing award-winning electronic health records across the system.

• Enhancing access to care by expanding services within the communities we serve with the opening of our Hematology/Oncology Center and our Comprehensive Breast Center in Stoneham, the Family Health Center in Malden, and the Hallmark Health Medical Center in Reading.

• Partnering with recognized leaders such as Joslin Diabetes Center, Massachusetts General Hospital and Tufts Medical Center and championing the great success of Hallmark Health's nursing program making us the first integrated health system in New England to achieve Magnet® status.

• Leading community efforts to promote wellness, including our nationally recognized programs such as Community-Based Care Transitions Program, our Baby-Friendly recognition, our Mobile Food Market and the Asian Elder Diabetes Project. Hallmark Health now partners with more than 100 community organizations to help improve the quality of overall health in the cities and towns we serve.

Mr. Herrington said that the Board will form a succession committee that will oversee a careful, comprehensive and thorough search for Mr. Sack's successor. The committee will undertake a search for a leader with the skills, experience and wisdom to lead Hallmark Health into its next stage of development. Alan Macdonald, Executive Vice President for Strategy and External Affairs and past Board Chairman, has been named interim CEO.

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