Friday, September 28, 2007

Hematoma Healing Process

QUESTION: My husband was in an automobile accident and has a hematoma on his
leg. He is in his 8th week of treatment, and it did go down from the size of
a cantaloupe to that of a lemon. The surgeon aspirated it one time, and is
considering surgery, but is hoping that time alone will clear it up. My
husband is 67 and getting impatient to "get on with life". Tell us what is in

ANSWER: I have no crystal ball to help in predicting your husband's future,
so I will rely on some basic principles and a little knowledge. By now you
know that a hematoma is a collection of blood, a blood cyst if you will, that
was caused by bleeding into the tissue of the leg after the trauma of the
accident. A cantaloupe sized hematoma demands careful attention, which
evidently has been going on and the fact that it is now down to the size of a
lemon is great progress. The aspiration procedure by the surgeon removed some
of the blood while it was still in liquid form, but by now the healing process
of the body is at work, working to return the leg to normal, by removing the
coagulated and consolidated clot bit by bit. The process is a complicated
one, and is helped by heat applications to the area and rest. I know that 8
weeks is a long period of time to "rest" but it requires a bit of patience and
time to repair all the damage that occurred during the accident; yet it is the
surest and perhaps the safest action that you can choose at this time. It is
apparent to me that your surgeon is being both cautious and practical, and
his willingness to allow time to take its course indicates to me that the
healing process is on track. If the operation to remove the mass that remains
did take place, there would be another period of convalescence needed after
the surgery, that might be even more difficult for an impatient man to endure.
At this point in time, perhaps your doctor can indicate some light activity
which your husband may safely pursue to help him get on with living.

Aspirin and Persistent Severe Headache

QUESTION: I have arthritis, for which I take 8 aspirin a day. I also have
severe headaches, for which I take fiorinal. Why am I still getting
headaches? With all the aspirin I take I feel that every pain in the body
should be suppressed. Do you have an answer?
ANSWER: I wish it really was that easy. A simple medication for every health
complaint that worked perfectly, and without side effects every time. Have a
pain, any pain at all, take an aspirin, or one perfect antibiotic for any
infection. However, the complex and wonderful workings of our bodies do not
permit us the luxury of relying on such one to one relationships. Pain is the
body's response to many different situations, requiring diligent
investigations and diagnoses of the cause, before the choice of an appropriate
medication to remedy the situation can be made. I do not know the cause of
your headache, but your letter makes it clear that aspirin is not the
solution. It may mean that in your specific case aspirin is just not
effective for your headaches, although it might work quite well for someone
else with the same problem. More important, however, is the possibility that
your headaches are a symptom of a situation for which aspirin is never the
medicine of choice. An example, to help make my point. Your headaches may be
the sign of an elevated blood pressure. Reducing this pressure would most
certainly put an end to the headache problem, but the medicine to achieve that
would not be aspirin, but one selected from a group of possible choices, all
of which have very different chemical formulas and different actions than
aspirin. I hope you now realize that you require a bit of personalized
medical attention, for the possibility of a serious condition does exist in
your case, and I would not delay a visit to the physician if I were you.

Hypertension Medicine and Loss of Sexual Drive

QUESTION: In talking with several women recently, it appears that several
husbands have lost interest and ability for sex after being diagnosed for
hypertension. The common denominator seems to be their medicine. The men
apparently are reluctant to pursue the problem. As a doctor, what route would
you take to correct this problem? These men are not too old!
ANSWER: Nowhere have I seen the power of communication more dramatically
demonstrated than in your question, with all its implications. Sharing
information makes us all wiser and sometimes leads to the discovery of
problems that are frequently not discussed, and from there to solutions.
While male impotence may stem from many causes, both physical and
psychological, there is no question that medications are frequently the
culprits. While the prescribing information may fail to take note of this
unwanted side effect, there isn't a textbook worth its cost that doesn't
include an impressive list of medications that reduce sexual ability. The
largest number are found under the heading "antihypertensives" with
psychotropic medication, both antidepressives and antianxiety agents, next in
line. Central nervous system depressants, including alcohol, as well as
sedatives and narcotics all are there as well. Now to the route to take, and
let us use the same technique to solve the problem that led to its discovery,
communication. If your husband has suddenly found himself deprived of powers
he had possessed formerly, and is unaware that his medications may be doing
him in, he must be suffering emotionally from this unexpected loss of his
manliness. This is kept locked up inside, frequently denied, but usually not
addressed openly. By sharing your knowledge (and this answer) with him, you
can take the first step on the path that can lead to the solution you seek.
Next step: the physician, who has heard this all before, but since not all
men have the same reaction, is also unaware that this problem now exists.
Communication, again. Last step, a change in medication for one which will
still control the hypertension, but does not generate this problem. There are
several such medications to chose from. I hope this answer will cause many of
my readers to stop and think, to determine whether or not they may be
unknowing passengers in the same boat.

Treatments for Genital Warts

QUESTION: I am plagued by genital warts, and feel there must be some
treatment that can offer me the hope of being rid of this hateful situation.
What should be done to remove these things from my body?
ANSWER: There are several possible treatments that you can obtain to help
you, though I must warn you that there is no one perfect solution to your
problem. Genital warts (and anal warts too) are the result of an infection by
a virus, the human papilloma virus (HPV). Some recent research has linked
this condition to the development of genital cancers, and it is recommended
that you have a Pap smear before any treatment is started so that the results
may be used to help guide the physician in deciding upon the best treatment in
your case. The most widely used treatment is the use of podophyllin and
tincture of benzoin, a solution which may be applied directly to the lesions.
Several applications may be necessary before all the warts have been
destroyed. If after 4 treatments the area is still not free of lesions, an
alternative procedure may be tried. These include cryotherapy (freezing the
warts with liquid nitrogen or solid carbon dioxide), burning the lesions with
electrosurgery, or surgical removal. Some physicians advise using cryotherapy
as a first line of attack, but in any case, the treatment should be
individualized, taking into consideration the number of warts, their location,
whether or not the patient is pregnant, and the failure of any other type of
treatments that might have been tried. None of this is too pleasant, so you
will need some patience and fortitude to see the process through to the end,
for it is important that you have the condition cared for.

Gall Stone Movement and Nonsurgical Treatment

QUESTION: After many years without any sign of their presence, my gall stones
suddenly sent a painful signal of their presence. My doctor thought that one
had gotten stuck in a little tube inside, but before any tests could be
performed, I got better. I was told if it happened again, the stone could be
removed without an operation. I want to know what caused the stone to move
now, and how they get it out without surgery?
ANSWER: It's not unusual for gall stones (biliary calculi) to remain silent
for long periods of time, and it is possible that you may not hear from them
again if you are both careful and lucky. About 20 million Americans share
your situation, and more than 500,000 gall bladders are removed each year (by
an operation known as a cholecystectomy). Gall stones form when the bile
contains a heavy concentration of cholesterol, but other less well understood
factors also play important roles. The gall bladder stores the bile between
meals, and then contracts when food to be digested reaches the area of the
intestines called the duodenum. The bile is pushed from the gall bladder to
the intestine through two small tubes, the cystic duct and the common bile
duct. Trouble starts when a stone that has been quietly residing in the gall
bladder goes for a ride along with the bile, and becomes stuck in the narrow
passage formed by the ducts. You are made aware of the fact by severe
abdominal pain, nausea, vomiting and fever. Frequently, a heavy, rich meal
has preceded this event, and probably was a part of the cause. Physicians may
locate the exact position of the stone using ultrasound waves or x-rays.
Although surgery to remove both stones and gall bladder is the most common
treatment, a newer procedure is available to doctors today when a stone
becomes lodged in the tract. A long tube called an endoscope may be passed
down the esophagus, through the stomach to the intestines. An instrument
which can be inserted inside the tube, may be used to crush or extract the
lodged stone. The procedure is a lot less traumatic than the surgical
operation. Your physician may choose to prescribe medications now, before the
next attack, which can dissolve the stones present in the gall bladder, and
prevent any future attacks.

What is Laughing Death

QUESTION: I don't know how you come up with all the information, but I think
this one may test you just a bit. It is a disease called "the laughing death"
and I became aware of it while serving in our Armed Forces. With just this as
a clue, what can you tell me about this condition?
ANSWER: Obviously, if I couldn't come up with an answer, I just would not
include your question in the column. Honestly, it has taken a bit of looking
to find out the information about a disease called "kuru" which only occurs in
the Fore tribe of the Papua region in eastern New Guinea. The best guess as
to its cause is that it results from a viral infection by a "slow" or
retrovirus that causes wide spread changes in the brain, and may have an
incubation period as long as 30 years. Other theories that cited toxic or
nutritional factors as the cause seem improbable. It occurs most frequently
in children and adult women, who suffer involuntary trembling and jerking
(ataxia) of the leg muscles, incoordination then spreading to the arms,
slurred speech, incontinence, and finally they are incapable of making sounds
or swallowing. As a degenerative disease of the central nervous system, it
causes about 70% of the female deaths in this tribe, and may be due in part to
the ritual cannibalism practiced by the women and children. There is no known
cure, and the affliction has never been identified outside of this area,
although it can be transmitted to chimpanzees. The incidence of the disease
has declined with the cessation of cannibalistic rituals. The term "laughing
death" is not commonly used, and possibly refers to the state of dementia that
may occur shortly before death.

What Are Kidney Stones?

QUESTION: Though I have had several attacks, and have listened to all my
doctor's advice, I guess I have never really understood about my kidney
stones. I know the symptoms, the pain is terrible, but what are they and
where do they come from? Your answer would be much appreciated.
ANSWER: You describe the pain accurately; it may be excruciating, and follows
the path of the stone as it descends along the urinary tract. Yet there are
some patients who never go through this torture, but have "silent stones" that
may produce no symptoms at all, yet when x-rays are taken, there they are.
Stones are formed from the minerals that occur in our urine. Normally they
may form minute crystals that are passed out of our bodies along with the
urine flow, but sometimes they clump together, and cling to the tissue lining
the inside of the kidney. There they continue to grow as new crystals are
added, and they harden as time passes. They may develop to any size, from a
grain of sand to almost the size of an orange. A number of substances can
form stones--calcium oxalate, calcium phosphate, uric acid, cystine, or
struvite--and some stones are composed of mixtures of these substances. If
you have had stones once, you are at risk of having them again. They occur
mostly in middle aged people, and in areas where hot weather causes excessive
sweating. If body fluids are diminished, the risk for producing stones is
increased. It is the same with reduced or blocked urinary flow; these
occurrences increase the possibility of stones. Certain genetic disorders as
well as foods rich in oxalate and calcium may cause stone formation in some
individuals. Despite the knowledge of all these factors as possibly
contributing to the manufacture of these nasty pebbles, no one is really sure
why they occur or why some people develop them while others do not.

Importation of Unapproved Drug Products

QUESTION: We are going to be traveling abroad this summer, and have heard of
a drug that can help my wife's condition that is not available as yet in the
United States. I am sure that our government would understand and allow us
to bring this medicine back into our country, but my wife fears that not only
will the drug be taken away, but that we might also face imprisonment if we
are caught. Can you provide us with any information that might help us?
ANSWER: The regulations which govern the use of medications in the United
States and which are enforced by the Food and Drug Administration (FDA) have
been formulated to provide drugs that have the greatest degree of safety, as
well as proven ability to combat disease effectively. The process of approval
is a long, difficult and expensive one, so that frequently medications are
available in other countries before they are approved for use in the United
States. However, the regulations of the FDA do allow importation of
unapproved drug products, providing four basic criteria are met. The product
must be purchased for personal use. The drug will not be sold commercially,
and the quantity must not be excessive. Usually a three month supply is
considered allowable. The use of the drug must be appropriately identified.
Last but not least, and perhaps the most difficult criteria to achieve, the
patient importing the medication must affirm in writing that the drug is for
their own use, and provide the name and address of a physician licensed in the
United States who will be responsible for the patient's treatment with the
drug product. The FDA considers this a humane method of implementing rules
that have been established to protect our society against the cruelties of
medical quackery and health fraud. Complying with these guidelines will
assure that you may openly and without fear import these medications for your
personal use.

Concern Over Teenage Football Injuries

QUESTION: My son is a wide receiver on his high school football team, a great
player, and very important to the game plan of his coach. I always fear that
if he were to be injured, he would get back in the game too soon, and really
damage his chances of a future career. Can you advise me as to the right type
of treatment he should be getting on the field, and what I can do to protect
ANSWER: It's not an easy question to answer specifically, and it's not an
easy game your son is involved in. It's a contact sport, and the violent
forces that go into that contact make the likelihood of injury very high.
According to the National Athletic Trainer's Association, 37% of all high
school football players suffered an injury that required the player to stay
out of action for the rest of the day in which the injury occurred. The best
"ounce of prevention" for such injuries is a sound, well designed training
program that provides exercises to develop muscular strength, muscular
endurance, cardio-respiratory endurance as well as speed, flexibility, power,
agility, coordination and balance. Your next defenses lies with knowledgeable
officials who apply the rules, particularly those concerned with player
safety, strictly to the letter. Good coaching is a must, and most high school
coaches are sensitive to the future aspirations of their players and consider
those factors first even in the heat of a hotly contested game. On the field,
first aid relies on four major principles. Any injured player must be removed
from the game for examination and the necessary treatment of the injury.
Appropriate first aid for almost all injuries includes rest (splinting if a
fracture is suspected), application of cold packs or ice to the injured area,
and rest for the injured part and player. Ice helps reduce the amount of
swelling and helps control pain. A cold pack or ice pack should be wrapped in
a towel, applied to the injury for twenty minutes, removed for ten minutes,
and then the cycle is repeated. All injured extremities should be elevated to
reduce swelling and the accompanying discomfort. Any suspected fractures
should be x-rayed and then treated. In a game that is close, particularly
where your son may be an important factor, even a father can be swayed by
events. There should be one individual on the field who, hopefully, is
maintaining an objective perspective. It is the school physician who may be
in the best position to assure that your son is treated correctly, and it is
from this nonbiased professional that you can obtain the best counsel if an
unfortunate injury does occur.

Questions on Diet for Inflammatory Bowel Disease

QUESTION: I suffer from an inflammatory bowel disease, and though I have
searched high and low for a diet that could help me avoid some of the troubled
times I've had, there is none to be found. Surely you must have come across a
helpful list in your work, and I would appreciate you sharing your knowledge
with me.
ANSWER: There is a very good reason that explains why you have been unable to
find a good diet to help prevent the painful symptoms of your condition.
There simply isn't one. Each inflammatory bowel disease (IBD) patient must
create their own list of foods to avoid based upon the reactions they have had
to the food. Many IBD patients can eat quite normally, enjoying a wide
variety of foods without any restrictions whatsoever. When the acute stage
hits, they switch to a bland diet, with less fiber and less spice than usual.
The important factors to consider are the maintenance of a well-balanced and
nutritious selection of dietary items to preserve good health and maintain
normal body weight and defense reserves. Certain foods do have a reputation
for irritating some patients' bowels, foods like nuts, raisins, seeds, bran
and whole grain, as these are not as easily digested as other foods. While
some patients tolerated cooked or canned fruits and vegetables, others may
not, making the proper choice of foods a highly individualized effort.
Keeping a log or diary of food intake and all possible reactions will provide
you with a written record of unhappy experiences with your diet, and serve as
a reminder of specific items to avoid. When you discover that a class of
foods may be the culprit, consult your physician or a dietician, who can
provide you with some hints about getting around the problems, or suggest
substitute items to use in maintaining your balanced nutrition.

Changes in Sexual Desire Following Hysterectomy

QUESTION: It's not something I feel I can discuss with my doctor, but a
recent hysterectomy has brought about some unwanted and unexpected changes in
my sexual desire. All my previous feelings have changed, and I am afraid I
have become a wife with a perpetual "headache". Is this a normal result of my
surgery, or can I be helped?
ANSWER: It is neither a "normal result" nor one you have to accept, for help
was only a conversation away, if you had but consulted with your physician.
It's not that this situation is unusual, for surgery of this type has both a
physical as well as an emotional impact upon your life, but there are no
lasting effects that must discourage you from your normal fulfillment. To be
sure, intercourse may be painful if wound healing is not complete, and should
await your follow up visit with your surgeon. Even if you had your ovaries
removed, hormone replacement can restore normal vaginal secretions. You need
reassurance and the knowledge that this operation is not the end of your
sexual life. Many deeply entrenched myths surround this surgery, including
the one that normal relations are no longer possible. Even husbands may feel
strange if not afforded the opportunity to express fears and doubts. You both
need an opportunity to open up and discuss your feelings. Both you and your
husband are entitled to a real sit down session with your doctor, who can
provide you with the answers to relieve your anxiety and end your headaches,
if you will only reveal your problem and request the needed counseling

Exercise After Heart Attack

QUESTION: After recovering nicely from a heart attack, my physician suggested
that a carefully structured exercise program could lead to new arteries
growing in my heart that would protect me from future attacks. I am now
jogging, though at times it's a struggle, and I keep wondering if this is
really working. What do you think?
ANSWER: Your question leads us into some interesting medical history, and a
current area of debate. Anatomically speaking, there are two types of
arteries; those that end at the tissue they feed, appropriately named "end
arteries," and secondary or branching arteries that connect main artery
systems, called "collateral arteries". When an end artery becomes blocked, as
during a heart attack, the tissue it serves dies, unless blood can flow to the
tissue through collateral vessels. An early English physiologist, Richard
Lower, described the presence of collateral vessels in the human heart in
1669, and this was accepted doctrine until 1873, when Josef Hyrtl, professor
of anatomy at Vienna, failed to find these arteries using a technique that
made a cast of all the vessels and corroded away all other tissue. These two
opposing views were debated for 80 years until 1960 when W.F. Fulton showed
that tiny capillary-like channels did indeed connect different coronary
arteries. It is pretty well agreed that reduced blood flow to the tissue of
the heart stimulate these capillaries to grow and increase blood flow to the
suffering tissue. It would certainly appear to be so in important experiments
conducted in animals, and we know that patients that have survived longest
with chronic coronary artery disease (CAD) show increased collateral
circulation when post mortem examinations are performed. Your physician is
correct in that patients with CAD do better when following a prescribed
exercise training program. What is missing is the proof that the increased
demand for oxygen needed by the heart during exercise can be the stimulus for
new growth in the collateral vessels in humans. Investigations that might
prove this are difficult to construct and costly to run. Until such data is
available it is difficult to answer your question absolutely, but in my
opinion from existing research, you are probably doing yourself a world of

Concern Over Coffee and Heart Attack

QUESTION: I have been a heavy coffee drinker for years, seven to eight cups a
day, but after a recent heart attack, my doc nixed my favorite beverage. I
must confess I have been sneaking a cup or two each day, but my wife is
concerned that I am doing real injury to myself. I need your advice, but if
the answer isn't an O.K. I'll probably hide your column!
ANSWER: It doesn't seem as if you are going to give up your coffee, no matter
what I write, but I am pleased to calm some of your doubts, and relieve some
of the guilty feelings I sense. This has long been a subject of discussion,
for the physicians who prohibit the use of coffee as well as tea and cola for
their heart patients are concerned that the caffeine contained in these
beverages may stimulate the heart to beat in an abnormal or irregular fashion.
In the presence of previous heart injury, this could provoke complications
that can become real problems. It is a legitimate concern, but there is a
growing amount of evidence which seems to show that the danger is more
theoretical than real. It is true that the more you drink the more likely
that you will affect the beat, and certainly I can't recommend or condone 7 to
8 cups a day, but I believe I am on safe grounds when I admit that 1 or 2 cups
a day won't hurt you. The stress of sneaking the coffee is probably doing you
more damage than the coffee. However, if you do continue to drink your daily
quota, you do owe your physician a confession so that he can properly assess
your cardiac condition in the presence of the caffeine, and continue to
counsel you.

Why Does Motion Sickness Happen and What Can be Done?

QUESTION: We are off again, traveling to visit our family, but that means I
must put up with all the discomforts of motion sickness that have plagued me
for years. Why does this happen, and is there really anything one can do
about it to prevent this annoying and sometimes embarrassing state of affairs?
ANSWER: When the discomfort of nausea and even vomiting strike during a
voyage, all the pleasure that is possible from a visit with loved ones may be
totally destroyed. It occurs when the body clues that keep us oriented in
space and our senses of balance become confused, when our eyes tell us nothing
is moving but the delicate mechanism of the inner ear (also called the
labyrinth) knows better as it perceives the motion of the plane or vehicle we
are riding in. Each sends different messages to the brain, a conflicting
story which can not be coordinated in a sensible way. That results in the
feelings of queasiness that may progress to a true motion sickness. "Motion
sickness" is the single term that incorporates "sea sickness", "air sickness"
and "car sickness," as they are all the result of the same mechanisms. A
knowledge of these mechanisms provide us with some action guidelines that may
prevent the sickness from occurring. Sit in a seat where your eyes can
observe the motion that your body is feeling. That means a window seat in a
plane or car. Looking at the passing scenery while you travel will prevent
conflict in the messages being sent to your brain. Don't read as you travel,
and sit in a seat that is facing the direction of travel. Eating before a
trip is unwise, particularly heavy, greasy or spicy food. If someone near you
is being sick, try to change your seat, for the stimulation of such an
experience may provoke the same condition in your delicate system. There are
many over-the-counter medications which are effective if taken properly and
with sufficient time before your trip starts. Ask your physician or
pharmacist for advice. With all these precautions your trip should be a
pleasant one. Enjoy!

What Causes Morphea and Will it Turn to Cancer?

QUESTION: My son was recently diagnosed as having a rare skin disease called
Morphea. He has three lumps on his back now. Can you tell me what causes
them, and whether this will ever turn to cancer?
ANSWER: Morphea, known also as circumscribed scleroderma, was first described
by Dr. C.H. Fagge, in the Guy's Hospital Report, in 1868. It is not a disease
one sees every day, and is usually observed more frequently in women than men.
With an onset between the ages of 20 to 40, it may be accompanied by headaches
and arthritic type pain. Actually it is a disease that attacks the collagen
elements of the dermis layer of the skin. The area becomes filled with fluid
(edematous) and swells, causing the lumps you have observed. It then proceeds
to form scar like tissue, making the skin feel hard. There are five different
varieties that are recognized, each a bit different in the way it looks, and
the areas of the body it affects. No clear cause has been discovered,
although its beginnings may be associated with trauma to the skin, pregnancy
or menopause. Usually no treatment is indicated, but in serious cases, the
affected areas may be injected with corticosteroids, cortisone-like
medication. If the scars interfere with necessary functions, surgery may be
performed to remove them. I found no mention of this condition becoming
cancerous in the material I read, but am pleased to report that several types
of morphea may improve spontaneously after a three to five year period.

Explanation of Infarcts

QUESTION: After a long period of testing and examining, our physician has
finally decided that my mother's problems were not caused by Alzheimer's
Disease, but by something he classified as "infarcts". He now feels that
treatment may permit mother to be cared for at home. We are confused and
would appreciate your help in explaining this to us.
ANSWER: I realize that you must be in a difficult situation as you try to
understand a complex diagnosis, and the implication it has for you and your
family. A few definitions may help. The condition your mother is suffering
from is called "multi-infarct dementia" (or MID). Dementia is defined as a
decline in intellectual function as seen in the loss of memory, loss of
language, impaired judgement or mathematical abilities, as well as other
mental activities. An "infarct" is an area of dead tissue that results when
the blood circulation to the area has been closed off, or obstructed. As the
number and size of these areas increase, and more brain tissue is lost, the
symptoms become more evident. Alzheimer's disease is certainly the most
common cause of dementia, and is responsible for 25% to 55% of the cases,
while MID is the second most common cause, and is diagnosed in from 10% to 30%
of patients with dementia. If there is a history of small or large strokes,
the chances that the cause of the mental decline is MID increases. High
blood pressure is another risk factor, as are diabetes, high cholesterol
levels and smoking. An important consideration in your mother's case is the
hope that appropriate treatment can stop the progression of the disease by
stopping the development of small clots in her brain that are causing the
condition. If this can be accomplished, than caring for her at home permits
her to remain in familiar surroundings, where she is best able to function.
Another common complication of MID is a mild to serious depression, with loss
of appetite, insomnia, feelings of guilt and suicide. This may occur up to
70% of the time, and requires additional care and treatment. You will need
frequent consultations with your mother's physician, so that each decision
about care may be based upon a thorough understanding of this condition.

What are the Implications of "Prolapse"?

QUESTION: A frequent pain in my chest brought me to my doctor's office. I am
a 44 year old woman in reasonably good health, and so the diagnosis of disease
of my heart valves called a "prolapse" was both a surprise and a cause of some
anxiety. What are the implications of this heart disease for me; will it
require that I change my life style?
ANSWER: Your condition, called mitral valve prolapse (MVP and in this case
does not mean "Most Valuable Player"), is a common abnormality of one of the
heart valves, the mitral valve. It is more common in women than in men, and
can be found in from 5% to 10% of our population. While most often discovered
in adults, MVP may be a congenital situation, present at birth. The mitral
valve prevents the blood coming into the heart from the lungs from flowing
backward. The valves are held in place by fine cords, and close each time the
heart contracts. If the valves are not formed properly, or the cords are too
long, they fail to close properly, and some blood may leak backwards. This
causes a murmur or low sound to be produced, which along with the click of the
improperly closing valves are the clues the physician hears when listening to
your heart through the stethoscope. Further tests with electrocardiogram,
chest x-rays, or echocardiogram (which uses sound waves to form a picture of
the heart) may be used to may be necessary to confirm the diagnosis, although
frequently the typical pattern of sounds and your general physical condition
are enough to identify the condition. In the majority of patients, MVP is not
a serious condition, and in fact, once the diagnosis has been confirmed and
the patient is assured that no real dangers exist, the chest pain disappears
without additional treatment. Most patients are in no danger and have no
symptoms, and even those who do have symptoms, rarely have evidence of
increasing heart damage. Most probably, MVP will not require you to change
your life style, or necessitate ongoing treatment. Only in the case of severe
leakage is surgical repair considered, and your own physician is in the best
position to offer you the personalized advice and consultation you may require
to allay your fears.

Understanding Results of the Spinal Tap

QUESTION: We have had a terrible anxiety provoking experience, as our
daughter was admitted to the hospital with meningitis. The doctors were
patient and caring, but when they explained all about the results of the
spinal tap, we were really too upset to understand. Can you tell us what was
meant by talk of cells, pressure and all the rest? Our daughter is fine now
and we are calm enough to listen.
ANSWER: Even in the best of circumstances, and that certainly does not apply
to the events surrounding a hospital admission, understanding all the
implications of a Lumbar Puncture (spinal tap) is not easy. But the results
that the physician can obtain from this procedure are critical, as it provides
an initial evaluation and diagnosis that not merely helps to establish the
diagnosis of meningitis, but may often identify the condition that is causing
the meningitis. The meninges are the tissues that cover and surround the
brain, and any irritation of these delicate structures produce the symptoms of
meningitis. Headache is the outstanding symptom, as well as fever, nausea,
irritability and confusion, all depending upon the severity and cause of the
inflammation. Since bacterial infection is life threatening, the physician
needs diagnostic information rapidly, and the spinal tap provides five
important bits of data that are extremely useful. They are pressure, number
of cells found, type of cells found, glucose in the spinal fluid, and protein
in the spinal fluid. For example, the pressure of the fluid in the spinal
column is normally about 100-200 mm, but may be increased or decreased
depending upon circumstances. In bacterial meningitis it is elevated.
Normally there are very few cells present, but that number may rise to as many
as 5000 per cubic mm in bacterial infections, yet stay below 700 when a virus
is the infecting agent. The types of cells found also aid the diagnosis, as
lymphocytes are most commonly found in most types of meningitis, while the
bacteria fighting white blood cells (polymorphonuclear leukocytes, to be
exact) are present in bacterial infections. Checking the amount of glucose
and protein in the fluid also help make the diagnosis as they, too, are
altered in different ways with different causes. While additional tests are
available to the physician, they may take precious time to perform, with
results available only after some period of waiting. Since choosing an
appropriate antibiotic and starting medication as soon as possible is the best
way to attack and overcome bacterial meningitis, the spinal tap is truly an
important first test. Not all the symptoms associated with bacterial
meningitis or viral meningitis are caused by these infections. Tumors, lead
toxicity, and even a condition (meningismus) that mimics the symptoms of signs
of meningitis without an infection, can create a diagnostic dilemma for the
physician, and it takes a careful workup to fully explore all the
possibilities. I am glad your daughter did well.

Melanoma and Its Treatment

QUESTION: We are facing the tragedy of a skin cancer called melanoma in our
family. We believe your column could help by telling your readers about this
condition and its treatment. Maybe then they can get the help they need,
before it's too late.
ANSWER: I hate cancers as a group of diseases, and probably melanoma ranks
first on my list. It is a malignant skin cancer that develops from the
pigment cells in the skin, and although it may take many forms and shapes, can
spread through the body so rapidly that it is fatal in just a few short
months. It is becoming more and more common, particularly in some of the
"Sunbelt" states of the United States, and the number of cases is doubling
every 10-15 years. Any colored skin lesion which changes in nature, size or
color, must be seen by a physician as soon as possible, for all suspicious
lesions must be removed surgically and then analyzed microscopically. A
thorough examination of the skin should be performed in high risk individuals;
those who have had a melanoma previously, first degree blood relatives of
melanoma patients, and particularly individuals with light complexions.
Although investigations using medications are ongoing, it is still the wide
excision surgical technique, which removes the lesion and a band of
surrounding normal skin, that offers the greatest probability of control. The
sooner the operation can be performed, while the disease is in its early
stages, the better the chances of success.