Can Older People Profit From Exercise Testing?

QUESTION: I'm ready to start but cautious. Can older people profit from
exercise testing?
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ANSWER: Exercise testing, the evaluation of how well a person can deal with
the stress of exercise, is a valuable test of the health of your heart. This
test is used to help diagnose arrhythmias and to assess the condition of the
coronary arteries and muscles of the heart. If you have had a heart attack or
heart surgery, an exercise test will help determine how much damage your heart
has sustained and will help you and your physician choose an exercise
rehabilitation program for you.
Because the incidence of cardiac problems increases with age, exercise
testing is done more often on older individuals that those under age 35, but
special considerations do have to be taken with elderly (over age 65)
patients.
In general, exercise testing is done in a physician's office or clinic
using a treadmill, although sometimes a bicycle ergometer (a form of
stationery bicycle) is also used. Before the test begins, you will be asked
about your normal exercise habits so that the technicians can determine what
speeds to start you out on. Your physician will probably take an
electrocardiogram (ECG) before the test begins, a step that may be skipped in
younger individuals.
Most elderly people have never been on a treadmill before. Your
physician or the technicians will show you how to walk on it to make sure you
are comfortable with it and allow you to warm up a bit before starting the
test. While using the treadmill, walk in a relaxed manner and look straight
ahead. Don't lean on the front handrail, because this can throw off the ECG
readings; use the side rails if you need to keep your balance.
To make sure a reliable reading is obtained, your physician may ask you
to stop taking certain heart medications, such as beta-blockers or calcium
blockers, a day or two before the test. He or she will give you instruction
on tapering down your medication and then restarting it.
When the test begins, you will simply be walking on the treadmill at a
speed of about 2 miles an hour. This is a speed most elderly people walk at
normally. At different stages in the test, the front elevation of the
treadmill will be increased, which will make it seem like you are walking up a
gradually steepening hill. If you have any trouble keeping up with the
treadmill or feel you cannot cope with the elevation, tell the technicians.

How Can People Who Exercise Die Suddenly?

QUESTION: I thought exercise promoted a long and healthy life, but some of
the things I've been reading in the paper says otherwise. How can people who
exercise regularly die suddenly?
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ANSWER: Although some experts argue that it's just a coincidence when people
happen to die suddenly while they are exercising, others believe that
strenuous exercise may increase the chance of sudden death in certain people,
even if they are in good condition.
Studies of apparently healthy and fit people who died during exercise
have shown that, even though they may have had no symptoms of heart disease,
many had at least one coronary risk factor, such as high blood pressure, high
cholesterol, or a family history of heart disease. Autopsies revealed that
the majority of these people had clogged arteries or other heart problems that
would endanger them during strenuous exercise, without providing any warning
symptoms.
In most cases, the cause of death was clogged arteries--coronary
atherosclerosis. Everyone over 30 years old should be checked for this
condition before beginning to exercise, and see a doctor if they develop any
symptoms that might be related to heart problems.

Is Charcoal Better Than Ipecac?

QUESTION: A recent crisis, when my child swallowed a whole slew of pills,
brought me to our local hospital's emergency room. They quickly administered
charcoal to my daughter, and when I asked why they didn't use ipecac, as you
once advised, answered by telling me it was "out of fashion". Well, what have
you to say about that?
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ANSWER: Fashions come and fashions go, and my old wide ties may once again be
worn without shame. In medicine we always move forward, and as new techniques
which are more effective are discovered, older but sometimes still useful
methods pass out of fashion. It is true that activated charcoal is becoming
more widely used in the treatment of poisoning and overdose of children, but
only in supervised clinics and emergency rooms. The advantage of ipecac is
that it can be kept at home, in a safe place in the medicine cabinet, as it
retains its potency for long periods of time. It is handy, and can be given
immediately after the accident, and it is effective even if the process of
induced vomiting is not the most pleasant of experiences. It also has the
disadvantage of causing problems if the vomitus is breathed into the lungs
during the process. Activated charcoal has many advantages too, as it is very
effective in binding to the chemical that has been swallowed and rendering it
inactive. And it is effective after the time when administering ipecac or
washing out the stomach becomes too late and useless. The activated charcoal
must be fresh to be effective, and so can't be kept at home for long periods.
And it's terrible stuff to try to give children, as it looks horrible, tastes
worse, and feels like sand going down. It is administered through a large
tube passed through the mouth into the stomach. New home poison treatment
kits may soon be on the market and will contain both materials, for both have
a place in the treatment of overdose and chemical poisoning. Much depends
upon what has been swallowed, and how long a period has occurred before
treatment can be started. Whatever the circumstances, even when immediate
home treatment seems effective, all such cases should be seen as soon as
possible by physicians, who can continue the necessary procedures

How Common Are Bite Injuries?

QUESTION: Just how common are bite injuries in the United States? Which are
most dangerous?
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ANSWER: Physicians in this country see about a million people each year who
have been bitten by either dogs, cats, rats, or humans. Many such bites do
not cause serious consequences but they all must be examined closely as soon
as possible following occurrences. The cost of the complications of bite
injuries is estimated at about $50 million yearly.
About two percent of all emergency room visits involve animal or human
bites. While most are not serious, at least 10 percent require stitches and
follow-up visits. Only approximately one-to-two percent require
hospitalization.
Bites are divided into two risk categories: those that cause a high risk
of infection--usually punctures to the hands and feet; wounds for which
treatment has been delayed; and bites on people who are suffering from some
immunocompromising disease where defense against infectious disease is low.
Lacerations of the face, torso and extremities are generally at low risk for
complicating infections.
Dog bites are the most frequent bite injury seen by physicians. Bites
from cats are less frequent but many have more serious complications than
those from dogs. Incidences of human bites are approximately the same as
those from rats and other rodents.
To treat properly, doctors first carefully inspect bite wounds to
determine how deep they go and how much damage has been done to tissues.
Sometimes x-ray examinations are necessary. After examinations, wounds are
carefully cleansed, and crushed and damaged tissues are removed, to try to
eradicate all germs that might cause infection in the wound. Then, decisions
are made as to whether suturing is needed and if antibiotics, or other
medications, must be administered. If 8 to 12 hours have passed since the
injury, chances are your doctor will choose not to try to close the wound with
stitches. And, since most bites do not become infected, antibiotics may also
be withheld.
Most bites from dogs are not terribly serious, however, they are
frightening. Cat bites are far more dangerous. Cats' fangs can create a much
deeper puncture wound that those from dogs, and cat bites lead to a far higher
number of infections; about 35 to 50% of all cat bites become infected.
Human bites are rather uncommon. Usually, they are inflicted by those
who are intoxicated, self-inflicted by patients experiencing seizures, or
during the events surrounding a police arrest (it's the arresting officer who
is the patient). Most such bites are to the hands. Of all bites, those
inflicted by humans have the greatest likelihood of becoming infected because
the human mouth contains the largest variety of different bacteria.
Rat bites occur about as frequently as those from humans, but most often
they cause little harm since most are from rats used in research, rather than
wild ones. However, all patients with rat bite must be closely followed as
these critters' bites can cause other serious conditions.
Whatever the source of a bite, and no matter how serious it looks, it's
not a bad idea to seek professional care, if just to avoid the serious
complications that sometimes occur.

Should Your Child Wear a Bicycle Helmet?

QUESTION: It doesn't matter how often I tell him, my kid won't wear a helmet
when he rides his bike. Should I make an issue of it?
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ANSWER: It might be wise to bring the matter up again in a nonnagging way.
Wearing a bicycle helmet is important and your child should know this. About
30,000 people are hurt while riding bikes each year and 650 die, mostly due to
head injuries. Almost all head injuries that occur in bike accidents under 35
miles an hour (and only very fit cyclists exceed that) can be prevented by
wearing a helmet.
Have you asked your son why he doesn't wear his helmet? Some older
models are heavy, hot, and uncomfortable. Newer bicycle helmets are lighter
and allow cool air to flow through. Although a new helmet would cost $30 to
$40 dollars, the money is well spent if it gets worn. If your son says he
won't wear his helmet because his friends will think he's a wimp, try showing
him pictures of pro bike riders, all of whom always wear helmets.

How to Reduce the Damage of Acid Burns

QUESTION: My partner had a bad accident and was burned with acid. We weren't
sure what to do, or what household chemicals could have been used to
neutralize the acid, so we stuck his hand in ice, and rushed him to the
hospital. He is doing fine, but if it ever happens again, what can we use to
reduce the damage?
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ANSWER: Chemical burns caused either by acids or alkali are always serious
and require prompt medical care. But you don't have to be a chemist, seeking
out a proper neutralizing agent, while precious time is passing, and the burn
is deepening. Just put the affected part under cool running tap water which
will rapidly dilute any chemical. Keep it up for at least 10 to 15 minutes
for an acid burn, longer for alkali burns. Average tap pressure is sufficient
but keep it flowing while you are making preparations for transporting the
victim to the nearest emergency room. The cool water will also provide some
relief from pain, and you can keep the injured portion wrapped in cool, wet
cloths while getting to the hospital, unless you have the advantage of a well
trained ambulance crew who may decide to start other appropriate treatments on
the way.
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The material contained here is "FOR INFORMATION ONLY" and should not replace
the counsel and advice of your personal physician. Promptly consulting your
doctor is the best path to a quick and successful resolution of any medical
problem.

What is Zollinger-Ellison Syndrome?

QUESTION: At first it was thought my husband was suffering from a stomach
ulcer. Now the doctor informs us that he has a disease with the strange name
of Zollinger-Ellison, but that the treatment is the same. What does this all
mean?
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ANSWER: The strange name comes from the discoverers of this syndrome, which
indeed closely resembles a stomach ulcer. It develops rapidly with pain that
is difficult to control, ulcer formation and diarrhea as its principle
symptoms; but the ulcers are found to be in different locations in the stomach
than are usually found with simple peptic ulcers. Even with tests performed
correctly, including x-rays and endoscopy (looking at the stomach through a
special telescope-like tube) this syndrome cannot be distinguished from
ordinary ulcer in more than 50% of the patients. Its cause is a tumor of the
pancreas or wall of the duodenum called a gastrinoma. These tumors result in
the increased secretion of gastrin into the blood which stimulates the cells
of the stomach to produce massive amounts of gastric acid. If a sensitive
blood test for gastrin shows that there are increased amounts, Z-E syndrome
can be diagnosed. The tumors, however, are hard to find. Arteriography,
which may show circulation to the tumor, is the best test but discovers them
in less than one case in two. Sometimes ultrasound can be used, but it too
detects tumors in only 20-30% of the patients. The good news is that the same
medications that block acid formation in peptic ulcer (called H2 blockers)
work very well for Z-E. However since a surgical cure is possible, an
exploratory operation should be considered to locate and remove the tumor.

Why Have Your Heart Arteries X-Rayed?

QUESTION: With several bouts of chest pain in my history, but no diagnosis of
heart attack, I am now on my way to having my heart arteries x-rayed. I know
what the test (coronary angiography) is all about, but wonder what they are
looking for. Are they trying to find a "silent" heart attack? What should I
be on the alert for?
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ANSWER: There are many excellent reasons for undergoing this test, which will
show your physicians the state of your coronary (heart) arteries, and how well
they are performing their job of bringing the flow of blood to your heart
muscles. When these arteries are blocked with plaques of fatty material and
calcium, blood flow is reduced or cut off completely, and chest pain (angina)
may result. But not all chest pain may be caused by coronary artery disease,
and so the first fact your physician is seeking is whether or not your chest
pain is coming from artery trouble. There will be evidence for or against the
diagnosis of any so called "silent" heart attack, and that question will be
answered for you. More important, a definitive diagnosis may be reached,
which can help direct the type of therapy necessary to help stop these chest
pains and get you back to normal. The treatments can range from diet and
exercise programs, a variety of medications, to surgery (by pass) to get the
blood flowing around any blockages that may be found. At any rate, I think
you will be relieved to finally know what is going on, and you can look to
your physician for a complete explanation of the findings. You may wish to
ask to see the x-rays, and to trace the path of your coronary arteries (with
the guidance of your doctor) so that you will understand the causes of the
pain, and dedicate your efforts to their correction.

Do Cholesterol Levels Fluctuate Daily or Seasonally?

QUESTION: I'm being honest, I do everything I'm told. I stuck to the diet,
stopped smoking and exercised. Yet I can't make head or tails out of the
changes in my cholesterol levels. My doctor says the lab is a good one and
the tests are dependable. Can cholesterol levels change with the weather?
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ANSWER: I find myself smiling at the implications of this question, and
wonder at the content of the conversation that brought you to write to me.
It's debatable. Some experts say "yes" while others insist that it just
doesn't happen. Your cholesterol level is not a constant, year-round number
but tends to fluctuate daily and, yes, may even change seasonally.
Seasonal cholesterol level fluctuations do not occur in everyone, and
evidently there is no psychologic reason when they do, except perhaps for the
effects of stress.
A recent study showed that cholesterol levels taken between November and
January were 39 percent below those of the same people measured between
February and April. Others have recorded seasonal fluctuations; still others
note individual fluctuations but not any associated with seasons.
In yet another study, it was found that cholesterol levels might be
steady for long periods and then all of a sudden undergo astounding shifts.
It truly does not matter if cholesterol levels vary with the season
because anyone whose level is at the edge of risk should be watched carefully
by a physician. It is important to reduce your cholesterol level if you are
at risk of coronary heart disease and you probably are at risk if your
cholesterol levels are high.

Are There Drugs That Can Decrease Cancer Pain?

QUESTION: My husband has had cancer for a few months and has just begun to
suffer from the pain that can come with it. Although he's suffering, he
refuses to complain to his doctor because he's afraid of being put on
morphine. Are there any other drugs besides morphine that could help him?
He's just been taking aspirin, which has helped a little.
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ANSWER: Yes, there are many drugs other than morphine that could help
alleviate at least some of the pain. Your husband's doctor will have to do a
thorough evaluation before prescribing, and several different medications may
have to be tried before just the right one is found for your husband. There
is certainly no reason for him to suffer in silence.
If your husband is experiencing mild to moderate pain, a nonsteroidal
anti-inflammatory drug (NSAID) may be effective. Aspirin is itself an NSAID,
and it's possible that a higher than normal dosage would lessen the pain.
It's important not to try this without a doctor's examination, as this could
cause impaired platelet function and increase the risk of bleeding.
Aspirin can be highly effective for the cancer patient with a normal
platelet count and no history of ulcers or gastrointestinal bleeding. Aside
from aspirin, there are more than a dozen other NSAIDs which are useful.
Anti-inflammatory agents are recommended by the World Health Organization's
Cancer Program for Pain due to mechanical compression of tendons, muscles,
periosteum, pleura, or peritoneum without nerve involvement.
The NSAIDs can also relieve pain in muscles or joints caused by trauma
during surgery or radiologic treatment, and visceral pain unassociated with
obstruction. Once the anti-inflammatory agents no longer work (or if they
don't work to begin with), your doctor may consider trying corticosteroids.
This class includes drugs such as prednisone or dexamethasone (Decadron,
Hexadrol). The corticosteroids can be efficient when significant pain is
caused by bony metastases or tumor infiltration of the nerve plexus. Both the
NSAIDs and corticosteroids have potential side effects and your husband will
have to take blood tests on a regular basis to make sure the medications are
not taking their toll on the various organs of the body.
If these treatments fail to give appropriate pain suppression, it may be
necessary to prescribe an opiate.
A compound of codeine with aspirin is frequently used if an analgesic
alone is not enough.
Morphine should only be considered as a final alternative for patients in
severe pain, but it is not to be feared. The proper use of this potent
analgesic allows many sufferers to enjoy life, and participate in the
recreation and family activities that are the real reason for all these
efforts in the first place.

What is the Best First Aid for Snake Bites?

QUESTION: With a camping trip coming up, and having read an article or two, I
thought this question was appropriate for your column. What is the best first
aid for snake bites?
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ANSWER: It certainly is appropriate, for I have received more than one letter
asking a similar question. And I've answered it before, only to find dozens
of new letters with differing opinions, ideas and techniques. Obviously
there's more than one way to handle the situation but here are my thoughts.
The first thing you should do when someone is bitten by a snake is to
remove or loosen any tight clothing the victim is wearing, calming the patient
and making him comfortable. The next major step, if possible, is to determine
what type of snake made the bite. If you're certain the snake is
nonpoisonous, cleansing the wound carefully, and an antitetanus injection
when available, should be sufficient treatment. However, if the snake is
poisonous or can't be positively identified, the best thing to do is to
immobilize the affected area and rush the victim to the nearest medical
facility. If the bite is on an arm or leg, try to keep the extremity below
the level of the heart during transport. Time is critical when dealing with
venomous snakes, and since different bites require different antivenins for
treatment, it is very important to seek professional assistance as quickly as
possible.
In the past, making an incision in the wound and sucking out the venom
was the advised treatment, but an unskilled person may do more harm than good
when he starts slicing at the wound with a knife. Therefore, incision
techniques are not advised unless medical care is not going to be readily
available. In such cases, the incision should be made across the fang marks,
extending only slightly beyond them, and penetrating only through the skin
surface. The incision must be made within fifteen minutes to be effective.
Since this technique is useless with coral snake bites, I feel it is important
to stress the need for identifying the type of snake that inflicted the bite.
The key to treatment and what techniques to use depend on it.
Today, first aid treatment includes the use of a suction pump that
creates an atmosphere of negative pressure on a bite wound. No incisions are
required, and though it comes with a compression band, the suction can be
effective without it. For the best results, the suction should be used within
minutes of the bite, and its effectiveness is sometimes increased by making
small puncture incisions in the fang wounds prior to extraction.
Pouring alcohol on a snake bite is useless because its vasodilating
properties can actually cause more harm than good. Ice packs, once believed
to reduce venom potency, are no longer advised either. They can actually
cause local tissue destruction. Carrying antivenin is sometimes advised, but
knowing what type to use and when is important, and there is always a risk of
anaphylaxis (severe allergic shock).
Because of the risks and the need for different treatment, the best
advice concerns preventive measures. If you are going on a camping trip,
familiarize yourself with snakes indigenous to the area. Wear boots or
leggings that fangs can't penetrate. Shake out sleeping bags, bedding, and
footwear before using them, and use caution around sheds and outhouses where
snakes are likely to be. And, as most experts agree, would-be rescuers can
best be of help by getting the victim immediate medical help.

A Warning about Pesticides

QUESTION: My kid almost died from swallowing pesticides--please warn your
readers that these are dangerous chemicals, not to be left around.
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ANSWER: No chemical can be dismissed as harmless, and all should be used and
stored with every possible precaution to prevent children from coming in
contact with them.
When children are exposed to pesticides, the symptoms may be more subtle
and confusing than they are in adults, so it is important to be aware of the
hazards and be prepared to handle the problem.
One problem is that the signs that suggest pesticide poisoning in
adults--salivation (drooling), lacrimation (tears), urination, and defecation
(bowel movement)--can be mistaken for normal behavior in an infant or toddler.
The commonest signs of poisoning in children include excessive salivation,
muscle weakness, and sluggishness. Many children will also have a rapid heart
beat, and some will have spasmodic seizures.
Pesticide poisoning can look like other, more common pediatric illnesses,
such as coma, head trauma, bronchitis, pneumonia, or even diabetes or
shigellosis.
One of the most clear-cut symptoms of pesticide poisoning is miosis--
contracted, tiny pupils of the eye, described as "pinpoint pupils."
Although the most common way a child becomes poisoned is by eating or
drinking pesticides. It can also occur from exposure to an area that has been
sprayed or fogged with the chemicals. Playing on a lawn or carpet that has
recently been treated can result in poisoning.
Ingesting a poison will usually produce symptoms immediately, but some
poisons, and poisoning that occurs through skin exposure, may come on more
slowly.
Laboratory tests can be helpful in diagnosing pesticide poisoning, but
treatment should begin as soon as poisoning is suspected. Treatment is aimed
at reversing the toxic effects of the chemicals. The antidote will depend on
the specific pesticide involved. Your local emergency room and advice from
your local Poison Control Center are your best front line defenses.
While treating acute poisoning is crucial, it is important to
correct--and better still, prevent--the situation that led to the episode.
Most children are poisoned in their homes by chemicals that had been stored
carelessly or placed in unmarked and uncovered containers. This is a good
time of year to perform a home safety check, and correct those dangerous
situations.

How Do You Treat Heat Stroke and Heat Exhaustion?

QUESTION: The heat wave is murder. Can you offer any information about its
causes, and treatment? I doubt that even you can make the weather cool off.
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ANSWER: You're right, I can't change the weather, but I will give you the
information I think you are looking for.
Usually your body is able to handle the heat. But when humidity goes
beyond 75% sweat evaporation, which is the body's mechanism for cooling,
becomes less effective, and heat stroke becomes more likely.
A number of factors can contribute to heat stroke. People who are very
old, very young, obese, or with congestive heart failure are at greater risk.
Certain drugs, including tricyclic antidepressants, amphetamines, and cocaine
or LSD, can make you more vulnerable. Not only can being in a very hot place
bring on heat stroke, so can fever, exertion, or simply not being used to the
heat. Since circulating blood cools you, a poor cardiovascular system will
make you prone to heat-related illness.
Heat stroke requires prompt treatment to cool the patient and replace
fluids. Its a "no joke" medical emergency, so get a call out for an ambulance
at once. Spraying cool water on the patient's skin can increase cooling by
evaporation, for a victim of heat stroke does not perspire, and the skin is
hot and dry. Using ice packs can help bring down body temperature rapidly,
if it's available. Because heat stroke that results in seizure is extremely
dangerous, emergency medical personnel may use anticonvulsant medications to
prevent seizure.
Heat cramps can be helped by resting in a cool place, stretching (but not
massaging) the cramped muscles, and drinking an electrolyte solution, such as
Gatorade. Salt tablets may not be helpful; they can upset your stomach and
make you even more dehydrated.
Heat exhaustion, which can mimic heat stroke, is usually indicated by a
slight temperature and mild symptoms such as headache, dizziness, or
giddiness, as well as flu-like stomach upset. It may be treated by the same
methods of cooling as heat stroke, but your doctor may choose to give you
intravenous electrolyte solution to get your fluid balance back to normal.
If you are prone to heat stroke, try to avoid situations that might cause
it. And even if you are healthy, don't overexert or allow yourself to become
dehydrated during extremely hot, humid weather. Remember the basic rules of
prevention: stay where its cool, or at least get out of the sun; reduce
activity to prevent additional strain and heat build up, and make sure you are
getting enough fluids to drink. If, despite all your efforts, you begin to
feel some of the symptoms I've described, don't delay seeking medical
attention.

Should You Use a Hot or Cold Pack on a Sprained Ankle?

QUESTION: Please settle a bet for me. I say that you should apply hot packs
to a sprained ankle, but my husband insists that the proper treatment is an
ice pack, like they use for football players who are injured. What is the
correct procedure?
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ANSWER: Far be it from me to interfere in a marital disagreement (what did
you bet?). Actually you may both be considered right; it's all a matter of
timing. All joints, such as ankles and knees, are surrounded by ligaments and
tendons, which are built of a tissue in which a protein, collagen, is a
primary building block. Collagen is an elastic, rubber-like material which
stretches like a rubber band. And just like a rubber band, pull it too far
and it tears, and the blood vessels which run through the tissue rupture,
spilling blood cells and fluid into the surrounding structures. You can
observe this as a bruise, swollen and discolored. When exposed to cold, the
collagen becomes stiff, and the tissue cell activity is reduced. This in turn
reduces the flow of blood to the area, and reduces the swelling and internal
bleeding. In addition, cold can lower nerve activity, reducing pain and
numbing the treated area. Heat, on the other hand, increases the flexibility
of collagen, allowing the tendons and ligaments to relax. It also increases
blood flow and speeds the healing process. Thus the correct sequence of
events is as follows: Cold is applied initially to an injury and throughout
the acute phase, which lasts about 48 hours. Then it is time for the hot
compresses, heating pads or heat lamps. Hot water bottles are effective, but
the water temperature should be maintained at about 104 F (about 40 degrees
Centigrade.) I leave it to you to figure out who won the bet.

Why Don't You Recommend Goggles for All Sports?

QUESTION: You recommend wearing goggles for racquetball but not for all
sports. Why?
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ANSWER: Not all sports carry the same risk of eye injury. In racquetball,
which is played in a small room with a ball going fast, there is a good chance
a player will get hit in the eye with the ball or the other player's racket.
A study of sports eye injuries done in the Canadian province of Quebec
found that ice hockey, which is wildly popular in Canada, was the leading
cause of such injuries, with baseball and tennis running about even in second
place. (In the United States, baseball accounts for the most sports eye
injuries because it is widely played.) The study notes that in the sports
where eye protection is mandatory, notably racquetball, the rate of eye
injuries has gone down.
Although different sports have different risks of eye injuries, if you
own sports goggles, wear them whenever you play, no matter what the game. Why
let them gather dust when they could be protecting you?

Should a "Flail Chest" Be Treated Medically or Surgically?

QUESTION: A recent accident brought my husband to the emergency room with a
number of injuries, including one they kept referring too as a "flail chest".
There was considerable discussion among the doctors, which I could not follow,
but they ended up treating this injury "medically" instead of "surgically".
My husband pulled through fine, but I always wondered what the discussion was
all about. Can you figure it out for me?
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ANSWER: In my opinion, the patient can frequently do better when physicians
with different specialty expertise and experience confer about a patient's
condition, and choose the best possible treatment. Let's first explain the
term "flail chest". When a section of the chest wall no longer moves with the
rest of chest, because of multiple fractures of several ribs, their cartilage
attachments, and the central bone of the chest (the sternum), it resembles the
free swinging portion of the tool the flail, that was used to thresh grain by
hand. This section of the chest now moves in during inspiration, and outward
with expiration (the opposite of normal) and reduces the ability of the lung
to fill with air. Breathing becomes labored and difficult, and the body
cannot get the oxygen it needs. For many years, treatment consisted of fixing
this moving chest section by external means. More recently, the use of
equipment to increase the pressure within the lungs during respiration was
successful. However, it is now believed that the treatment of the injured
lung beneath the ribs is most important, and by reducing fluids, the
congestion which also develops in injured lung tissue may also be reduced.
Pain relief and the use of corticosteroids is most useful, and thus flail
chest can be successfully treated medically, rather than by mechanical or
surgical fixation. There are times, however, when the situation demands that
breathing be aided using a respirator, and when surgical intervention to
stabilize the chest wall is a must. Your husband was fortunate that this was
not necessary, and his recovery time was probably reduced.

Are Ferrets Safe Pets?

QUESTION: My son is driving me crazy. He has taken to hanging out at a pet
shop where there are some ferrets for sale. The store owner assures me they
make fine pets, but I know I've read something about doctors disagreeing with
this. Can you help?
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ANSWER: You are right, doctors don't like ferrets as pets, if you are to
consider the number of references appearing recently in our scientific
literature. There have been a number of reports of ferrets biting babies
quite savagely; not the mere nipping that can occur in play. Some cases have
been so severe as to require plastic surgery. No one is clear on the reasons
for this, but some speculate that babies may emit an odor resembling baby
rabbits, a favorite prey of ferrets. Some say it is the smell of milk that
clings to the infant's clothes that stimulate these attacks. The fact is that
many reports show that ferrets will climb into a crib and attack a child
without provocation. Ferrets are still considered wild animals by many health
authorities, and an incident of biting requires the animal be destroyed.
Considering all of the many possibilities of animal pets that do exist without
these dangers, you would be taking the right tack in convincing your son to
transfer his affection to some other species.

What Kind of Treatment Must Athletes Use After Abusing Drugs?

QUESTION: Every time you read of an athlete hooked on cocaine, they tell you
he must undergo treatment, before he can return to the game. Is this real
treatment, or do they just lock the guy up where he can't get at the drug
until he sweats it out?
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ANSWER: Most treatment centers avoid the "cold turkey" approach you indicate,
and offer real but complicated treatment to rehabilitate any addict. The
process of medical detoxification is a difficult one, because the chemical
imbalance in the patient caused by the drugs is very different and varies
considerably from one patient to another. The fact is that though researchers
have sought to discover a single medication which could be used to effectively
control withdrawal from cocaine dependence, no such medication exists today,
and each patient must be treated as an individual, using various medications
in differing dosages to affect a cure. Many such agents exist; tyrosine,
tryptophan, amantadine, levodopa, bromocriptine and desipramine to name a few.
These medicines are used most effectively to treat other diseases. For
example, levodopa and bromocriptine are used to treat Parkinson's Disease and
amantadine is effective against the Influenza A virus. Once the initial stage
of treatment is over, there is still a long period during which the patient
must be counseled and assisted. This outpatient phase includes psychological
testing, family counseling and education, guidance, and above all urine
testing to verify that no cocaine has been used during this time. Medications
may be used for as long as 4 to 6 months, but even with the best care, high
hopes, and determination, relapses are all too frequent.

Why Shouldn't One Take Antibiotics Left Over from an Old Prescription?

QUESTION: Prescription drugs cost a fortune, and I frequently get better
sooner than my doctor thought I could. That means I can always save a number
of pills if I ever get sick again. Why shouldn't one take antibiotics that
are left over from an old prescription?
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ANSWER: For many highly important reasons!
Taking such antibiotics could cause serious effects including severe
allergic reactions. Your first experience with an antibiotic may have just
been enough to provoke a reaction when it is taken next, particularly if you
only took a small amount the first time. Once you restart a medication on
your own, you interfere with managing the illness you are currently
experiencing and can complicate your doctor's efforts to diagnose exactly what
disease you have now.
Among the serious problems doctors face are patients not taking every
antibiotic capsule or pill as prescribed.
Many patients fail to tell the doctor or admit to this type of "self
medication," possibly because they really know better. It really is foolish
to stop taking the medicine as soon as you begin to feel better, without
giving the medicine the necessary time to complete its job, and take the
dosage over a period of time that can completely wipe out the infection.
Hoarding medications in the cabinet against a future possible occasion
doesn't save money, and puts you in real jeopardy.
In a recent study, Illinois researchers found antibiotics in the urine of
17 of 270 patients. Only five of them admitted self-medication. That is
dangerous. Not admitting to taking self-prescribed medication could result in
doctors administering other medicines that can cause life-threatening
reactions.
I'm all for saving money, so ask your doctor to prescribe just the
quantity of medicine you need for this illness (he probably is doing this
anyway) and then take your medicine as directed, knowing that in this way it
will do you the most good.
It's worth repeating: when your physician prescribes medication for
you--particularly antibiotics--TAKE IT ALL.

Can Treadmill Tests Predict Heart Attacks?

QUESTION: I've been advised to take this test to try to take a look into the
future. What do you think? Can treadmill tests predict heart attacks?
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ANSWER: Treadmill exercise tests are most frequently used to evaluate
cardiovascular fitness and to diagnose levels of coronary artery disease and
myocardial infarction. In general, however, the test scores have been
designed to provide diagnostic, not prognostic, information.
Recently, however, a new treadmill test was designed that can offer some
predictive information. Based on the outcome of the scores, doctors have
discovered that patients of the same age, sex, and amount of angina can have
very different prognoses. The reverse is true as well. Patients with totally
different clinical backgrounds may be at identical risk. As a result of these
findings, physicians now have a whole new way of evaluating a patient's risk
status.
Cardiac catheterization and left ventricular testing still offer the most
significant prognostic information in coronary disease and it is still
debatable as to whether treadmill tests can ultimately take the place of
invasive testing. However, with the improved techniques, treadmill tests can
determine who is at high risk and they are certainly valuable aids for
deciding on a patient's management.

What is a "Spinal"?

QUESTION: I recently spent several days in a hospital for stomach problems.
My roommate was very anxious about a procedure his doctor called a "spinal"
and which he knew would be most painful. On the morning of my discharge, a
group of doctors and technicians entered the room, pulled the curtains around
my roommate's bed and, I suppose, performed the spinal. I never did see what
happened and am most curious to know what a spinal is and why it is performed.
------------------------------------------------------------------------------
ANSWER: I can appreciate your curiosity, particularly when you had to leave
before the end of the story. To start with the medical name is "lumbar
puncture" (LP) and refers to a diagnostic test which is performed to obtain a
fluid (it's called cerebrospinal fluid or CSF) which bathes the brain and the
spinal cord. The spinal cord, a bundle of nerves running from the brain
through the spinal column to all parts of the body, is the main "cable" of
nerves that carries the current that permits our magnificent brain to control
so many of our body's functions. The spinal column, constructed of
alternating layers of bone (vertebrae) and cartilage (disks), commonly called
the back bone, has a hole running through its entire length, to contain and
protect this cord. However, the cord becomes thinner and thinner as it sends
out branches to the body, and in the area of our low back (lumbar region), it
no longer occupies the full space. Instead the CSF (fluid) fills the space
between two membranes which cover the spinal cord. This permits the physician
to insert a long, but thin, needle between two vertebrae into the space and
collect CSF for analysis. The procedure is performed under local anesthetic
to reduce discomfort as much as possible, but the idea of a needle in one's
back is certainly intimidating. It is an important procedure, however, and
can help in determining brain hemorrhage, infections in the central nervous
system, as well as changes which can occur in some maladies of the spinal cord
itself. The "spinal" or LP may also be used to administer medications,
anesthetics, and radiopaque materials used in performing special x-rays of
this vital structure.

Should Cancer Patients Use Narcotics to Ease Pain?

QUESTION: I suppose that everyone knows that drugs are addicting, but I
thought medications were supposed to be something else, to be used to help
people in pain. Now it is my mother that needs relief from her constant pain
from cancer. What do you think about allowing cancer patients to administer
narcotics to themselves to better control pain?
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ANSWER: Patient controlled analgesia (PCA) was developed in 1968 as a
technique whereby small amounts of intravenous narcotics can be administered
on demand by a patient-activated infusion pump. It was perfected because many
believe that pain-relieving requirements are difficult if not impossible to
predict and very decidedly different from patient to patient.
Recently a noted researcher reported that allowing a hospitalized patient
to decide when to receive pain medication is likely to reduce total narcotic
use and produce near-ideal pain relief while minimizing sedation and side
effects. Risks of accidental or deliberate overdose seems minimal since only
a tiny amount of drug can be delivered and a mechanized device controls the
interval between doses.
Other studies have shown that patient anxiety caused by having to wait a
specific amount of time or to continually ask for pain medication increases
the total drug requirement and may lead to addiction.
PCA seems to be an enlightened approach to analgesia, yet there are many
who find it a very hard concept to accept.

What is an MRI Test?

QUESTION: I'm to have a new test called MRI. As with anything medical, and
unknown, I have become quite worried about this whole deal. Is there
anything I can do to prepare myself for the test?
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ANSWER: Magnetic resonance imaging (MRI) is used to check for possible
disorders of the brain or spinal cord, or for problems with the lower back,
heart, chest, pelvis, and other areas. It places you in a strong magnetic
field, where a series of radio signals will be beamed at the part of your body
being studied. This will stimulate certain atoms in your own tissue to
produce radio signals of their own. The resulting signals are translated by
computer into pictures of that body part.
Because MRI involves magnets, you will need to remove all jewelry and
metallic objects, and the test is not for people with pacemakers, surgical
clips, or other metal objects in their bodies.
During the test, you will be lying on a table that will slide you inside
a large metal cylinder. Although you will be able to talk through a
communications system, tell your doctor if you have ever had claustrophobia or
anxiety from being a small enclosure.
Finally, as with x-rays or photos, you need to relax and remain still
during the test. You won't feel anything, but you'll hear a soft tapping from
the radio signals. Afterwards, unless your doctor gives you other
instructions, you'll be able to resume normal activities immediately. It
would seem that your biggest task at present is to remain calm awaiting a
test that will cause no physical pain and will assist your physician in
caring for you.

What are the Guidelines to Taking Pills?

QUESTION: There are times when the instructions on the label of my medicines
confuse me, and I always forget to ask the doctor or the pharmacist. When it
says "every 4 hours" do I have to get up at night? And what if I forget to
take a pill, do I take two the next time? Must I take a pill while eating,
when it says "take with meals"?
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ANSWER: Thank you for your questions. I am almost embarrassed for my
colleagues by your need for this information, that is so basic, but so
important for you to know if you are to gain the full benefit of your
medication. The answers are all easy to remember, but cut this article out
and save it for the future, just in case.
When the label reads "every 4 hours" it really means only during waking
hours. It would say "around the clock" or "throughout the 24 hour period" if
your physician intended you to really take it at 4 hour intervals at night.
If you miss a pill, be sure to take the next one exactly on time, and since
different medications act in different ways, it might be necessary to double
up on the next dose. Here is where a call to your physician or pharmacist can
really pay off with the proper information for your special medicine. You
don't need to take a pill during your meal when the instructions read "with
meals", but be sure to take it immediately after you have finished eating.
Generally this is indicated when the medication works best or more safely when
there is food in your stomach. Since there are so many types of medicines,
you always need to know exactly how your personal medications should be taken.
Remember "When in doubt, shout out!" into the ear of the people who can and
want to help, your doctor and pharmacist.

Should Women Over Forty Have Routine Mammograms?

QUESTION: I'm forty and my gynecologist recently suggested that I have my
first mammogram done and then go routinely every two years. Do you agree?
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ANSWER: At about the age of forty, most physicians feel that women should
have their first mammogram done, and I'm in total agreement. They should
continue having them regularly at two-year intervals up to about the age of
fifty. At that age the American College of Radiology recommends yearly
mammograms. I tend to think that the two-year interval can be maintained even
for women in their fifties.
Of course, women in their twenties and thirties at high risk for breast
cancer should have them done immediately. These are women with histories of
breast cancer in their families, and, of course, with them a mammogram should
be performed now, not at the age of forty. This is not a scare tactic but
just plain common sense. The earlier that a cancer is detected the better the
outcome. And for women who are premenopausal with family histories of breast
cancer, the risk is the greatest. So don't be alarmed at the advice of your
gynecologist. It is a precautionary regimen in medicine aimed at prevention.
Mammograms are simply and expertly done with no pain to the patient.
A recent patient of mine, who happened to be thirty-five, went for her
first mammogram, because her mom had breast cancer in her thirties. A small
mass less than 1 cm in diameter was found, and before I referred her to a
specialist I wanted to assure her and discuss her options. Malignancy was
suspected even before the biopsy. First I told her exactly what would happen
in the biopsy to allay some of her fears. When the biopsy proved positive, we
discussed the options within the surgery. Because of the small size of the
lesion, I told her that her disease was in its very early stages. Since this
was the case, she had had the option of lumpectomy (the removal of part of the
breast with the growth) and follow-up radiation therapy. A radical mastectomy
(complete removal of both breasts) was not necessary in her case. More and
more research is indicating that lumpectomy followed by radiation is just as
effective, possibly more so, than mastectomy in treating breast cancer. More
breakthroughs occur daily in our fight against breast cancer.

Can Magnetic Imaging Help Diagnose Knee Injuries?

QUESTION: Can magic imaging help diagnose knee injuries?
------------------------------------------------------------------------------
ANSWER: That's "magnetic resonance" imaging or MRI, and while it is not
magic, it is very helpful in diagnosing many different conditions. MRI works
on a completely different principle from that of x-ray imaging or computed
tomography (CT or CAT scanning), which both used x-rays.
In MRI, x-rays are not used at all. The patient is placed in a machine
that creates a strong magnetic field, which causes the hydrogen atoms in that
body (and there are a lot, hydrogen is extremely common) to line up and point
in the direction of the field. A short pulse of radio waves then causes these
atoms to wobble a bit and then go back to spinning in alignment. This wobble
releases some of the radio energy back and depending on the density of
hydrogen in the tissues, different tissues send back different signals. These
signals are processed into computerized pictures of the tissues.
Unlike X-rays, the MRI process does not "see" bone tissue, because it
lacks hydrogen atoms, but it is excellent for soft tissues, which may be seen
even more clearly without being hidden by the dense bone. MRI imaging offers
great accuracy for diagnosis especially in structures like the knee, which are
made up of many types of tissue. Physicians can examine the knee for damage
to the muscles, ligaments and tendons, as well as for tumors, cysts, and
changes in the joint fluid.
There are no known adverse affects to MRI, although some people feel
claustrophobic while in the machine. Another plus is that there is no need to
inject any contrast materials into the joint to make certain features stand
out. However, MRI is expensive, but the cost is coming down as it is becoming
more widely used.

Do Chemical Peels Do the Same Thing as Face Lifts?

QUESTION: Do chemical peels do the same thing as face lifts? I'm thinking of
having one of them to gain a more youthful look.
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ANSWER: Chemical peels and face lifts serve different purposes and have
different effects. With the face lift, hidden incisions are made, and the
skin is lifted, the facial muscles are tightened, and extra skin is removed.
The results will be tighter, less wrinkled neck and jowls. This surgery
should be done only by a board certified surgeon with special training in the
procedure. It's done under local anesthesia as an outpatient. Those
patients who get the best results are around the age of fifty--that is before
wrinkles are excessively deep.
Chemical peels help to remove the fine lines and wrinkles which we
commonly get around the eyes and mouth as we age. The doctor "paints" a
chemical on the skin, causing the upper layers to peel. What's left is new,
tighter skin, with many fewer wrinkles.
Naturally, the results will be different for each patient, and the aging
process continues along its merry way. You can help yourself to prevent
wrinkles by limiting your time in the sun, wearing sunblock and not smoking.

What are the Medical Dangers of Scuba Diving?

QUESTION: My husband has expressed an interest in learning to scuba dive; I'm
trying to discourage him, because I've read about so many medical dangers
involved. What do you say--are you on my side?
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ANSWER: After so many years in Family Medicine, I've learning not to take
sides in family discussions. But your husband is not alone; from 1975 to the
present, the number of scuba divers has more than doubled. No matter how
dangerous, it's not a sport we'll see disappear overnight. So the way to deal
with it is to discuss intelligently some diving-related injuries.
Some basic laws of physics are at the root of diving injuries. We know
that water pressure is double that of air pressure, and that as pressure
increases the volume of gases is inversely proportional. So during ascent and
descent in diving, the volume of gases in our body (oxygen and nitrogen)
changes rapidly. During a dive the volume of nitrogen in our blood and
tissues can double and then quickly halve. Decompression sickness or "the
bends" usually occurs within one hour after a dive, but it may not occur until
after twelve hours. Symptoms are pain, marbling of the skin, pulmonary
compromise, or central nervous system involvement. If left untreated, it can
lead to paraplegia, and most importantly it is not easy to diagnose. The pain
only variety usually occurs in the shoulder and elbow, and relief is found
when the joint is moved, hence the term "the bends." Another possible injury
is related to lung expansion. Going back to our laws of physics, as pressure
decreases, gases within the lungs of the diver expand; these gases must escape
or serious complications can occur. The last type of injury is called middle
air barotrauma or "squeeze", resulting from compression of the tympanic
membrane due to increased pressure.
Certainly, there are risks. But there are thrills and enjoyment as well.
Precise training, strict adherence to the rules, and constant vigilance can
lead to pleasure without injury. Now, with all this information, why don't
the two of you sit down and talk it through again?

What Sexual Activity is Normal for a Man Age 72?

QUESTION: Though I retired several years ago, I am still well and active. I
feel much the same as I did 10 years ago, and still want to experience life to
its fullest. After I retired, my wife and I moved to this community, where we
felt we could make new friends of our own age and experience. But there are
some really strange ideas about sex floating around this place, and they are
making me question myself and my feelings. Would you please discuss what
sexual activity is normal for a man my age (72)? There is more than one
couple waiting for your answer to this very important question.
------------------------------------------------------------------------------
ANSWER: More people than you would ever imagine are interested in your
problem, as my mail is always full of questions that speak to sexuality in
people of your age. There are many changes that occur with the aging process
that affect an individual's outlook and personal perceptions on sexual
activity. The testicles actually become smaller, their sperm count is lower,
erections become less firm, and the desire for sex may come less frequently.
As important as the physical changes are the mental and psychological ones,
and the feelings that are important to the sense of fulfillment and
satisfaction. In this way each of us is unique, and bring to our lives a
complex variety of factors that create a variety of motivations and needs.
You are apparently a robust 72, and your desires to continue in the manner of
a younger man are not only understandable and commendable, but are normal--for
you. By the same token, a description of normal would be different for
someone suffering from a chronic disease, such as diabetes, for the abilities
and desires would be determined by the state and progression of their disease.
Be thankful for your vigor, live your life in your own personal way, and stop
worrying about definitions of normal.

How Many Men are Homosexual or Bisexual?

QUESTION: I'm just curious. How many men in our population are homosexuals
or bisexuals?
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ANSWER: While there is no way to know exact percentages, random polls have
found that 2% of adult men claim to be homosexual, with another 2% considering
themselves bisexual. The actual percentage of men who have ever had homo- or
bisexual relationships is higher for several reasons:
1 - Many boys and teenagers experiment sexually with their own sex.
2 - About 5% of men who claim they are heterosexuals say they also have
interest in homosexual activity and, in fact, many in this group do
report some physical relations with men.
3 - In adult men, half of those who consider themselves homosexual also
claim to have sexual relations with women. One survey found that 86%
of men claim they have never had a homosexual experience. Of that group,
92% say they haven't had a homosexual relationship past the age of
twelve.
Another statistic you may be interested in knowing--about 1% of men
report themselves as asexual.

Can You Use Estrogens to Treat a Runner Who Has No Periods?

QUESTION: I'm a woman runner with a problem, but can't seem to get a straight
answer from anyone. Please help. Can you use estrogens to treat a marathon
runner who has no periods?
------------------------------------------------------------------------------
ANSWER: The use of estrogens in women athletes whose periods have stopped is
a controversial subject. The reason periods stop with strenuous exercise is
not clearly understood, so we aren't sure how to treat the problem, or whether
it should be treated at all. At first, it was believed that these changes in
menstrual cycles were temporary, and that they had no long-term effects. Now
we know that women athletes may also suffer from changes in their bone
density, which can lead to fractures and other skeletal problems. There are
also concerns about the long-term effects of these changes on fertility.
There are more questions than there are answers in this area, and more
research will hopefully supply the answers we need to treat the problem.
At this time, there are many opinions among even the experts in the field
of hormonal therapy, so it is not surprising that many women are very confused
about it. Estrogens are known to increase the risk of endometrial (uterine)
cancer, and they can also cause bloating and depression in some women. The
one common approach to estrogen therapy for athletes is careful monitoring of
bone density. If periods are disturbed and the bone density is decreased,
serious thought should be given to modifying nutrition, exercise and possibly
estrogen therapy. Comprehensive counseling regarding all these factors is
necessary before a good plan can be established.
It's clear to me that most women will benefit from increasing their
calcium intake and limiting fat in their diets. Regular, moderate exercise in
a variety of forms should start at an early age, but exercise should not be
regarded as a cure for all health problems. We don't have all the facts on
estrogen yet, and each time it is prescribed, it should be with careful
thought to all the risk factors.

What are the Symptoms of Lead Poisoning?

QUESTION: We are terribly worried, as recently the community was put on
notice about lead in our water and the damage it can do to your body. Can
you discuss lead poisoning so we will all be able to recognize its symptoms?
------------------------------------------------------------------------------
ANSWER: I can and will, but recognizing the symptoms of lead poisoning is not
always easy, and can easily be confused with other ailments. In the adult,
the symptoms are slow to develop and do so over a period of several weeks.
They can include headache, vague abdominal discomfort which increases and
develops into colicky abdominal pain, accompanied by vomiting and
constipation. Headache is frequent, as well as loss of appetite, and
frequently a metallic taste in the mouth. The appearance of symptoms in
children is much more rapid and acute, developing over a period of 4 to 5 days
with persistent and forceful vomiting, changes in gait, changes in
consciousness leading to seizure, finally to coma. When exposure to lead is
halted, the symptoms may disappear without treatment, only to return if
exposure to lead recurs. Specific tests exist to determine the amount of lead
in the blood (blood lead concentration-PbB) as well as sensitive screening
test which are particularly useful in testing at-risk children. Ordinary
blood counts can reveal the disease when the the white cells display a picture
called "basophilic stippling". Even x-rays are helpful as they reveal lead in
the bones. Treatment for lead intoxication involves the use of chelating
agents. A chelating agent has the ability to bind metals to it, eliminating
its toxic effects and clearing the lead from the body, through the kidneys
in the urine. The use of such powerful chemicals requires skill and careful
attention to the function of the kidneys during the process. For this reason
chelating agents are never given as preventive medication to patients without
symptoms. Of course, here as in all medicine, preventive effort should be
begun, directed at eliminating the source of the lead, from paint,
contaminated foods, folk medicines containing lead, burning lead painted wood,
and water that has come into contact with lead plumbing.

Can Parents' Actions Influence Their Daughter's Femininity?

QUESTION: Is it true that parents' actions can influence their daughter's
femininity?
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ANSWER: Femininity and masculinity is part of role socialization, the way all
of us learn the subtle and not-so-subtle points of the gender role that
society assigns men and women. Parents have a strong role in gender role
socialization, primarily by serving as role models. Children see their
parents taking care of the house, going to work, and engaging leisure
activities. These nonverbal lessons teach children how adult men and women
behave in society. Although girls are exposed to both masculine and feminine
behaviors, they pick up a larger proportion of the feminine behaviors that
they see.
Parents reinforce nonverbal clues by reinforcing what they think is
appropriate behavior for their daughters. But a narrowly defined view of
what is feminine can become a straightjacket. Too much restriction can limit
the activities that a girl feels comfortable doing and reduce her choices in
careers and accomplishments as she becomes older.

What Makes a Person Get Embarrassed?

QUESTION: I'm a bit "red-faced", but I'll ask anyway. What makes a person
get embarrassed?
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ANSWER: Embarrassment is a state we've all experienced to some degree. It
stems from social situations and is essentially caused by sensitivity to the
way others think about us. An embarrassed person is feeling conspicuous,
mortified, and is extremely aware of what other people may be thinking about
them.
Some people get embarrassed more severely or more frequently than others.
It may be caused by an inability to perceive social cues that leads to
embarrassing social gaffes. Some people are excessively modest and simply
feel more embarrassed than other people in the same situation would.
Embarrassment alone is not a health problem but it can lead to one. Some
people let a physical problem that embarrasses them go without treatment until
it is untreatable. Many times, the problem concerns sexual, digestive, or
urinary functioning and it is important for physicians to defuse the person's
embarrassment and offer reassurance. I'm glad you overcame your feelings, and
asked the question.

What Can Be Done to Prevent Relapses in Drug Addicts?

QUESTION: What can be done to prevent relapses in drug addicts?
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ANSWER: This is an extremely difficult and controversial question. When you
consider the numerous facilities and countless dollars that are spent yearly
in the attempt to curb drug abuse in our country alone, you'd have to assume
that if there were any simple and sure-fired way of controlling the problem,
we'd have discovered it by now. Unfortunately, preventing relapse in narcotic
drug abuse is extremely difficult and management requires highly
individualized treatment. However, prevention is not impossible and the more
we learn about the chemically dependent individual, the better we will be able
to attack the problem.
Studies of chemically addicted people have revealed that in most cases
the addict is not hooked on one particular chemical, but on intoxication
itself. It has been observed that when a drug abuser's drug of choice becomes
unavailable or boring for some reason, he or she almost certainly seeks out a
substitute drug. Based on this finding, the first step in treatment in any
addiction is total abstinence from all potentially addictive chemicals.
Restricting the user's drug of choice is not enough. Even drugs that are
generally not considered habit-forming in the general population can have
mood-altering effects on an addicted patient, and any inclination on that
patient's part to purchase over-the-counter sleeping pills or weight-loss
pills should serve as a strong warning that a chemical relapse is on the way.
Another major step in helping to prevent a drug relapse is counselling.
People become addicted to drugs for a multitude of reasons, and attempting to
understand personal problems that make a person vulnerable to a chemical
dependency can play a large part in preventing a relapse. It has been noted,
for example, that people who deny their addiction or have no crisis-management
skills will very likely have a relapse within the first year of treatment.
Others who have family problems, or suffer from low self-esteem, shame, or
guilt, may experience a relapse at a slightly later point. For this reason,
determining a patient's emotional and psychological state can be of vital
importance. There are a great many self-help and support groups devoted to
helping addicts overcome their dependence and, I'm happy to report, many have
been quite successful in their attempts. Needless to say, however, if a
patient decides to drop out of one of these groups, it should be taken as a
prime indication of an impending relapse.
In certain instances, such as during hospitalization, drugs that can
cause chemical dependence may be necessary for treatment. Though different
from narcotic abuse, the dependency on these drugs can be just as potentially
damaging. However, with the physician's careful attention to dosage and the
patient's understanding of his or her potential addiction, relapse can usually
be avoided.
People who have been chemically addicted face constant danger of relapse
and preventive guidelines can vary a great deal. Counseling and restriction
of all chemically addicting drugs is a must. Careful observation of the
patient's psychological state should be constant, so that signs of addictive
compulsions can be predicted in advance. There are no guarantees, but if a
patient recognizes his or her addiction and wants to break it, recovery is
attainable.

Is Being a "Pushover" for Sex Related to Divorce?

QUESTION: I have just gone through a long and painful divorce, and now am
trying to get my life back in gear. I am still young and a talented business
woman, but now find that I have become a "pushover" for sexual activity with
my dates. Is it possible that this is due to my recent divorce or do I need
professional help?
------------------------------------------------------------------------------
ANSWER: A divorce is never pleasant, even when both parties agree to the
separation. In cases where a person feels rejected or displaced, the need to
restore self-esteem and repair damaged pride may take the form of excessive
sexual activity. The brief but sometimes intense relationship serves to make
you feel wanted and attractive, and to release some of the sexual tension that
has built up. It also serves to combat the depression that follows any change
in life style. Surely counseling can help before this becomes a habit that
can permanently damage your already disrupted life. And please during this
time remember the rules of safe sex, to reduce some of the other risks, like
infection, you are now running.

Can Cocaine Affect the Nerves?

QUESTION: It's important for me to know so I can help a loved one. Can the
use of cocaine affect the nerves?
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ANSWER: Yes, without doubt! The incidence of strokes and psychiatric
difficulties is greatly increased when cocaine is used. In fact, there is a
dramatic increase of such problems in persons who use cocaine. The amount of
cocaine or the method that cocaine is used does not appear to have any effect
on the problems; new users and "experienced" coke users have the same risk of
life-threatening neurological problems as a result of the drug.
The neurological problems may be catastrophic, such as seizures and
strokes, and there may be no warning that such a disaster is about to occur.
Sometimes, the cocaine user may experience temporary blindness, numbness or
tingling before the major problem occurs. These episodes are may be life
threatening and the symptoms are warnings that should be heeded. Stop cocaine
use immediately and see your physician. If you experience these symptoms and
are not a cocaine user, see your doctor without delay. Your body may be
warning you of an impending stroke.
There are also a wide range of behavioral and psychiatric symptoms than
can be laid at the door of coke use. They can run the gamut from agitation
and restlessness to anxiety, depression, psychosis, paranoia, and even a
preoccupation with suicide.
Any nerve-related problem in an otherwise healthy young person should be
thoroughly evaluated by a physician. Ignoring problems such as headaches,
numbness, tingling, vision disturbances, or personality changes may mean that
the problems are being allowed to progress to the point of disaster. Death or
at least a permanent loss of health may be the result. Cocaine may or may not
be involved, but the astute physician and the caring family member or friend
will be concerned enough to find out and treat the reason for the problem. If
cocaine is the culprit, there are many excellent treatment programs available.
The person with the cocaine problem may be depending on you to help him get to
the root of his symptoms, and will need your support as he works to eliminate
cocaine from his life.

How Safe are Car Seat Belts for Small Children?

QUESTION: I read an answer about crossing seatbelts over to take care of
three kids in your column. However, I have another real concern that stemmed
from your answer. How safe are car seat belts for small children?
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ANSWER: Seat belts are not particularly safe for small children, but they are
safer than nothing. Small children (those under age 4 or under 40 pounds in
weight) should be strapped into federally approved child car seats. These
seats will help keep a child from being thrown violently within the car during
an accident. Children's car seats are available in sizes to fit infants and
toddlers and should be used each time the child is in a car. In some states,
it is the law that a child must be in a car seat or strapped in at all times.
If a car seat is not available, strapping a child in with a lap seat belt
is better than not using anything. A small child is very top heavy. Their
heads are the heaviest part of their bodies. If a car is stopped suddenly,
the unrestrained child is thrown forward and a serious head injury or death is
often the result. In a severe accident, an unrestrained child can fly around
the car like a rag doll. Remember, car accidents are one of the leading
killers of our children.
The best answer, of course, is to do the right thing, do it right, and do
it regularly. That may mean buying an extra child's car seat or two, but it's
the only way I know of preventing the tragedy that can occur when youngsters
are not properly buckled up in devices that have been engineered to protect
them.

Heart Murmur in the Aorta

QUESTION: Recently, after many years without medical care, I visited a
physician who discovered a heart murmur in my aorta. He was very patient with
me and tried to describe my condition, but the only term I remember is
"regurgitation"; but doesn't that apply to vomiting? Do you have enough
information to tell me what is wrong?
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ANSWER: It is always hard to concentrate when the anxiety of a new and
unexpected diagnosis disturbs our thinking. But you have given me more than
enough clues to your condition for me to discuss it. It is a disease called
aortic regurgitation (AR), sometimes called aortic incompetence or
insufficiency, which affects the aortic valves that separate the left
ventricle of the heart from the main body artery, the aorta. These valves are
responsible for keeping the blood flowing in the right direction, from the
heart to the body. However, when they become diseased they no longer close
completely, and allow some blood to flow backward into the left ventricle,
thus the term "regurgitation". In adults, the commonest cause of mild AR are
a two leafed (or bicuspid) valve where normally there are three valves, or
severe hypertension. It may also be found associated with ankylosing
spondylitis and other forms of arthritis. The murmur your physician heard was
caused by the blood flowing backward for an instant, right after your heart
has contracted. Treatment will depend upon your symptoms. Frequently they
are minimal, but you may become breathless on exertion or develop heart
palpitations. If the symptoms of heart failure develop, surgically replacing
the damaged valves is currently the treatment of choice. Since your physician
seems concerned and knowledgeable, I am sure you will be able to discuss all
of this with him again, particularly the appropriate treatment in your case.

Calcifications in the Aorta

QUESTION: When my doctor showed me the x-rays he had taken of my low back, he
pointed out some small white flecks which he called "calcifications in the
aorta" (I made him write it down so I would get it right). He said they
probably didn't mean anything serious, but I want to be sure. Do you think
they are serious?
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ANSWER: Many things can be seen when an x-ray is carefully studied that
sometimes have no relation to the original reason for the study, and may have
no bearing on your state of health. The calcification seen on your x-ray are
the result of atherosclerosis, frequently called "hardening of the arteries".
Although such a finding would require additional work up and investigations in
a man under the age of 45, it is considered a normal part of the aging
process, and may frequently be seen in older patients. As the arteries age
they weaken and develop plaques of atherosclerosis, in which calcium may be
deposited over time. It is the accumulation of this calcium that created the
small white flecks that were observed on the x-ray. While there is no cause
for alarm, and I am sure that these flecks have nothing to do with your back
problem, it would not be unwise to have a general checkup that might look at
your overall condition, and provide you with a further reassurance as to the
insignificance of these findings.

Antiviral Medications

QUESTION: Whenever I visit my doctor with a cold, or what he calls a "stomach
virus", I am told that there is no medication that kills these viruses. Yet
when some of my friends visit their physicians, they are given antibiotics to
help cure their symptoms. Do their doctors know something mine doesn't, and
do you think it's time for me to change my doctor?
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ANSWER: Many different types of infections may cause the same symptoms. For
example, a sore throat may be the result of a bacterial infection, perhaps a
streptococcus causing a "strep throat", raw and painful, and readily treated
with an antibiotic which can only kill bacteria. The same sore throat caused
by a virus will be unaffected by antibiotics, since the mechanisms by which
viruses live and reproduce are quite different from those of bacteria.
Medical science has just begun to develop effective medications which can
control viral infections, but as yet none have been developed for the more
common respiratory and digestive complaints. However, we now have amantadine
as an effective prophylactic agent against the influenza A virus. Other
antiviral agents exist for infections caused by herpes viruses (acyclovir),
and still another is useful in the treatment of symptomatic HIV (AIDS)
infection and is called zidovudine. Many of the present antiviral agents
interfere with the virus' ability to manufacture DNA and RNA, genetic
material necessary for reproduction. All of the currently available antiviral
agents have very specific indications for use, and many of them have severe
side effects, which may further limit their use. I don't think your friends'
physicians know any more than your doctor, it appears to be a question of
different diseases. However, any time you begin to lose confidence in your
own physician, even when diagnoses and treatments have been appropriate, may
be a time for reconsidering this most important relationship.

Colitis Caused by Antibiotics

QUESTION: After a recent chest infection, I developed a terrible bout of
diarrhea. This came on with severe stomach cramps and weakness. I took some
medicine we had at home, but to no avail. When I finally visited my doctor,
he performed a complete examination with a scope, and informed me that I had
colitis that was caused by antibiotics. Despite my request, the doctor gave
me no medications. I am wondering about both the diagnosis and the treatment.
Will you please comment?
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ANSWER: You may be aware of the fact that many types of bacteria normally
live in our digestive system without causing us any ill effects. However,
when antibiotics are given to combat infections in any portion of our body,
these potent medications kill the normal bacteria in the intestines as well
and allow certain resistant bacteria types to take over the territory usually
occupied by the "friendly" germs. The most frequently recognized, Clostridium
difficile, is a gram-positive rod that produces a poison that can damage the
cells that line the colon. When this occurs, all the symptoms which you
experienced may be provoked; diarrhea, abdominal pain, and fever. In some
cases the disease, known as "antibiotic associated colitis," may be so severe
that dehydration, hypotension (low blood pressure) and even perforation of the
colon may occur. The diagnosis is based upon the findings of a colonoscopy
(examination of the colon with a telescope-like instrument) as well as the
results of a stool culture which finds the presence of Clostridium difficile,
and the history of recent use of antibiotics. Taking medications which reduce
the normal movement of the bowels (peristalsis), and which can help with
ordinary diarrhea, is a no-no in this case as it may prolong the time that the
bacteria and toxins remain in contact with the tissue of the colon. Treatment
varies with the severity of the disease and the findings of the colonoscopic
exam, but always requires stopping the antibiotic. Once the antibiotic has
been discontinued, the colitis will generally subside by itself in 10 to 12
days, without any additional medication or treatment. Although the presence
of the bacterial toxin may remain for several months, no further treatment is
necessary if you remain without symptoms.

Anorexia in Teens

QUESTION: With all the recent publicity about the serious consequences of
anorexia in teen ages, I take my responsibilities in a high school health
program very seriously. Can you give me any idea of how common this type of
behavior is, so that my suspicions won't become exaggerated?
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ANSWER: It is common enough for you to stay on guard, according to at least
one study published in the Journal of the American Medical Association a year
or two back. The activity of abnormal purging behavior was reported in 13% of
1,700 tenth grade high school students. Purging takes three forms; vomiting
which is the most frequently reported, the use of laxatives, and the use of
water pills or diuretics. It is more frequent in girls, who outnumber the
boys by a 2 to 1 margin. This type of behavior was found in teenagers who
were preoccupied with their weight. They were "calorie counters" who dieted
frequently and suffered from pangs of guilt whenever they felt they had over
eaten. Because of peer pressure as well as the styles of society, many youths
maintain normal weight levels in unhealthy ways, and are at risk of becoming
true anorexics if not properly counseled and advised. These adolescents are
at a crucial point in their lives when they must establish rational goals
based upon knowledge obtained from their education. A program which teaches
the basics of nutrition and establishes guidelines for appropriate levels of
weight, encourages exercise, and provides the information necessary to
distinguish between healthy and harmful reducing methods can be an effective
method in overcoming the development of eating disorders. Your participation
and concern for your students may be just the influence that may avoid a
disaster from occurring either now or later in life.

Ankle Sprains and Treatment

QUESTION: I turned my ankle several weeks ago, and still suffer from some
pain. Why would a simple thing like a sprain take so long to heal and what
can I do to treat it?
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ANSWER: Ankle sprain is not always the simple thing folks take it to be.
When one of the ligaments that help form the ankle ruptures or tears, home
remedies may not be sufficient to get the patient back on the foot rapidly.
Sprains can be classified into three grades of seriousness. Grade 1 is where
there is no ligament tear, and there is mild tenderness and some swelling.
When there is a partial tear or rupture, and obvious swelling and
discoloration or difficulty in walking, it ranks as a Grade 2. When a
ligament is completely torn, and the ankle becomes unstable with the patient
unable to walk, it is classified as Grade 3. Care is graded as well. For the
case of Grade 1, elastic strapping or taping, elevation of the foot, followed
by gradual walking and exercise suffices. For Grade 2, a below the knee
walking cast immobilizing the ankle for three weeks is advised. Grade three
is of course the most difficult to treat, requiring casting and even surgery.
Arthrography, a special x-ray technique, is used when surgery is considered to
determine the exact state of the injury, and to help plan the surgical
procedure. However, this must be performed during the first days following
the injury to be of value. Nonsteroidal anti-inflammatory medications
(NSAIDs) help reduce inflammation and control pain. In your case, it would
seem that an x-ray is in order to rule out any bony injury, and medical
consultation and advice about treatment is required. You have gone too long
to try home remedies now.

Aneurysm of the Heart

QUESTION: Following a recent severe heart attack, my father developed an
aneurysm in his heart. We have discussed the situation with his doctor, who
because of a gradual decline in Dad's condition is recommending surgery. We
have tried to study up on this condition, but are becoming confused as we read
of the same condition in the brain and aorta. Is there any chance you can
sort this out for our family?
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ANSWER: To start the sorting out process, let's define an aneurysm for you.
The word comes from the Greek word that means "a widening," and in fact an
aneurysm is a widening or sac formation in a weakened section of the wall of
any artery, vein or the heart. Aneurysms occur most frequently in the portion
of the aorta (the largest artery in the body) the passes through the abdomen.
They are found less frequently in the heart, the major blood vessels of the
chest, and the brain. In your father's case, a portion of the muscle of the
heart died when he had his heart attack. The artery leading to this section
of the heart wall became blocked, probably by a blood clot, and the blood
flow to the heart tissue stopped. Without the oxygen and nutrients carried by
the blood, the heart tissue could not survive. During the healing process,
the dead heart muscle was replaced by a thin scar, without the necessary
strength to contain the pressure that develops each time the heart contracts.
It is probably this area that is now bulging outward with each beat, forming a
sac or aneurysm. This, in turn, reduces the ability of the remaining heart
muscle to perform the vital function of pumping the blood to the body. While
the heart works harder to compensate, it uses more oxygen, and if the supplies
are inadequate, angina may develop, or heart failure may rear its ugly head.
When the aneurysm is removed surgically, the efficiency of the heart is
improved, angina disappears, and your father's general condition improves.
Frequently, a cardiac artery bypass procedure is performed at the same time as
the aneurysm is removed, to help improve the circulation to the heart. In
your reading, do not be confused by reference to arterial aneurysms, where the
walls of the vessels are weakened by progressive atherosclerosis, or brain (or
berry) aneurysms which are the result of a congenital condition. The
operation sounds well advised in your father's case, and should be performed
as soon as possible, before he worsens further.

Guidelines for a Nursing Home Visit

QUESTION: This will be our first visit to a beloved and alert aunt in her new
surroundings, a nursing home. It is also our first experience with such
visits, and we are all feeling just a bit nervous about what should or should
not be said or done. Can you provide us with some guidelines?
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ANSWER: While there are a few small details that may help, the best advice I
can offer you is to be yourselves, and allow your aunt to be herself, as she
enjoys the brightness that your visit will provide. This is her new home, and
she will proudly introduce you to her new friends. Allow her to be the
hostess she was in former surroundings, and take her up on the tour she will
most certainly offer you. But be alert and attentive, on the watch for signs
of overdoing it a bit, or of distress. Listen carefully to what she says, as
well as how she says it, and answer her directly and honestly, just as in the
old days. You may want to call the home before your visit to be sure that you
will arrive at a time that will not disrupt normal schedules and activities.
If your gifts are to include food, be sure they are permitted on special
diets, but bring a small luxury that may not be routinely provided. Small
living plants make fine gifts, and may help to brighten a room. Most visits
are mainly conversation, remembering good old times, and will provide your
aunt with some moments of pleasant remembering, and an attentive and loving
audience. Listen carefully for hidden meanings, and pay attention to
nonverbal clues that may indicate the state of your aunt's well being.
Encouragement and reassurance is an important function of your visit, so touch
frequently. Be sure the tone of your voice conveys your love and concern. If
you can find some treasured photos from previous meetings, take them with you,
in a frame perhaps, as a souvenir of your visit. If other family members are
responsible for your aunt's welfare, call and share your experiences and
observations with them. Then enjoy the warmth provided by your good deeds.

Aerobic Cautions

QUESTION: I have made up my mind, partly because of your column, partly
because of encouragement from friends, to begin remaking this tired old body
of mine. After a fine physical exam, my physician agrees that I may proceed
with an aerobic dance class. Any final instructions from you?
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ANSWER: You do make me proud. You are in for lots of fun, and an improvement
in your strength, endurance and even flexibility. But here are a few
cautionary words. Be sure you begin each session with the warm-up and
stretching exercises that are a most important component of the session.
Don't come late and try to dive right in; it doesn't work that way. Do the
cool down exercises as well, without omitting the stretches. Don't push too
hard, particularly in the beginning. It isn't necessary to go full tilt for
the full hour. Just sway in time to the music when the going gets rough, but
stay in there. I don't believe in the slogan "no pain, no gain" for this
activity and your reasons for participating, so "hurt" may be left to the
side. Buy the right shoes for aerobics, and don't substitute running shoes,
or try it barefoot. A good instructor won't permit this anyway. The greatest
risk of injury comes from overuse, so moderation is the rule. Most important
of all is to keep it pleasurable, for fun is a great motivation, and you will
stick with it long enough to do you some good. Have a blast!

Draining Of Abscesses

QUESTION: This discussion has been going on for years, for I am sure that I
read somewhere that you should never open an abscess with a needle, for fear
of starting an infection. My husband insists that all such things must be
opened as soon as they are ripe, to prevent the spread of the poisons through
the body. Would you please clear this up once and for all?
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ANSWER: Your husband gets the nod on this one, provided he restricts his
activity to abscesses. Blisters are another thing however, and I believe your
beliefs stem from the warning not to open blisters caused by friction or
prolonged activity. The fluid inside a blister is sterile, and the tissue
beneath the liquid pad formed by the blister is damaged by the trauma. The
blister protects the area from further damage and should not be drained, but
covered by a thick bandage to add another layer of protection to the injury.
Abscesses are another story. They are collections of pus beneath the skin,
formed by collection of white cells assembled to fight an invading bacterial
infection. Abscesses begin as cellulitis, an inflammation within the solid
tissue, noted by the redness, heat, swelling and tenderness that accompany the
inflammation. As the tissue dies, a space is created which becomes filled
with tissue fluids, white cells, bacteria and parts of the destroyed cells,
forming pus, and creating the abscess. Abscesses can grow, destroying
adjacent tissue, and eroding blood vessels. When the bacteria get into the
blood stream (septicemia), the infection may spread to all parts of the body.
By incising an abscess the contents may be drained away, reducing the chances
of spreading infection, and allowing the body's own power to repair itself to
begin to heal the wound.

Therapy and Treatment for Bell's Palsy

QUESTION: It is one of the most frightening things that has ever happened to
me. The whole left side of my face has fallen down, and I can't even smile.
My doctor has diagnosed this as a bell palsy, and assures me that I'll soon be
better, but I need more information. Will you please help me?
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ANSWER: When an entire half side of a face suddenly becomes weak and
unresponsive, the most common cause is "Bell's Palsy", the result of pressure
on the facial nerve. Although the cause is unknown, it is felt to be a viral
or immune disease in which the facial nerve swells within the ear bone,
causing a pressure which damages the nerve. A number of tests are usually
performed to assure an accurate diagnosis, including a hearing test, a balance
test, a taste test, x-rays to locate infections, tumors or other abnormalities
in the bone, and an electrical test to check the function of the nerve. Once
all of these have been carefully performed, the diagnosis of Bell's is
relatively easy. And in many cases, so is the treatment, for complete
recovery within several months invariably follows partial facial paralysis.
However, physical therapy to maintain the tone of the affected muscles is
often recommended. Since the ability of the eye to blink is affected, the
cornea of the eye may become dry from lack of lubrication, and develop an
ulcer. Closing the eyelid with your finger from time to time can help, and
the frequent use of artificial tears may also be recommended. It may be
necessary to place a patch on the eye temporarily to protect the delicate
corneal tissue, and the use of glasses to prevent dust particles from blowing
into an eye unprotected by a blink reflex is also a good tip. Remain calm,
and the chances are you will be back to yourself in a few months.