Archive For: Medical Conditions

Kidney Stones: Treatment & Prevention

This Too Shall Pass: Treating and Preventing Kidney Stones

More common, frequently less painful and far more preventable than reputed, kidney stones have, thankfully, entered a new era of highly effective, noninvasive procedures. We bring you up to date on this eminently treatable condition.

Q: Why do kidney stones happen?

A: They form when substances such as calcium, oxalate, cystine or uric acid are present at high levels in urine, becoming crystals that gradually increase in size to a stone.

Q: How likely am I to experience kidney stones?

A: One in 10 people deal with kidney stones in their lifetime, more frequently men, but in recent years, women are rapidly closing the gap. Genetic factors also play a role: if kidney stones are prevalent among your family members, you are at higher risk of developing them.

Q: Are kidney stones very painful?

A: Over the years, the pain associated with kidney stones has taken on an almost mystical aura, sometimes described as “worse than childbirth.” However, the truth is that not every kidney stone causes intense pain. Some are small enough to pass unnoticed, and many are asymptomatic and only discovered when blood is found in the urine during routine testing. Others are large but can stay in the kidney forever without incident. It is only the stones that become “stuck” on their way out of the body that cause renal colic, or waves of severe pain, which can be promptly treated with pain medication.

Q: Does back pain mean I have kidney stones?

A: This is frequently asked by patients concerned about pain felt in the flank area near the kidney. A careful history will be taken to help determine the location of the pain, but a fairly simple way to distinguish the cause is to change positions. If the pain worsens, it is more likely to be a musculoskeletal type of strain. Kidney stone pain is less likely to be positional.

Q: How do you determine if treatment is needed?

A: A noninvasive, less expensive ultrasound is used for screening, but a spiral computed tomography (CT) scan provides superior imagery used to more accurately pinpoint the stone’s location. If only a partial obstruction is seen and not much pain is involved, time is on your side and we can wait to see if the stone passes naturally. At that point, many patients can rest comfortably at home and may be given antispasmodics (such as Flomax) to relax the ureter, pain medications to manage pain and instructed to drink plenty of water to aid the stone’s passage.

Q: What if it doesn’t pass on its own?

A: It’s reassuring to realize there is no urgency to remove the stone unless the kidney is obstructed or infected or the patient is experiencing intractable pain. And when removal is indicated, urologists (specialists in diseases of the urinary tract) have a number of options available, many of them noninvasive or minimally invasive. Open surgical procedures are a rare event. Instead, an outpatient ureteroscopy can be done, using an endoscope to break up or remove the stone. Even less invasive is lithotripsy, good for small stones, which directs high-energy shock waves toward the stone and breaks it into fragments to more easily pass out of the body. For extremely large or resistant stones, a minimally invasive percutaneous nephrolithotomy is conducted to remove the stone via an endoscope inserted through a small incision in the skin.

Q: What is the best way to prevent kidney stones from forming again?

A: We can take the time to develop an individualized approach, based on your stone’s composition. First, your stone will be tested and categorized as calcium oxalate (the most common type), calcium phosphate, a mix or a non-calcium type. Also recommended is a 24-hour urine collection to form a clear picture of how the crystals form in your body, as well as blood tests for further analysis. While those who have formed stones before are at higher risk for forming a subsequent one, we know that dietary modifications tailored to stone type and – if needed – drug therapy can substantially reduce that risk. If you form calcium oxalate stones, we’ll work on a plan to avoid foods high in oxalate, such as spinach, beets and rhubarb, and keep sodium consumption at a minimum. Also important to know is that despite its role in the stone’s composition, there is no need to restrict calcium. In fact, increasing your calcium intake with higher-calcium foods such as milk, yogurt and cheese can help lower oxalate levels in the urine. Finally, keep in mind that the single best preventive measure is to simply fill a bottle with water and drink often.

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An Update on the Measles Outbreak in the US

What are the newest guidelines for measles vaccinations?

  • Adults with no evidence of immunity should get 1 dose of MMR. Immunity is defined as documented receipt of 1 dose, or 2 doses, 4 weeks apart if high risk, of live measles virus-containing vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birthdate before 1957.
  • High-risk people, including healthcare personnel, international travelers and students at post-high school educational institutions, should receive 2 doses.
  • Persons who previously received a dose of MMR vaccine in 1963–1967 and are unsure which type of vaccine it was, or if it was an inactivated measles vaccine, should be revaccinated with either 1 (if low-risk) or 2 (if high-risk) doses of MMR vaccine. At the discretion of the state public health department, anyone exposed to measles in an outbreak setting can receive an additional dose of MMR vaccine even if they are considered complete for their age or risk status.

Why does a birthdate prior to 1957 confer immunity to measles?

People born before 1957 lived through several years of epidemic measles before the first measles vaccine was licensed in 1963. As a result, these people are very likely to have had measles disease. Surveys suggest that 95% to 98% of those born before 1957 are immune to measles. Persons born before 1957 can be presumed to be immune. However, if serologic testing indicates that the person is not immune, at least 1 dose of MMR should be administered.

Why is a second dose of MMR necessary?

Between 2% and 5% of people do not develop measles immunity after the first dose of vaccine for a variety of reasons. The second dose is to provide another chance to develop measles immunity for people who did not respond to the first dose.

Are there any situations in which more than 2 doses of MMR are recommended?

There are two circumstances when a third dose of MMR is recommended, according to ACIP.

  1. Women of childbearing age who have received 2 doses of rubella-containing vaccine and have rubella serum IgG levels that are not clearly positive should receive 1 additional dose of MMR vaccine (maximum of 3 doses). Further testing for serologic evidence of rubella immunity is not recommended. NOTE: MMR should not be administered to a pregnant woman.
  2. Persons previously vaccinated with 2 doses of a mumps virus–containing vaccine who are identified by public health authorities as being part of a group or population at increased risk for acquiring mumps because of an outbreak should receive a third dose of a mumps virus–containing vaccine (MMR or MMRV) to improve protection. More information is available at www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6701a7-H.pdf

Many people age 60 years and older do not have records indicating what type of measles vaccine they received as children in the early 1960s. What measles vaccine was most frequently given in that time period? That guidance would assist many older people who would prefer not to be revaccinated.

Both killed and live attenuated measles vaccines became available in 1963. Live attenuated vaccine was used more often than killed vaccine. Without a written record, it is not possible to know what type of vaccine an individual may have received.

  • The killed vaccine was found to be not effective and people who received it should be revaccinated with live vaccine.
  • Persons born during or after 1957 who received killed measles vaccine or measles vaccine of unknown type, or who cannot document having been vaccinated or having laboratory-confirmed measles disease, should receive at least 1 dose of MMR.
  • Some people at increased risk of exposure to measles (such as healthcare professionals and international travelers) should receive 2 doses of MMR separated by at least 4 weeks.

Do people who received MMR in the 1960s need to have their dose repeated?

Not necessarily.

People who have documentation of receiving live measles vaccine in the 1960s do not need to be revaccinated.
People who were vaccinated prior to 1968 with either inactivated (killed) measles vaccine or measles vaccine of unknown type should be revaccinated with at least one dose of live attenuated measles vaccine. This recommendation is intended to protect people who may have received killed measles vaccine which was available in the United States in 1963 through 1967 and was not effective (see above).
Persons vaccinated before 1979 with either killed mumps vaccine or mumps vaccine of unknown type who are at high risk for mumps infection (such as persons who work in a healthcare facility) should be considered for revaccination with 2 doses of MMR vaccine.

Please explain the Advisory Committee on Immunization Practices (ACIP)’s revised definition of evidence of immunity to measles, rubella, and mumps.

In the 2013 revision of its MMR vaccine recommendations, ACIP includes laboratory confirmation of disease as evidence of immunity for measles, mumps, and rubella. ACIP removed physician diagnosis of disease as evidence of immunity for measles and mumps. Physician diagnosis was previously not accepted as evidence of immunity for rubella. The decrease in measles and mumps cases over the last 30 years has made the validity of physician-diagnosed disease questionable. In addition, documenting history from physician records is not a practical option for most adults. The 2013 MMR ACIP recommendations are available at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf

What can be done for unvaccinated people who have already been exposed to measles, mumps, or rubella?

The measles vaccine, given as MMR, may be effective if given within the first 3 days (72 hours) after exposure to measles. Immune globulin may be effective for as long as 6 days after exposure. Post-exposure prophylaxis with MMR vaccine does not prevent or alter the clinical severity of mumps or rubella. However, if the exposed person does not have evidence of mumps or rubella immunity they should be vaccinated since not all exposures result in infection.

Adult ADD

Attention Please: ADD/ADHD is Not Just a Childhood Condition

In the 21stcentury, it’s standard procedure to test unfocused, impulsive and restless children who struggle to achieve in school for Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD), and provide support and treatment well into adulthood. But for those who came of age prior to the 1970s, that diagnosis was rarely made, leading to a lifetime of challenges. Only now, as ADHD and ADD are recognized as conditions that often do not disappear with maturity, are some seniors finally finding the answer to problems that have haunted them for years.

ADD is a condition of varying degrees, and in cases of milder severity, whether in the young or older patient, can be difficult to diagnose; especially in older adults, because the symptoms are different than in children.  Hyperactivity is rarely the primary indicator, although remnants are felt such as restlessness and talking too much. Most frequently experienced by adults is a tendency to be easily distracted, a decline in working memory and a lack of focused attention. As we get older, the challenge may lie in distinguishing these issues from the normal aging process, mild cognitive impairment or early dementia.  Forgetting names, misplacing things, or having problems with organization and planning can be hallmark traits of ADD or an aging brain. The key to identifying the difference is longevity of symptoms. ADD doesn’t suddenly appear full-blown in an adult, but leaves a years-long trail of distraction in its wake.

Experts advise that symptoms can shift with age, but these are found fairly consistently in older adults with ADD*:

  • “Swiss cheese memory,” characterized by things that slip through the cracks
  • Issues with working memory, such as being easily thrown off course mid-task
  • Misplacing items
  • Forgetting words or names, brain going ‘blank’ periodically
  • Difficulty learning new things
  • Talking excessively, often without realizing it
  • Interrupting others
  • Trouble following conversations
  • Difficulty maintaining relationships and keeping in touch

According to the organization ADDitude, a leading source of information, support and advocacy for people living with ADHD, asking this simple question – “Would you have been talking about these symptoms 20 years ago?” – can be one of the most accurate of all indicators. Patients who answer in the affirmative, remembering constantly being chided for a messy room, branded as a daydreamer or underachiever, and finding it difficult to keep organized and on time at a first job, are more likely to have previously undiagnosed ADHD. In fact, the majority would say “I can’t remember a time that I wasn’t this way.”

Gratifyingly, adults who are diagnosed with ADHD or ADD in their older years find it can be revelatory to finally identify the cause of their ongoing challenges, and receive the support they need at a particularly vulnerable life stage. Coping with ADD as a senior actually parallels the issues faced by young people with ADHD when they leave home. The loss of structure for both groups can strain their ability to adequately care for themselves, and poor sleeping or eating habits can result, which exacerbate ADHD symptoms. However, treatment which may include appropriate doses of stimulant medication and cognitive behavioral therapy, has been shown to work as well for adults as children, and provide a newfound satisfaction with life.

As Dr. David W. Goodman, assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine and director of the Adult Attention Deficit Disorder Center of Maryland, explains: “People may ask, ‘if you’ve had this problem for so long, why bother treating it now?’ Imagine you believed yourself to be as others labeled you throughout your life – careless, irrational, a daydreamer, dumb or just plain odd. Then, you realize a treatable disorder caused these symptoms, and they aren’t a reflection of who you are. It’s liberating to understand the difference between what you have – a disorder – and who you are – a person.”

*Source: Kathleen Nadeau, Ph.D. presentation at the 2018 Annual Meeting of the American Professional Society of ADHD and Related Disorders

Did You Know?

Although ADHD and ADD is a commonly seen psychiatric condition in the US, second only to generalized depression, adults in their 50s, 60s and 70s often go undiagnosed and untreated.

Fewer than half of adults with ADHD ages 45+ have ever sought any kind of treatment and only 25% have tried medication.

Source: www.additudemag.com

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The Age of Anxiety

Higher Anxiety? Our ‘age of anxiety’ began four centuries ago

It can come on suddenly and intensely, causing shaking, confusion and difficulty breathing for no apparent reason…trigger an irrational avoidance of elevators or public transportation…or become a steady drumbeat of worry always in the background. All are known as anxiety disorders, one of the country’s most commonly experienced yet largely untreated mental health issues. Is our era of 24/7 disturbing news, packed schedules and often unrealistic expectations spurring a rise in these disorders, or does it just seem that way?

Modern life can be disquieting, but the truth is that anxiety disorders have always impacted large numbers of people around the world. Consider this description of Hippocrates’ patient in 1621’s The Anatomy of Melancholy: “He dare not come into company for fear he should be misused, disgraced, overshoot himself in gestures or speeches, or be sick; he thinks every man observeth him” – a classic case of what would now be diagnosed as social anxiety disorder. Recent research notes that anxiety disorders may be under-recognized and under-treated, but there is no evidence that its prevalence has increased. While the incidence rose from 9 to 15 percent in college students since 2009, according to the Journal of American College Health, the authors attribute the finding to a greater willingness to admit having a mental health issue and increased acceptance of it as a bona fide health problem.

Constant anxiety undeniably takes a toll on health, potentially increasing levels of the stress hormone cortisol and raising blood pressure and may drive inflammation and plaque formation that leads to heart attack and strokes. A reaction to stress that occurs in a region of the brain called the amygdala, anxiety prepares people to confront a crisis by putting the body on alert. The ‘fight or flight’ response serves us well when faced with actual danger but is counter-productive when dealing with worries around work, money, family life or health. However, it’s only when daily function is affected that a disorder is diagnosed, as shown below:

Everyday Anxiety: Worry about finances, health, family or other important life issues
Anxiety Disorder: Constant and unsubstantiated worry that causes significant distress and interferes with daily life

Everyday Anxiety: Embarrassment or self-consciousness in an uncomfortable or awkward social situation
Anxiety Disorder: 
Avoiding social situations for fear of being judged, embarrassed or humiliated

Everyday Anxiety: A case of nerves or sweating before a big test, business presentation, stage performance or other significant event
Anxiety Disorder: 
Seemingly out-of-the-blue panic attacks and preoccupation with the fear of having another one

Everyday Anxiety: Realistic fear of a dangerous object, place or situation
Anxiety Disorder: 
lrrational fear or avoidance of an object, place or situation that poses little or no threat of danger

Everyday Anxiety: Anxiety, sadness or difficulty sleeping immediately after a traumatic event
Anxiety Disorder: Recurring nightmares, flashbacks or emotional numbing related to a traumatic event that occurred several months or years before

The American Psychology Association defines these types of anxiety disorders (obsessive-compulsive disorder and post-traumatic stress disorder are now categorized separately):

  • Generalized anxiety disorder (GAD): the most common, it’s characterized by excessive, long-lasting worries about nonspecific life events, objects and situations.
  • Panic disorder: brief or sudden attacks of intense terror and apprehension, leading to shaking, confusion, dizziness, nausea and breathing difficulties; can occur with or without a particular trigger.
  • Specific phobia: irrational fear of a particular object or situation.
  • Agoraphobia: fear of places, events, or situations, especially open spaces, that may cause you to panic and feel trapped, helpless or embarrassed.
  • Social anxiety disorder: fear of negative judgment from others in social situations or of public embarrassment.
  • Separation anxiety disorder: not exclusive to youngsters, but also experienced by adults who feel disconnected from a person or place that provides feelings of safety or security.

Additionally, anxiety disorders may play a role in exacerbating other conditions such as irritable bowel syndrome (IBS), chronic respiratory disease and heart disease.

Reassuringly, the number of treatment options, both pharmaceutical and non, has grown. Most effective is a combination approach of psychotherapy (cognitive-behavioral therapy, focused talk therapy or exposure therapy), stress management (deep breathing, meditation and yoga) and antidepressant and/or anti-anxiety medications.

Finally, considerable benefits are seen from a healthy lifestyle – reduced intake of caffeine, tea, cola and chocolate, avoidance of recreational drugs and excessive alcohol, and emphasizing exercise, a nutritious diet, and most importantly, a good night’s sleep. According to a recent University of California at Berkley study, the amygdala was particularly stimulated when sleep deprived, mirroring that of anxiety disorders, suggesting that sleep therapy could reduce anxiety in people suffering from panic attacks, GAD and other conditions.


Did You Know?

40 million

People in the U.S. affected by anxiety disorders
Source: NIMH.gov

37%

Percentage of Americans with an anxiety disorder who receive treatment
Source: ADAA.org

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The Enemy Within: Autoimmune Disease is on the Rise

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A condition that is thought to have tripled in prevalence over the last 50 years, impacting over 23 million people, could justifiably be seen as an epidemic, or at least, a growing health concern. Autoimmune diseases, though, are not often thought of in that way because they manifest as 80+ different illnesses that nevertheless share the same root cause: a malfunctioning immune system that mistakenly attacks its own tissues. Virtually every human organ system can be impacted: the brain and spinal cord in multiple sclerosis, the skin in psoriasis, the joints in rheumatoid arthritis, the intestines in Crohn’s disease and ulcerative colitis, the insulin-producing cells in the pancreas in Type 1 diabetes, the thyroid in Hashimoto’s disease, among others.

Ironically, 100 years ago, Nobel Prize-winning immunologist Paul Ehrlich, MD, was openly skeptical of a concept in which the body turns on itself, calling it “horror autotoxicus” (literally, the horror of self-toxicity). That set back acceptance of autoimmunity another half century, according to today’s leading neuro-immunologists. Now we are beginning to recognize the pervasiveness of autoimmune disease and develop therapies based on new research into its complex causes.

Notably, the gut, which houses 80 percent of the immune system, has come under increased scrutiny for the role it can play in causing disease. One theory posits that a ‘leaky gut’ may allow undigested food particles, microbes and toxins to enter the blood stream, and trigger inflammation that goes on to
disrupt the proper functioning of the immune system.

There is also a growing consensus that these diseases result from complex interactions between genetic and environmental factors. Autoimmune disease is commonly clustered in families, but may affect different organs. For example, a mother may develop rheumatoid arthritis while her daughter copes with juvenile diabetes, her sister has Hashimoto’s thyroiditis, and her grandmother deals with Graves’ disease. Environment and lifestyle may contribute to the increased incidence of these diseases, including chronic stress.

For the many living with an autoimmune condition, there is hope in the form of new medications, advanced treatments and genuine breakthroughs in the precision medicine approach. Experts predict substantial advances in the next decade, fueled by more than 310 medicines and vaccines for autoimmune diseases already in clinical trials or awaiting review by the Food and Drug Administration (FDA). Options go well beyond simply relieving symptoms or replacing substances destroyed by the disease, including:

  • Therapies to suppress the immune system and preserve organ function, such as methotrexate, used to treat cancer, now also successfully used for rheumatoid arthritis and several other autoimmune diseases.
  • Real progress in biologics, which target specific enzymes and proteins. Monoclonal antibody medicines are being used to block inflammation in rheumatoid arthritis, preventing irreversible joint damage and enabling remission; to inhibit the activity of proteins implicated in Crohn’s and colitis and systemic lupus erythematosus; and are newly approved by the FDA to neutralize inflammatory processes linked to psoriasis.

Running on a parallel and complementary path are natural methods, which continue to gain traction. Areas under investigation include: reducing foods high in sugar and saturated fat, practicing de-stressing techniques, lowering the toxic burden caused by constant exposure to environmental factors and restoring intestinal health with a diet that includes prebiotic and probiotic foods.

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Bring It Down: Healthy Blood Pressure Numbers May Go Even Lower

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If you’ve ever wondered why a blood pressure check is part of almost every visit to a doctor’s office, consider what is communicated through the familiar black cuff in just a few seconds. The force of blood pushing against the walls of the arteries as the heart pumps is a critical measure of how well your heart muscle works – systolic blood pressure (SBP, or the top number of a reading) measures the pressure in the arteries when the heart beats; diastolic blood pressure (DBP, or the bottom number) refers to the pressure in the arteries when the heart muscle is resting between beats and refilling with blood.

Readings that exceed the norm, hypertension or high blood pressure, indicate an increased risk of heart attack, stroke and kidney failure. However, exactly what constitutes ‘normal’ blood pressure for optimal health has been debated and tested for decades, and recommendations have fluctuated over time. While the gold standard is under 120 mm Hg/80 mm Hg, the targets for treating hypertension have varied over the years – less than 140/90 in the 1990s, down to 130/80 in 2003, raised to a controversial 150 or less in 2014, and retreating to less than 140 in 2015.

At the end of 2015, a landmark study of more than 9,300 patients, the Systolic Blood Pressure Intervention Trial (SPRINT), moved the needle down even further. Those who were treated most aggressively to drive down blood pressure to 120/80 experienced a significantly lower risk of cardiovascular events, chronic kidney disease, and death. In fact, the outcomes were so convincing that the trial was actually halted after just three years, much sooner than planned, leading the American Society of Hypertension to state: “The early termination of this trial represents an exciting moment in the history of hypertension treatment.” Still, notes of caution were sounded because multiple medications were required, sometimes causing adverse side effects, and experts
agreed more study was needed to justify changes in clinical practice.  Additional evidence followed this year, with an analysis of adults aged 75 years and older who participated in the SPRINT study. The benefits of lowering blood pressure to 120 were even more pronounced, resulting in a one third reduction in risk of cardiovascular events and death, even among the frailest older patients. This finding could benefit almost six million seniors over 75 with elevated blood pressure, according to the Journal of the American College of Cardiology.

While the outcomes are promising, and point in an even more downward direction, experts have not yet reached a consensus on optimal blood pressure targets. For now, hypertension patients should consult with their doctor to determine whether this lower goal is best for their individual care.

Who’s at risk? Virtually everyone

Even those who don’t have high blood pressure by age 55 face a 90 percent chance of developing it during their lifetime, so learning how to identify, prevent and control hypertension can benefit us all.  Consider these best practices:

Identify.

  • Regular checkups are key, as people can live with high blood pressure for years without experiencing any symptoms while internal damage to other parts of the body may be silently occurring.

Prevent.

  • Keep a healthy weight: in an overweight person, every 2 pounds of weight lost can reduce SBP by 1 mm Hg.
  • Eat well: a diet rich in fruits, vegetables, and lowfat dairy products can reduce SBP by 8 to 14 mm Hg.
  • Limit sodium: (see Nutrition Corner, below)
  • Keep active: 30 minutes of aerobic activity most days of the week can reduce SBP by 4 to 9 mm Hg.
  • Moderate alcohol consumption: for women, a single drink a day may lower SBP by 2 to 4 mm Hg.
  • Quit smoking: not only does smoking raise your blood pressure temporarily, but the chemicals in tobacco can damage the lining of your artery walls.

Control.

  • If lifestyle measures alone are insufficient, your physician will determine the appropriate medication, which may include diuretics, beta-blockers or ACE inhibitors.

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Joint Assets

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The aching, swollen, stiff joints associated with osteoarthritis (OA) have long been considered an inexorable result of aging. According to conventional wisdom, cartilage, the smooth connective tissue on the end of bones that cushion the joints, simply breaks down over a lifetime of walking, exercising and moving, allowing the bones to rub together. When medications and physical therapy no longer provide relief, a costly and time-intensive mechanical joint replacement may be the only solution. However, advances in research and a focus on prevention are providing
a new outlook on an ageold problem…we bring you the latest insights, below.

Prevention

The connection between overweight and OA is even stronger than previously thought. Recent studies show that up to 65 percent of cases of OA of the knee could be avoided if weight was reduced. Consider that your knees bear a force equivalent to three to six times your body weight with each step, so a lighter weight relieves the burden considerably. For women, extra weight is even more of a risk factor than men. In addition, fat tissue produces proteins called cytokines that cause inflammation, and in the joints, this can alter the function of cartilage cells.  Gaining weight results in your body releasing more of  these harmful proteins. However, losing even a few pounds can reduce joint stress and inflammation and decrease by half the risk of OA.

Avoid practicing a sport in an intensive and prolonged way. An injured joint is nearly seven times more likely to develop arthritis than one that was never injured. The condition is now seen more frequently among 30 to 50-year-olds than previously because young athletes or middle-aged ‘weekend warriors’ who tear their anterior cruciate ligament (ACL) or menisci of the knee have a much higher risk of osteoarthritis 10 to 20 years after their injury. Take steps to manage or prevent diabetes, which may be a significant risk factor for OA. Some studies suggest high glucose levels trigger the formation of molecules that make cartilage stiffer and less resistant to stress, and cause inflammation that leads to cartilage loss.

Management

Low impact exercise is key to living well with osteoarthritis. While resting aching joints can bring temporary relief, lack of movement will ultimately lead to more discomfort.
Exercise strengthens the muscles around the joint, acting like a shock absorber, helping to reduce pain. In addition, exercise helps with weight control and is a natural mood elevator. Experts recommend low-impact activities like swimming, walking, biking, and moderate weight lifting. The Arthritis Foundation developed a form of tai chi specifically for people with arthritis,
featuring agile steps and a high stance, that helps increase flexibility and improve muscle strength inthe lower body.

Some new approaches to pain management show promise, but beware of unsubstantiated claims. Platelet-rich plasma (PRP) injections, which involve withdrawing blood, spinning
it to separate the platelets and then injecting the concentrated platelets into a joint, are being studied for long-term effectiveness.  Experts advise against costly supplements such as glucosamine, chondroitin and shark cartilage, all of which have proven of little benefit for people with OA. Some elements of Chinese medicine, including herbs and acupuncture, may help control OA symptoms in some people, but these therapies have not yet been confirmed in large, well-designed clinical studies. Also unproven are low-power laser light, copper bracelets or magnets, chiropractic manipulation and acupressure. The most effective over the counter medication are NSAIDs (non-steroidal anti-inflammatory drugs such as Advil). While Tylenol helps reduce pain and is the safest medicine for older people or those with kidney disease, it does not lower inflammation.

Finally, if you do need an orthopedic implant in the future, take comfort in the fact that development of the next generation of devices is well underway. They will likely be biologic, composed of protein and cells instead of metal and plastic,…functioning as well as a normal joint and created to last a lifetime.

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In Our Sights: Sharper Focus on Macular Degeneration Offers New Hope

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In the not so distant past, age-related macular degeneration (AMD), characterized by a loss of central vision, was deemed just another unfortunate consequence of growing older. The gradual breakdown of light-sensing retinal tissue that results in a blind spot directly ahead has caused each generation to struggle with driving a car, reading a printed page or recognizing a friend’s face. As the population ages, the sheer number of people affected grows rapidly. Another case of AMD is diagnosed every three minutes in the U.S. More than 2.1 million Americans with advanced AMD now will grow to 3.7 million by the year 2030, according to the National Eye Institute, who warns the condition will soon take on aspects of an epidemic. A surge of clinical trials and investigative research aims to prevent that from happening, with sights set firmly on restorative, curative solutions.

Scientists exploring the possible causes have made much progress isolating a group of genes that increases the likelihood of an individual developing AMD. Other studies point to inflammation as the trigger. The macula needs a constant, rich blood supply to work correctly, and any interference such as narrowing of the blood vessels, fatty plaque deposits, or a shortage of antioxidants, can cause the macula to malfunction and become diseased.

Treatments have likewise advanced. Last fall, a decades-old drug used to treat HIV/AIDS was reported in Science as unexpectedly exhibiting the capability to halt retinal degeneration. Nucleoside reverse transcriptase inhibitors, known as NRTIs, are already FDA-approved and can be rapidly and inexpensively translated into therapies for both dry and wet AMD (see sidebar), say the study’s authors. At the same time, a nanosecond laser treatment was successfully used to reduce drusen (small fatty deposits beneath the retina) and the thickening of Bruch’s membrane, both hallmark features of early AMD. Importantly, the structure of the retina remained intact, suggesting “this treatment has the potential to reduce AMD progression,” according to Medical News Today. Stem cell transplantation shows enormous promise, as reported in Lancet, with sight restored long-term to a group of patients with severe vision loss. Additionally, injectible drugs and pills that target inflammation associated with AMD are in nationwide trials.

Technological innovations to help AMD patients include the 2013 introduction of a miniature telescope implanted behind the iris to magnify images. Google is moving into the space with a patent for a contact lens containing a built-in camera that will enable audible warnings via a remote device, detect and describe faces, and act as a text reader.

Today’s AMD patients have no shortage of low-vison aids to help them adapt and live well. Google is developing a patent for a contact lens containing a built-in camera that will enable audible warnings via a remote device, detect and describe faces, and act as a text reader. Additional solutions range from ‘smart’ thermostats, watches and remote controls to talking devices.

Finally, understanding who is at risk for developing AMD can be key to prevention. These include: white, female, smoker, family member with AMD, high blood pressure, lighter eye color, obesity, and possibly, over-exposure to sunlight. To minimize risk, follow a healthy diet with plenty of leafy green vegetables and fish high in omega-3 fatty acids, exercise to keep weight and blood pressure under control, eliminate tobacco use, and wear sunglasses to protect from UV rays and high-energy visible (HEV) radiation.

When Dry Becomes Wet

Diagnosis of AMD is first confirmed with a visual acuity exam and testing with an Amsler grid. Those with AMD see the grid’s straight lines as wavy or blurred with dark areas at the center. Additional tests help determine the type of AMD — the dry form affects about 85 percent of AMD patients, and in about 10 to 15 percent of cases, progresses to wet. The difference is significant. The wet form usually leads to more serious vision loss, caused by new blood vessels that leak fluid and blood beneath the retina, resulting in permanent damage. While no treatment currently exists for dry AMD, in the last decade, a number of effective therapies have been implemented for wet AMD. These include monthly, intraocular injections (anti-VEGF) to inhibit a protein that stimulates formulation of new blood vessels, photodynamic or ‘cold’ laser treatment, thermal (heat) laser photocoagulation…and on the horizon are topical eyedrops that may someday replace injections. Nutritional supplements containing antioxidant vitamins, lutein and zeaxanthin are also effective in reducing the chances of dry AMD worsening to wet.

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A Quick Spin on Dizziness, Vertigo and Other Balance Disorders

Common, rarely life-threatening, but very unsettling, an attack of dizziness or vertigo can send your world into a spin with simple acts like turning around to back up a car, bending down to tie a shoe or looking up at the sky.

A range of sensations may keep you off balance, from tilting, swaying, whirling and floating, to feeling lightheaded, or conversely, heavy-headed. The swirl of symptoms may seem similar, but there are important differences that define these conditions:

  • Dizziness: lightheadedness, faintness
  • Vertigo: spinning, a sense that the room is moving, akin to the tipsy feeling from too much alcohol
  • Disequilibrium: unsteadiness, a feeling you are about to fall

While dizziness or vertigo represent some of the most frequent reasons people visit their doctors – an estimated one out of four adults has sought treatment for the condition at some point – getting to the root cause can sometimes be a frustrating experience, say experts at the Vestibular Disorders Association. That is because numerous issues can trigger dizziness/ lightheadedness, from cardiovascular concerns such as arrhythmia, atherosclerosis and low blood pressure or conditions such as dehydration, low blood sugar or anemia. Vertigo is caused by head injuries/trauma, disorders of the vestibular system (parts of the inner ear and nervous system that control balance) or rarely, the cerebellum. In addition, aging itself can affect the vestibular system’s function by decreasing the number of nerve cells, and diminishing blood flow to the inner ear.

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Lyme Disease: Solving the Puzzle

Lyme Disease 2

Unsurprisingly for an illness known as “The Great Imitator,” the misconceptions surrounding Lyme Disease continue to proliferate. Acute or chronic? Highly treatable or stubbornly resistant? Misdiagnosed because of symptoms that mimic conditions like lupus, multiple sclerosis, Parkinson’s and Lou Gehrig’s disease, or overestimated for the same reason? While television celebrity Yolanda Foster recently gained national attention during her bout with chronic Lyme disease, she also fanned the flames of controversy surrounding this sometimes mystifying condition. A brief overview of current knowledge follows…however experts have not yet reached a consensus on all aspects of this disease.

Research indicates that Lyme disease is transmitted to humans by a bite from a tick infected by the spirochete bacteria, primarily found on the East Coast and in the Midwest. Carried by deer and migratory birds, Lyme disease is on the rise, estimated at 300,000 cases annually in America, considerably larger than the 30,000 cases earlier reported by the Centers for Disease Control (CDC).

The distinctive bull’s eye rash is one identifiable marker of the disease, seen in 70 percent of patients. In the early stages, fatigue and flu-like aches and pains are typical; in later stages, nerve numbness or pain, facial paralysis or weakness, and heart problems are seen; and if not treated, serious and long-term complications that affect the brain, joints, nerves, heart and muscles can occur, according to the Lyme Research Alliance.

Lab tests are generally needed to confirm the diagnosis, followed by a course of oral antibiotics. However, people with early Lyme disease do not develop antibodies for several weeks, resulting in frequent false negatives on the commonly used ELISA or Western Blot antibody tests. For that reason, treating patients based solely on clinical findings, such as a rash and known exposure to ticks, is recommended by some experts, while others advise more aggressive, longer and individualized treatment. All agree, however, that earlier treatment is more effective.

About 20 percent of patients with Lyme disease continue to experience symptoms months and years after treatment ends…and this is where the real debate begins. Muscle and joint pain, cardiac and neurological problems and fatigue have been reported by those with chronic Lyme disease. Some experts believe it indicates an ongoing bacterial infection, while others attribute lingering symptoms to residual damage to tissue and the immune system. Still others, including Dr. Allen Steere, who first recognized Lyme disease back in 1975, say it is being over-diagnosed, mistaken for chronic fatigue or chronic pain.

The continued questioning spurred John Aucott, MD, assistant professor of rheumatology at Johns Hopkins University School of Medicine and founder of the Lyme Disease Research Foundation, to launch the nation’s first controlled study examining long-term health and outcomes of the disease.

“It does no good to keep debating the existence of long-term problems related to Lyme disease while people are suffering a debilitating illness. These patients are lost. No one really knows what to do with them. It’s a challenge, but the first thing we need to do is recognize this is a problem,” he said.

The headwinds have been strong. Lyme disease ranks well below breast cancer and HIV/AIDS for federal funding, despite a significantly higher rate of cases, according to lymedisease.org, but Aucott’s study and others represent hopeful progress.

In the meantime, decrease your risk of contracting Lyme disease by wearing shoes, long pants tucked into your socks, a long-sleeved shirt, hat and gloves when walking in woodsy areas; sticking to trails and avoiding low bushes and long grass; and using insect repellents with a 20 percent or higher concentration of DEET. If you are bitten by a tick, call my office promptly, but do not panic…your chances of acquiring Lyme disease are no more than 1.4 percent.

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