Vertigo – A Virtual Volatile Whirl of the Mind

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Spinning around as fast as possible until one feels too dizzy to stand up straight is one of the most amusing activities commonly practiced by children; and they engage in this merriment because the spinning action creates a false sensation of movement known as vertigo.  But for the 69 million adult Americans who suffer from this disorder, experiencing the sudden onset of unprovoked vertigo is not as much fun.  Patients with vertigo have a hard time carrying out simple tasks given that they feel as if they are constantly traveling on a ship being tossed about in the open ocean.  Despite the fact that vertigo can be an extremely uncomfortable scenario, it is generally due to a benign cause such as disequilibrium in the ear canal [although in older patients, vertigo might signify an ominous sign related to cerebrovascular disease].  The good news is that for the majority of cases of vertigo, simple and effective treatment is available.

Vertigo can be perceived as self-motion versus motion of the actual environment, and in order to understand vertigo one must first comprehend how balance is coordinated in the human body.  The two systems involved are the vestibular system (structures in the ear that sense angular and linear motion) and the brain.  The vestibular system on the right and left sides exist in perfect harmony; however, when the head turns one way or the other the brain reads the inner nerve signals and is able to interpret that to mean the body is leaning in a specific direction.  Yet, when there are abnormalities within the vestibular system itself (making it unbalanced at its baseline state) and patients proceed to physically move their head, the brain receives too many signals resulting in vertigo.  In addition to the spinning sensation, patients with vertigo also experience significant nausea and vomiting.  The most common causes for vertigo include stones (calcification of fluid, like gall or kidney stones) in the ear canals, inflammation of the canal due to viruses and bacteria, excess fluid in the ear canal, medication toxicity, or a tumor.  In older patients with known risk factors for cardiovascular disease, vertigo could be caused by a brainstem (area of the brain where balance processing occurs) stroke.  The diagnosis of vertigo is mostly clinical, with the exception of tumors and strokes which require an imaging modality such as an MRI.  The treatment encompasses medications (e.g. meclizine) which suppress the vestibular symptoms.  In addition to this, certain physical maneuvers can be conducted to ameliorate the symptoms.

For patients who develop new onset vertigo, a visit to a primary care doctor might do the trick.  In a preponderance of cases, vertigo is a short-lived condition that can be readily treated with medications.  On the other hand, if patients have refractory symptoms they might need to undergo vestibular rehabilitation (physical therapy).  Lastly, for the patients who suffer from intermittent benign vertigo, all that is needed is to stop by the nearest pharmacy and purchase the available over-the-counter medications.  Whatever the case, taking action at the first sign of symptoms will promote quick relief and ensure that things don’t spin out of control.

Tetanus – Your Shot Not to Get Locked-Up!

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Is your tetanus shot up to date?  If this question rings a bell it’s because this is one of the most frequently asked questions in the emergency room, which is generally brought up in the instance of a patient who has an open wound or animal bite.  Even though patients are familiar with the term “tetanus,” they don’t really understand what tetanus is or why a tetanus shot matters (likely because tetanus is extremely rare in the U.S.).  Nevertheless, it is still important for the public to learn about the disease process and its respective control through vaccination. Tetanus is a severe nervous system disorder which commonly occurs in patients who never completed their vaccination sets or who did not keep up with the vaccines later in life.  Moreover, due to the fact that we cannot get rid of tetanus in the environment, vaccination remains the only treatment that confers full protection.

Tetanus is a neurological disorder caused by a toxin which is produced by the clostridium tetani bacteria.  These micro-organisms are normally found in the soil and in the guts of numerous mammals.  When the bacteria encounter damaged tissue (e.g. devitalized tissue from infections or open wounds from lacerations) they undergo a biological reaction and produce the tetanus toxin.  The toxin ascends into the spinal cord and within 8 days patients demonstrate the clinical effects of the toxin.  The most common physical presentation includes a stiff neck, trismus (i.e. lockjaw), risus sardonicus (severe painful spasm of the facial muscles appearing like a grin), abdominal rigidity, painful swallowing, and airway obstruction.  Additionally, patients will also develop restlessness, rapid heart rate, profuse sweating, elevated blood pressure, and cardiac arrhythmias.  The diagnosis is based on clinical history and a physical examination.  Once a patient contracts tetanus, they must undergo extensive treatment, which includes: debridement of the wounds; antibiotic therapy [although this is minimally effective once the disease is present]; and immunoglobulins (a.k.a. antibodies) to neutralize the toxin.  Furthermore, patients will also need to receive the full vaccination series because, as opposed to other disease processes, having tetanus once does not protect you from future infections.

Tetanus is a serious disorder with potentially devastating effects.  As a result, even after patients receive the full vaccination series as a child, they should make sure their vaccinations remain updated through adulthood.  The Centers for Disease Control and Prevention (CDC) recommend a routine tetanus booster every ten years and active immunization with antibodies should be given to those with high risk wounds such as burns and contaminated lacerations.  Aside from this, there are certain high risk populations that continue to be susceptible to tetanus and these include intravenous drug users, immigrants, patients who live in rural areas, and the elderly.  Unfortunately, immunization to tetanus in the U.S. continues to decline and even though we are lucky enough to still have a low disease occurrence, this might not always be the case.  If adults don’t keep up with their vaccinations, the prevalence of disease will rise.  A simple visit to your primary care doctor and a quick shot on your arm is all that’s necessary to keep your head straight and your neck clean!

Achilles Tendon Rupture – The Athlete’s Achilles’ Heel

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Here’s the scenario: while playing softball with his friends, a 40 year-old male recreational athlete running to home base suddenly develops a severe pain on the back of his calf and subsequently falls to the ground in agony – this is the classic case of an Achilles tendon rupture: an extremely painful condition whereby the Achilles tendon snaps.  Even though this particular example pertains to a recreational athlete, this condition is also often witnessed in competitive athletes as well as in anyone who might suffer from tendon degeneration.  An Achilles tendon rupture is a serious injury that entails a prolonged recovery course; however, the overall treatment for this condition is excellent.  Most patients experience a full recovery and can eventually resume all types of exercise activities.  Of course, not having to experience this condition is what everyone wants so taking the time to learn and practice preventative measures might save you a trip to the operating room.

The Achilles tendon (so called because of the Greek warrior Achilles’ vulnerability in this very spot) is the largest tendon in the body and connects the heel to the soleus and gastrocnemius muscles (both in the calf region).  Due to its anatomical location, this tendon has a limited blood supply, resulting in the formation of a vulnerable area which is prone to injury.  Movements that involve running, jumping, overuse, and sudden acceleration or deceleration predispose patients to tendon injury.  The most commonly witnessed scenario generally involves a patient who abruptly changes their physical activity (e.g. rarely exercising to an intense workout or an athlete boosting a fitness activity).  Patients with this condition report that when the Achilles ruptures they feel as if someone else had physically kicked them on the back of the ankle; they also describe a pop-like sound.  The diagnosis can be made on physical examination but most patients undergo an MRI for confirmation.  Once the rupture is diagnosed, patients will have their leg splinted and will undergo evaluation by an orthopedic surgeon.  Patients then have two therapeutic options: conservative management, where they get a cast and intense rehabilitation; or surgical treatment.  Although there are risks and benefits associated with either option, what has been consistently reported is that patients who undergo surgery have a smaller risk of re-rupturing the tendon.

Some of the risk factors associated with tendon rupture include:  age, which is a significant determinant because as age increases, blood flow decreases, resulting in an inflamed and weakened tendon; medications, such as the fluoroquinolone class of antibiotics (commonly used to treat pneumonia and urinary infections); and the use of oral steroids.  Additionally, several poor training techniques such as flawed running mechanics and improper footwear can also lead to damage.  As a result, anyone who engages in physical activity (with the exception of elite athletes, who follow specialized training regimens) should engage in the following: dynamic warm-up, post-running stretching, running on soft surfaces, limiting mileage to 40 miles per week, usage of proper foot wear, and strength training of the calf muscles.  Implementing these simple changes into your routine workout will protect your tendons and ensure that you never have to hear the ‘pop’!

Psoriasis – More Than Meets the Eye

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Whether you’ve noticed it on beachgoers or are just familiar with the multitude of television ads, our everyday cognizance of psoriasis is an indication of just how common this disease is in our population.  In fact, psoriasis, the skin disease that causes large and unusual rashes, is so prevalent it has been estimated to affect 7.5 million Americans.  Although this skin disorder can occur at any age, it mostly manifests in adulthood.  In the past, scientists thought that psoriasis was simply due to an overproduction of skin cells, but more recent data has shown that psoriasis entails a much more complicated disease mechanism that involves engagement with the immune system.  Moreover, psoriasis has been found to transpire with a variety of other disorders that pertain to the cardiovascular and autoimmune systems.  Luckily, psoriasis is mostly a benign disease and significant advances in medical research have provided us with targeted and effective treatments.

Psoriasis has a variety of presentations, but its most frequent form is known as plaque psoriasis.  Patients with this type of psoriasis will have a raised red patch of skin with defined margins and silver scales on the surface.  Researchers have found that patients with psoriasis have an immune-initiated reaction whereby there is an abnormal signaling component in the patient’s own cells, resulting in the formation of an abnormal skin layer.  The plaques (i.e. skin patches) appear symmetrically over the scalp, elbows, knees, and back.  Several environmental factors have been delineated as triggers for psoriasis and they include: medications, trauma, alcohol, smoking, stress, and infections.  Patients with psoriasis are generally asymptomatic but a few may describe a sensation of irritation and itching at the plaque site.  In the majority of cases, a thorough clinical history and examination will suffice for a diagnostic determination.  The treatment for psoriasis is variable and depends on the severity and extent of the disease.  For those with a mild form of the disease, topical steroids and ultraviolet phototherapy (use of light to slow the growth of skin cells) will suffice for effective treatment; whereas those with more severe varieties  of the disease will require a combination of phototherapy and oral medications that can modulate the immune reaction (e.g. methotrexate).

Psoriasis is affiliated with an array of diseases including arthritis, diabetes, hypertension, inflammatory bowel disease, and kidney disease.  Being associated with such a wide range of disorders does not come as a surprise, given the fact that psoriasis is now considered a multisystem inflammatory disorder which can exert effects in a variety of organ systems.  Psoriasis is more common in Caucasians, and as most other medical disorders, there is a genetic component to its manifestation and development.  Interestingly, scientists have found that geographic location plays a considerable role in psoriasis, as disease prevalence increases with distance from the equator.  Other notable and potentially modifiable risk factors include smoking, obesity, and vitamin D deficiency.  The good news is that there are multiple treatment options for this disorder and most patients experience an improvement within two months of medical therapy.  Early treatment for psoriasis will result in better outcomes, and expectantly, this intervention will also increase the chances for constructive management of any of the other associated disease processes.

Melanoma: Monitoring Skin + Moderating Sun = Meaningful Safeguard

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Most people, especially those of us for whom warm weather is restricted to summer, love to display a beautiful tan year round.  We’ve even gone so far to invent tanning salons, a cottage industry that has sprung up in the last two decades, which treats 28 million Americans every year.  Unfortunately, whether the tan comes from artificial ultraviolet radiation obtained in tanning beds or from natural sunlight, exposure is associated with a markedly increased risk of skin cancer.  Melanoma is the most serious type of skin cancer and sadly, the number of new cases in the U.S. continues to steadily increase.  If not discovered early, this dangerous cancer can easily metastasize to any organ.  Therefore, the public should become familiar with the clinical signs associated with melanoma, but most importantly, they should also learn to identify the significant risk factors related to this disease so that they can actively participate in disease prevention.

Early melanoma is generally a superficially confined tumor but as time elapses it can spread into the deeper skin layers and other tissues.  There are a variety of physical presentations for melanoma but the most common form presents with a flat pigmented skin patch that is surrounded by an irregular border.  In addition to this, the patch can be several different types of color, ranging from red to blue-black.  Patients with melanoma are asymptomatic and, therefore, should undergo a routine comprehensive skin exam by their primary care physician.  This is especially critical if the patient has risk factors for melanoma.  If a suspicious lesion is noted, a biopsy sample will be taken; this is the diagnostic test of choice.  The treatment for melanoma varies with the degree of localization versus metastasis and can include surgical excision, radiation, and chemotherapy.  When melanoma is caught early, a simple surgery might be all that is required for curative treatment but if the patient has disseminated disease, the chances of being cured decrease drastically.

Scientists have delineated a number of key risk factors which dramatically increase the chances of developing melanoma.  One of the major risk factors is the aforementioned ultraviolet radiation of any kind.  In addition to this, researchers have found that the timing and pattern of exposure to solar ultraviolet radiation plays an important role; and studies have demonstrated that intermittent intense sun exposure poses a much higher risk than chronic steady exposure.  Not surprisingly, patients with a genetic predisposition have a higher risk of developing melanoma, and being of Caucasian descent will increase your risk by a factor of 10.  Another important risk factor is the number of moles present on the skin [as a high number of moles represent marked sun exposure].  Interestingly, patients with Parkinson’s disease have an increased risk of melanoma, although the cause for this remains unclear.  For those who have an increased risk, screening exams should be formally performed; while for the rest of the population, periodically looking at your skin and having a primary care doctor examine your skin is a good general rule.  Of course, wearing sun block and avoiding intense ultraviolet exposure will be the most fundamental intervention that anyone can undertake.

Tourette Syndrome – A Torrent of Tics

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Occasional eye blinking, squinting, and mouth twitching are all normal reflexive movements that are encountered every day, but when these motions become prolonged and uncontrollable they are categorized as “tics”.  Patients who manifest symptoms in this manner are likely to have a condition known as Tourette’s, a disorder commonly seen in children and characterized by unintentional tics that encompass repeated sudden movements or vocal utterances.  Although it is difficult to discern the exact number of patients who suffer from this condition, it is estimated that 3 out of every 1000 children have Tourette’s.  This disorder can significantly interfere with a child’s learning ability and is frequently associated with conditions such as ADHD (attention deficit hyperactivity disorder), OCD (obsessive compulsive disorder), and other psychological disorders.  The exact causation of this inherited disorder has not yet been established, but what researchers have been able to discover is a variety of successful behavioral and medical treatments that can significantly improve the symptoms.

Tourette syndrome is a neurological disorder in which patients have abnormalities of the mesolimbic region, a well-established neurological pathway which is known to affect movement, compulsion, and pleasure sensations.  Tourette’s is more common in males and its onset of presentation is between the ages of 2 through 15.  Similar to the aura (e.g. perception of a strange light) that precedes migraine headaches, patients with Tourette’s have a premonitory urge that occurs before the tic presentation; this is followed by the tic itself which can be motor, verbal, or a combination of both.  Common manifestations of motor tics include: frequent eye blinking, grimacing facial movements, head jerking, body gyrations, and obscene gestures.  Vocal tics often present as a repetition of words and phrases, in addition to the usage of profane language (due to a neurological disinhibition, i.e. “no filter”).  Moreover, children with Tourette’s are likely to suffer from insomnia, nightmares, and enuresis (i.e. bedwetting).  Due to the fact that there is no confirmatory laboratory or radiographic test for this disorder, the diagnosis is based on clinical criteria alone.

If the symptoms of Tourette’s hinder a child’s school performance or their social development, definitive treatment should be considered.  One of the essential behavioral treatments available is habit reversal training, a psychological therapeutic regimen that teaches patients how to recognize the symptoms that precede a tic, allowing patients to control the tics before they occur.  Most children do well with behavioral treatment alone, but in severe cases prescription medications might be necessary.  Fluphenazine, one of the most commonly used drugs, works by blocking the action of dopamine (a neurotransmitter involved in the mesolimbic pathway).  Another potential treatment includes botulinum toxin (a.k.a. botox), a paralytic toxin that can be injected into the specified muscle in order to decrease the amount of motor tics.  Luckily, half of the patients with Tourette syndrome will get rid of the tics by age 18, and for those who still have them, the symptoms markedly decrease over time.  However, because this childhood disorder is oftentimes associated with learning disabilities, parents should be extra vigilant of their children’s behavior.  If a child has Tourette’s, early behavioral therapy will be the one intervention that will help them reach their expected developmental milestones.

Necrotizing Soft Tissue Infections – It’s Either Vigilance or Vanishing Vitality

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A young Georgia college student lost her hands, as well as a foot and a leg, after she acquired a necrotizing infection through a leg wound injury sustained while zip lining.  As a consequence of this and other similar cases that made headlines, the public now knows about the existence of a series of dangerous organisms known as flesh-eating bacteria.  These specific infections fall under the umbrella of what is formally known in the medical field as a necrotizing (necrosis = tissue death) soft tissue infection, a critical disease in which bacteria can traverse into the deep tissues of the human body.  Although these infections can affect anyone, patients with a vulnerable immune system are at higher risk.  Thankfully, these infections are rare, but if a patient does acquire a necrotizing infection, statistics have shown that their risk of death is as high as 40%; while in newborns the risk is even higher, reaching a staggering 60%.  Despite these alarming percentages, early identification and proper treatment can markedly decrease the risk of death.

Necrotizing soft tissue infections are caused by a variety of bacteria which can affect any number of physical layers within the human body, ranging from the skin to the muscles and deeper tissues.  Commonly, patients will be found to have a multitude of different bacteria causing the infection, while in other cases only one type of bacterium (e.g. the microbe found in strep throat) is responsible.  The organisms involved in necrotizing infections produce dangerous toxins which cause a severe inflammatory reaction resulting in tissue destruction, organ failure, and subsequent death.  There are a series of conditions that can predispose patients to these infections which include: diabetes, drug abuse, obesity, traumatic wounds, recent surgery, and immunosuppression (e.g. patients undergoing chemotherapy).  During the initial phase, most patients experience a specified area of swelling and redness that is painfully tender.  As the infection spreads, the skin discolors to a bluish-gray hue accompanied by the appearance of blisters.  During the end-stage of the infection, systemic symptoms such as fevers will ensue.  Unfortunately, patients are not always subjected to these obvious skin indicators given that these bacteria are able to find their way into the bloodstream even in the absence of any obvious physical skin trauma.

Inopportunely, the only demonstrable diagnostic test for necrotizing soft tissue infections is surgery, because despite modern technology this continues to be the only way that we can fully visualize the dead tissue [other adjunctive diagnostic studies include blood tests and CT scans].  The treatment against the bacteria involves surgical removal of the infected tissue and intravenous antibiotics.  Additionally, the majority of patients will require multiple surgeries to completely remove the infected tissue.  Notwithstanding the fact that there is no specific way to prevent this condition and that making the diagnosis continues to be considerably challenging, patients can still play an important role in managing their disease risk.  Paying close attention to a potentially infected skin site and being cognizant of the symptoms of a necrotizing skin infection will be the one intervention that will lead to prompt recognition and treatment of a potentially fatal disease.

C-Section – When Plan A Becomes Plan B Through a C

Hospital Ship USNS Comfort Treats Victims Of Earthquake In Haiti

Most of humanity appreciates that the birth of a child is one of the most sacred acts of nature, but through human ingenuity this primordial act can either be accomplished naturally through the vaginal canal or with the aid of a surgical procedure known as a caesarean section (aka C-section).  Yet, there seems to be no consensus whatsoever on the preferred mode of delivery of an infant; some mothers advocate for a natural birth while others are proponents of a somewhat planned delivery.  Although there are medical reasons for why a mother might have to undergo a caesarean section, the World Health Organization recommends a C-section rate no greater than 15%, due to the fact that C-sections are associated with higher maternal and neonatal complications and risks.  Notwithstanding this, the C-section rate in the U.S. is a whopping 33% and many researchers are trying to decipher why the numbers are so high.  Even though we might never be able to elucidate the exact cause, the fact remains that a C-section should certainly be performed if a vaginal delivery poses danger to either the mother or child; but if there is no impending harm [after a thorough evaluation by the physician], the mother should designate her preferential mode of delivery.

A caesarean section is a surgical procedure performed under anesthesia whereby an obstetrician makes an incision through the uterus to deliver a child.  There are numerous medical indications for this procedure, which include: poor progression of labor due to anomalous fetal position; abnormal fetal heart rate; heavy vaginal bleeding as a result of early placental separation; or any other emergency that threatens the life of the mother or the baby.  Unfortunately, similar to any other surgical procedure, a C-section carries numerous risks, such as: complications related to anesthesia, longer recovery period, organ injury, wound infection, blood clot formation, neonatal respiratory problems, future abnormal placental development, uterine rupture, and of course, higher cost.  Interestingly, mothers can nowadays formally request a C-section, the most commonly cited reasons for which include: convenience of a scheduled delivery, fear of the pain and length of a vaginal delivery, prior traumatic experiences, concern for potential fetal harm as it travels through the canal, vaginal post-partum complications (e.g. urinary incontinence), and averting the need for emergency surgery.

Some researchers have proposed that the U.S. obstetric population is in essence a higher risk group, thereby explaining our need to frequently perform these procedures.  Others have wondered whether U.S. obstetricians are just acting in a more conservative fashion due to the fear of litigation commonly associated with complications of vaginal deliveries.  Furthermore, a few have been so bold to say that the reason the number of mothers requesting a C-section is steadily increasing is purely out of convenience.  Because data with the aforementioned occurrences is not widely reported or collected, the explanation as to what’s driving our rates may always remain obscure.  The bottom line is that one delivery method is not necessarily more favorable than the other; so if you are an expectant mother, make sure that you fully understand all of your options, because the right choice has to involve you!

Lupus – The Disease of a Million Symptoms!

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The incidence of Systemic Lupus Erythematosus SLE, a.k.a. lupus has nearly tripled in the last 40 years, and, empirically speaking, scientists believe that this is due to our enhanced diagnostic ability to detect mild disease.  So, given that we are successfully diagnosing a vast amount of cases, you might be led to think that the evaluation for this disorder must be a straightforward one.  Yet, despite advanced medical testing technology, lupus remains a challenging diagnosis to make.  It is classified as a boundless disease that has the ability to attack any organ system in the human body and, as a result, the symptoms of lupus can emulate those of any other disease process.  Those symptoms are highly variable and they range from generalized weakness and fatigue to significant pulmonary and neurologic complications.  Therefore, as with most other diseases, if we educate the public on the prototypical symptoms of lupus we can increase our chances of disease recognition, so that when pertinent signs do occur, the diagnosis of lupus may at least be considered.

SLE is a chronic autoimmune disease in which the body forms antibodies that have a faulty signaling process.  Instead of the antibodies carrying out their typical duties of attacking foreign substances, they turn against their own cells and end up striking the patient’s own organs; this results in an inflammatory reaction which subsequently destroys the specified organ.  Although lupus can affect any organ, it has a predilection for the skin, joints, kidneys, lungs, and the nervous system.  Lupus is more common in females and it occurs between the ages of 16 to 55.  The majority of patients will frequently manifest a variety of non-specific symptoms such as fever, fatigue, muscle pains, and weight changes.  In addition to this, patients with SLE classically develop: arthritis; a butterfly-shaped facial rash; kidney dysfunction; pleural effusions (fluid buildup in the lungs which cause shortness of breath); pericarditis (inflammation of the outside layer of the heart which causes chest pain); delirium; seizures; and thromboembolic disease (blood clot formation).  Once the disease is suspected, the diagnosis is made through a series of specialized blood tests.  In a subset of patients, an organ biopsy might also be required.

The treatment of lupus is focused on ameliorating the symptoms of active disease and on the prevention of future flare-ups.  In general, patients will be started on anti-inflammatories, steroids, and immunosuppressant drugs, all of which will reduce the effects of the autoimmune reaction.  Furthermore, studies have shown that exercise, smoking cessation, and sun protection can also decrease the exacerbation of disease.  Of note, patients of African American and Latino descent are known to suffer a more aggressive disease course, so special attention should be given to lupus patients in these categories.  The hardest part about lupus is considering the diagnosis in the first place, as its presentation can mimic any other disease.  The goal is to spread awareness and educate the average person on the subject so if ever a patient, they can potentially bring the diagnosis of lupus to their physician’s attention.  An open and informed doctor-patient conversation might actually be what leads to the contemplation, diagnosis, and treatment of what is a complex and life-long disease.