What is a Pressure Ulcer (AKA Pressure sore)?

shutterstock_89421025bed-soresPhoto credit:  http://diseasespictures.com/bedsores/

A patient came in to see me today with a sore on his heel that’s been bothering him for the past few months.  He’s diabetic and has lost feeling in the bottom of his feet.  He’s had these pressure sores in the past but has trouble getting them to heal up.

Pressure sore:  Areas of skin that have been damaged by pressure such as sitting or lying in one position for a very long period of time.  They can also be called “bedsores.”  The are more commonly found in areas of the body where the bone is near the surface of the skin such as on the hips, elbows, ankles and back/buttocks. The skin and soft tissues become damaged because not enough oxygenated blood can get to the area to promote healing usually due to the compression of the damaged skin and soft against hard bone tissue.

Appearance:  The sores change in the way they look depending on how long they’ve been present and how much damage has been done.  In the beginning, the sore appears as a small red patch of skin, and if not treated, the skin will break down and cause a hole or crater to form (we call this an ulcer).

Stage 1:  The skin is intact without ulcers but when you push on the skin it does not change colors to indicate good blood flow.  Usually, healthy tissue will be pink and when you push on the area with your finger you can notice it will become less pink and in a couple seconds the pinkness will return.  This does not happen in the damaged skin at this stage – it may have a darkly pigmented color.

Stage 2:  There is an open, shallow ulcer with a red-pink color at the base of the wound.  Sometimes there may be blisters present which are either intact or ruptured.

Stage 3:  Structures beneath the skin such as fat may be exposed but at this stage, you should not see bone, tendons or muscle tissue.

Stage 4:  Structures beneath this skin including bone, tendon and muscle may be seen in the bottom part of the ulcer

People at Risk:  Some patients are more at risk than others of getting pressure sores.

1)   Patients who cannot move very well because they have a medical problem.  These people may sit or lay in one position for a long time.  They need help to move to a different position so that the skin doesn’t form sores.

2)   Older people are more prone to pressure sores because they often don’t move around as much and their skin is more fragile and thinner than a younger person.

3)   Patients who have diabetes or nerve problems in their feet may not feel when a small pebble or area gets into their shoe or pressure pushes on the foot causing injury.

4)   Patients in the hospital or nursing home are at especially high risk for many of the factors noted above – increased age, decreased mobility, and other complicated medical problems.

Prevention:  Some things can be done to lower the chances of getting pressure sores

1)   Repositioning the patient’s body every two hours so that they are not lying on one area where the skin is being crushed, pinched or pressure is building

2)   Putting pillows between the ankles and knees to decrease the pressure on the skin over these boney areas

3)   Raising the head of the bed when the patient is lying on their side to decrease the pressure on the hip bone

4)   Getting special foam or soft mattresses that decrease the pressure on the areas of the body that have the most pressure on them

For patients in wheelchairs:

1)   Use a special cushioned seat if possible to prevent pressure on the sacrum

2)   Every hour tilt forward or to the side to release pressure on the seat

3)   If ankles or heels press on the chair, use foam padding to protect against sores

4)   Check skin regularly for signs of pressure or ulcers

Treatment:  Pressure sores are treated differently depending on the stage of ulceration and how severe the damage to the skin is.

1)   If there is mild erythema, the treatment is generally off-loading the area but decreasing the amount of time that this area is compressed by body re-positioning, and/or using pillows to cushion the area.  We also use transparent films over the ulcers to protect the areas.

2)   In patients who have diabetes, adequately managing blood sugars to keep them under good control is very important.  Elevated blood sugars impede wound healing.

3)   If there is dead or dying skin or soft tissues, this often needs to be removed to help prevent infection.

4)   Special bandages may be needed to keep the healing tissue moist but prevent tissue maceration (from being too moist). Sometimes the dressings that we use to treat wounds can be very expensive.

5)   Antibiotics may be prescribed if there is a wound infection

6)   Medication for pain may also be prescribed

There are some tools to score the pressure and grade the healing process.  These are helpful for patients who come back for repeat visits to wound care clinic or their primary care provider and there is a need to grade the healing by giving them a score.  Some clinical features that are examined include:

1)   Amount of Exudate

2)   Skin color surrounding the wound

3)   Peripheral tissue swelling

4)   Peripheral tissue firmness around the wound

5)   Amount of granulation (healing) tissue

6)   How much epithilization is present

It’s important to optimize the nutritional status of patients with wounds.  Particularly for patients who have Stage 3 and 4 ulcers, they need enough protein and calories to help heal these wounds.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

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Testosterone Deficiency – aka “Low T”

shutterstock_148300076Low testosterone is a hot topic right now in primary care.  Recent advertisements are on television discussing various testosterone treatments available to men with “Low T.”  I’ve recently had quite a few patients asking me to check testosterone levels and then they usually have questions about testosterone treatments if the blood levels are abnormal.

Testosterone is a hormone that is produced in both men and women, but it is usually present at higher levels in men.  The consequences of low serum testosterone are not known for certain but there are several possible symptoms of low levels including (research is still being done):

  1. Low sex drive, erectile dysfunction, poor morning erection
  2. Fatigue
  3. Being slow to go through puberty (if it is too low during childhood)
  4. Decreased bone mineral density
  5. Decreased muscle mass
  6. Decreased muscle strength
  7. Anemia
  8. Decreased mood
  9. Decreased cognitive function

Of course there are other, more common causes of low sex drive and fatigue that can affect grown men instead of low testosterone levels.  Experts believe that the current trials have demonstrated weak and indirect inferences about the usefulness of testosterone for osteoporosis in men.

Testosterone levels naturally decrease as men age.  This normal decline in testosterone however has not had established clinical consequences.  We are still studying the effect that the natural decline of testosterone levels have in the body.  Elderly men often ask if they should be prescribed supplemental testosterone to keep their levels from decreasing.  The answer is difficult because we currently do not entirely understand whether the changes in body generally associated with aging (decreased muscle mass, decreased energy) may be related to naturally decreasing testosterone levels or even if treatment with testosterone reverses the decreasing muscle mass and energy we see in the average person with increasing age.  We’re also concerned about adverse consequences of testosterone with diseases that are testosterone dependent such as prostate cancer.

Controversy regarding testosterone whether to prescribe testosterone therapy:  A committee of the Institute of Medicine of the National Academy of Sciences Committee reviewed available studies and concluded that no beneficial effects of administering testosterone have been well established.  The Endocrine Society however has published evidence based guidelines for testosterone therapy in adult men with deficiency of testosterone.  The guidelines from the Endocrine society are:

  1. Testosterone therapy should be prescribed only for men with low serum testosterone levels on more than one test and who have symptoms of testosterone deficiency and have no known pituitary or testicular disease.
  2. In order to minimize the potential risk of causing testosterone-dependent diseases, the target level of testosterone level in the blood should be between 300-400 ng/dL (10.4 to 13.9 nmol/L)

The Institute of Medicine’s committee on testosterone concluded that there is insufficient evidence to conclude that testosterone treatment of elderly men has any well-established benefit thus far on improving muscle strength, physical function, vitality, sexual function, cognition and quality of life.  They recommended further investigation.

Potential to cause harm:  High testosterone levels has the potential to cause cancer of the prostate but data are limited.  The common practice in treating prostate cancer is to lower serum testosterone levels with medications.

Screening for low testosterone:  One approach has been the following:

  1. If a male has symptoms of possible testosterone deficiency such as decreased sex drive, energy, mood or osteoporosis or anemia a serum testosterone level can be checked early in the morning (before 8am when normal testosterone levels are highest).  If the level is low, it should be repeated for confirmation.
  2. Free testosterone levels should only be evaluated in men who have obesity.
  3. If testosterone levels (both times) is less than 200 ng/dL (6.9 nmol/L) evaluation for causes of hypogonadism can be performed. If there is no pituitary or testicular disease, discuss  with the patient about possible treatment with supplemental testosterone (ie. Benefits vs risks).

Testosterone treatment:  One approach to treatment has been the following:

  1. If treatment is started and the symptoms that led to measuring the testosterone are not corrected (improved energy, sex drive, anemia, etc.)  within a few months then discontinuing the testosterone treatment can be considered.
  2. Before starting treatment, a digital rectal exam should be performed and a PSA (prostate specific antigen) measured.  If a man has higher than normal PSA with no identifiable risk factors a urological evaluation should be performed before any testosterone therapy is started.
  3. 3 months after starting the testosterone treatment, a digital rectal exam and PSA should be repeated.  If there is a prostate nodule or the PSA has increased more than 1.4ng/mL (and confirmed) urological consult should be sought.  If the PSA and digital rectal exam is not considered abnormal, the digital rectal exam and PSA should be performed once a year  (just as with any man).

References:  Bhasin S, Cunningham GR, Hayes FJ, Matsumoto AM, Snyder PJ, Swerdloff RS, Montori VM, Task Force, Endocrine Society. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2010 Jun;95(6):2536-59.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Sexual Dysfunction in Men – Erectile Dysfunction and Beyond

shutterstock_136970978Purchasing medications for erectile dysfunction:  I first want to comment the issue of purchasing medication on the internet, through mail order , magazine articles or television ads that claim to sell medications such as Viagra, Cialis or Levitra or some herbal supplement for erectile dysfunction without the need for a prescription and at a low cost.  I highly recommend that you do not purchase these products this way because the sources are not known to be safe or reliable.  Would you purchase your blood pressure or diabetes medicine from someone you don’t know but who claims to be legit?  I sure wouldn’t!  It is not known if these drugs sold without prescription through ads like this are counterfeit or contain toxic chemicals which could be damaging to your health.

Men often come to talk with me about medications that may help with sexual problems such as inability to acquire or maintain an erection for sexual intercourse.  Since this is a popular topic in the primary care office, I thought I might discuss male sexual dysfunction, possible causes and some treatment options.

Some male sexual complaints may include:

1)     Premature ejaculation

2)     Delayed or inhibited ejaculation

3)     Lack of interest in sex (decreased sex drive)

4)     Unable to become erect or maintain an erection for satisfactory sexual intercourse (we also call this impotence or erectile dysfunction)

Erectile Dysfunction (ED):   Your doctor may diagnose erectile dysfunction if the man cannot acquire or maintain an erection during 75% of attempts to have sexual intercourse.  If a man has only occasional inability to have an erection and this improves later, they do not have erectile dysfunction (ED) as defined by the American Urological Association.

Possible causes of male sexual dysfunction:

1)      Limited blood flow to the penis can be caused by:

  1. Cigarette smoking
  2. Uncontrolled diabetes (high blood sugars)
  3. High blood pressure (hypertension)
  4. Alcoholism
  5. Illicit drug use
  6. Aging
  7. Depression
  8. Common medications prescribed by your doctor

2)     Psychological causes:  Performance anxiety, stress or decreased mood can lead to impotence.  Many patients explain that they accept a decrease in sexual function as being normal due to aging.  Often times there are reasons for decreased sexual function in men that once addressed can improve sexual function and increase the satisfaction with their sexual health.  One of the possible reasons such as performance anxiety is when the focus of the sexual act shifts from a romantic experience to one filled with anxiety about the ability to acquire or maintain an erection.  It’s also true in some men that as they mature, their interests and concerns may expand.  If he’s preoccupied with concerns about money or business matters, he may lose the sexual focus needed to maintain an erection.

How to determine the cause of male sexual dysfunction:   When a man expresses concern about sexual dysfunction, I usually start off by trying to determine the cause by asking some questions, performing an exam and then ordering some laboratory tests.  If you will be visiting your doctor and have concerns about sexual dysfunction, I recommend that you think about the following and be ready to discuss these items with your doctor:

1)      Do you get erections at night or in the morning when you first wake up?

2)     Are you having any personal problems with your sexual partner?

3)     Did the sexual dysfunction come on gradually or all the sudden?

4)     Do you have medical problems such as diabetes, high blood pressure, tobacco use, alcohol or illicit drug use or other psychological factors that could contribute to the dysfunction?

What to expect during a physical examination:  Some men may be resistant to come to their doctor to discuss sexual dysfunction because they’re not sure what to expect during the physical exam.  Your doctor may do the following:

1)     Check your blood pressure – it’s very important to get your blood pressure at goal

2)     Examine the penis, testicles and blood vessels in the groin

3)     Examine the chest for signs of abnormal breast swelling in men

Laboratory testing:  Your medical provider will often check several lab tests that can influence a man’s sexual ability.

1)     Testosterone (hormone) level – hormone

2)     Blood sugar tests – a fasting blood glucose or an A1c

3)     Thyroid hormone test (TSH)

4)     Prolactin (hormone) level

5)     Home nocturnal penile tumescence (NPT) is a test that measures how many erections the man is getting during the night when sleeping.  Men who have damage to the blood vessels or nerves involving the sexual organs usually have decreased nocturnal erections and we call this “organic” impotence.  Men with normal night-time erections are more likely to have psychologically related impotence although there may be a combination of the two factors involved.

6)     If the nocturnal penile tumescence test is abnormal, your doctor may ask you to have some special tests such as a ultrasound test to examine the deep arteries of the penis and groin to make sure they are getting enough blood flow.

Treatments for male sexual dysfunction:  Men often come in to the clinic and ask for medication without understanding that medication may not help if the cause of the problem is not discovered.  It’s very important to determine the cause of the sexual dysfunction because the improper use of medications can have serious side effects and may not actually cure or help the problem.

Medications to treat erectile dysfunction:

Testosterone therapy:  If your testosterone level is too low, correcting this by taking testosterone medication can improve sex drive, erectile dysfunction, increase muscle mass and reduce the risk of osteoporosis.  Men who do not have low testosterone levels do not benefit from additional testosterone and may actually have unhealthy side effects if they take testosterone inappropriately.  Treatment options may include testosterone injections that may be given every 1-2 weeks, testosterone gels (Androgel is a commonly prescribed example), a testosterone skin patch (Andoderm is a popular example) or a testosterone lozenge that remains in the mouth for 12 hours are the most common treatment options for low testosterone.

Counseling:  We realize that depression, anxiety and increased social stresses can cause erectile dysfunction. Sexual therapy is often helpful in these cases.  The great thing about counseling is that there are no medical side effects because this does not involve taking a medication.  Counseling can actually fix the problem which is often more desirable than relying on a medication which must be used repeatedly.  Some examples of where psychotherapy can be useful are:

1)      Performance anxiety, when a man suddenly experiences one or more failures during sex.   Often this is not due to the inability to perform but more related to anxiety about failure.

2)     Men who have depression or anxiety often have a lowered sex drive.  Counseling can help improve both while improving sex drive and function without the need for medication.

3)     Couples where one partner has a serious medical condition might be worried about possible the safety of sexual activity.  It is often helpful to discuss this with a medical professional or counselor who can help with these concerns.

Phosphodiesterase-5 inhibitors (PDE-5) – Viagra, Levitra and Cialis:  These medications work by increasing the natural chemicals in the body that allow the penis to become erect.  The do not increase sexual desire.  These medications are effective in restoring the ability to have an erection in about 70% of men and work best in men with psychological erectile dysfunction problems (in combination with treating the underlying psychological component).  In men with damage to the blood vessels or nerves of the pelvis/penis due to high blood pressure or diabetes, these medications help about 55-60% of the time.  For men who have sexual dysfunction after prostate surgery, these medications help in only 25%.   The main difference between Viagra, Levitra and Cialis is the cost of the medication and amount of time that the medication takes to begin working and how long the effects last.  Some people may find the one particular medication works better for them than another but all three work in a medically similar way.

Possible side effects:  PDE-5 medications such as Viagra can cause headache, dizziness, indigestion and flushed (red colored) skin or blurred vision.  Most side effects only last a short time, but because Cialis has a longer duration than the others, the side effects may also last longer.  There is also a possibility of drug interaction with nitroglycerin if a patient uses that for chest pain or blood pressure.  Using PDE-5 medications and nitroglycerin can cause dangerously low blood pressure.  If a man is taking nitrate medications we generally do not recommend Viagra, Levitra or Cialis.

Drug interactions:  In addition to nitroglycerin, patients who take doxazosin or terazosin (which are used to treat enlarged prostate and hypertension) should not take PDE-5 medications because the combination can cause a dangerously low blood pressure.   Other medications such as erythromycin, ketoconazole, rifampin, phenytoin and grapefruit juice can alter the time that these erectile dysfunction drugs remain in the body and subsequently can cause more side effects.

Safety:  We are unsure if Viagra is safe for patients who have had a heart attack, stroke or life-threatening heartbeats (arrhythmia) within 6 months.  We are also not sure if it is safe for men who have had untreated high or low blood pressure or a condition called retinitis pigmentosa which is a medical condition of the eye that can lead to blindness.

Penile self-injection:  Patients may inject a medication into an area of the penis called the corpora cavernosa and this causes an erection by allowing the blood vessels within the penis to expand.  No sexual stimulation is needed to create the erection.  The common medications used are alprostadil or papaverine.

Possible side effects:  many men stop doing penile self-injections because of pain at the injection site.  There is also a risk that the penis may remain erect after intercourse.  Prolonged erection is called priapism.  If it lasts longer than 4-6 hours it may be a medical emergency and those patients should be seen in an emergency room.  If blood stays inside the penis for more than 48 hours permant scarring of the tissue inside of the penis may result.

Insertion of a pellet into the urethra:  MUSE (Intraurethral alprostadil):  The same medication used for penile self-injection can be inserted into the urethra (opening where the urine comes out) and the medicine is absorbed and causes an erection.

Possible side effects:  There can be some pain in the penis as the blood vessels enlarge to create the erection.  There is less chance of prolonged erection with this than with self-injection.

Vacuum-assisted erection devices:  A rigid ring is placed at the base of the penis (near the body) to hold the blood in the penis and then vacuum pressure is used to draw blood into the penis to create an erection.  About 67% of patients are able to achieve and erection with a vacuum assisted device but only about 25-50% of people who use them are satisfied with them.

Possible side effects:  Although the man will be able to have an orgasm, he is usually not able to ejaculate with a vacuum-assisted device because the ring that holds blood in the penis also compresses the urethra and that prevents semen from exiting.

Inflatable implant:  With an inflatable implant, an erection is produced by squeezing a small pump that has been implanted surgically in the scrotum.  The pump causes fluid to flow from a reservoir (also implanted surgically) in the lower pelvis to two cylinders residing inside the penis.  The cylinders expand to create the erection.

As you can see, there any many possible reasons that can lead to male sexual dysfunction and multiple treatment options.

For more information, you may check out the web resources below:

American Urological Association

The Hormone Foundation

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Keeping your Bones Strong and Healthy – All about Osteoporosis Prevention and Treatment

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Osteoporosis:  A medical disorder that causes the bones to become weak, thin and fragile.  Bones that are weaker are more likely to break (fracture).  Women are more commonly affected by this disorder because after menopause lower levels of estrogen are produced by the body.  Estrogen is a hormone that helps keep the bones strong.

It is very important to detect low bone density (weak bones) because there are treatments available which can protect and actually help build up bone and prevent bone fractures in those people who are at the greatest risk.

Why do we care?  Bone fractures, especially in the hip cause a huge change in lifestyle and lead to decreased mobility, decreased ability for patients to care for themselves, and increased risk of death due to physical deconditioning, increased risk of infection (from surgery and also from decreased mobility respiratory illness).   In fact, people who sustain a hip fracture are more likely to die than a person of the same age who does not experience this injury. About 20 percent of people who have a hip fracture die within a year of their injury. It is estimated that only one in four persons have a total recovery from a hip fracture.  Most people spend from one to two weeks in the hospital after a hip fracture. The recovery period may be lengthy, and may include admission to a rehabilitation facility. People who previously were able to live independently will generally need help from home caregivers, family, or may require the services of a long-term care facility. Hip fractures can result in a loss of independence, reduced quality of life, and depression, especially in older people.

Fractures that occur in the spine due to osteoporosis can lead to pain and cause changes in the curvature of the spine.  We’ve all seen older folks who have difficulty walking due to having abnormal curvature of the spine and these patients often have osteoporotic fractures in the vertebra of the back.

Risk factors for osteoporosis:

1)  Sex – women are more likely to get osteoporosis than men

2)  Age – risk of osteoporosis is higher with increasing age

3)  Race – there is a higher risk of osteoporosis in people of white or Asian descent

4)  Family history – you are at higher risk of osteoporosis if you have a parent or sibling with osteoporosis, especially if there is a family history of bone fracture

5)  Body frame size – men or women who have a smaller body frame size are at higher risk because they have less bone mass to draw from as they age

6)  Hormone levels – osteoporosis is more common in patients who have too much or too little of certain hormones  (estrogen, testosterone, thyroid, parathyroid or adrenal hormones for example)

7)  Low calcium in the diet – a lifelong lack of getting enough calcium increases the risk of developing bones that are thinner and more fragile.

8)  Eating disorder – Patients with anorexia are at increased risk of osteoporosis due to decreased nutritional intake of calcium

9)  Weight loss surgery – those patients who have surgery to help them lose weight are at higher risk of osteoporosis because of a reduction in the size of the stomach or a bypass of some of the intestines.  This may decrease the absorption of calcium or vitamin d.

10)  Certain medications – see below

Prevention:  Several important steps to maintaining proper bone formation and density can be done without the need of medication.  These include proper diet, exercise and not smoking.

A)  Diet:  Preventing the bones from thinning involves getting enough nutrients, especially calcium and vitamin D.

  1. Calcium:  Most experts agree that men and women who have not reached the age of menopause yet consume at least 1000 mg of calcium each day (combination of diet and supplements).  Women who have already gone through menopause should consume at least 1200mg of calcium each day (combination of diet and supplements).   Foods that have calcium include dairy milk, cottage cheese, yogurt, hard cheese, green vegetables (especially kale and broccoli).  A way to calculate the amount of calcium from food is to multiply the number of servings of calcium rich foods by 300 mg.  One serving size of dairy milk or yogurt is 8 oz.  1oz of hard cheese or 16 oz of cottage cheese is one serving size.
  2. Vitamin D:  Most experts also agree that men over age 70 and women who have gone through menopause consume at least 800 international units (IU) for vitamin D each day.
  3. Alcohol:  Drinking more than 3 drinks per day can increase the risk of fracture due to increased risk of falling and poor nutrition.

B)  Exercise:  We understand that our bones maintain their strength if we continue to use them.  Patients who become immobile are at increased risk of bone fractures because their bones tend to become thinner with decreased use and activity.  Patients who are more physically active are generally stronger and less prone to falling as well.  Exercising 30 minutes or more three times per week or more is recommended to maintain bone strength.

C)  Smoking:  Smoking cigarettes is known to speed bone loss.  One study suggested that women who smoke one pack per day throughout adulthood have a 5-10% reduction in bone density by menopause.  If you smoke, I suggest you get help with stopping to help prevent osteoporosis.

We can reduce the risk of bone fractures by reducing falls.  Several ways to reduce falls in older adults include:

1)  Avoiding (as much as possible) medications that can cause dizziness

2)  Provide adequate lighting to areas both inside and outside the home

3)  Ensure there are no loose rugs or electrical cords that could lead to tripping or falling

4)  Avoid walking in areas outside that are unfamiliar

5)  Avoid slippery surfaces such as ice or wet/polished floors

6)  Ensure good eye care by visiting an eye doctor regularly

Screening for Osteoporosis:  There are several different recommendations for when to start screening for osteoporosis.  The U.S. Preventative Service Task Force (USPSTF) recommends screening women who are age 65 or older who has no increased risk of fracture as compared to a 65 yo women of Caucasian decent.  If a woman has a previous bone fracture or an early family history of osteoporosis (especially a mother with an early bone fracture) or has thyroid disease or take medications that can increase the risk of thinning the bones, screening earlier is generally recommended.

Assessment tools:  There are several tools that have been developed by the WHO (World Health Organization)  – (see FRAX) to help assess risk for osteoporotic fractures.  These tools ask questions that relate to risk factors for osteoporosis and attempt to calculate a probability of hip fracture even without knowing exact measurements of bone density measured by special x-ray tests.

DXA Bone Mineral Density Test:  A bone density test uses special x-rays to determine how many grams of calcium and other bone minerals are packed into a bone segment.  Bones that are commonly tested include the spine, hip and forearm.  We do this test to identify patients who are at higher risk for bone fracture, as well as to monitor the progress of therapy for patients who are being treated.   Bone density tests are not the same as bone scans.  Bone scans usually require the patient to get an injection before the procedure and are used to detect bone fractures, bone cancer or bone infections.

Medications that increase the risk of bone thinning:  If you take any of these medications, ask your doctor about whether you should have your bone density tested:

1)  Glucocorticoids such as prednisone or dexamethasone

2)  Anti-Seizure medications such as Dilantin, Tegretol, Phenobarbital or Primadone

3)  Heparin – medication to treat abnormal blood clotting

4)  Acid reducing medications called proton pump inhibitors (PPIs) such as Prilosec may increase the risk of osteoporosis or fractures but more research is needed.

Treatment for osteoporosis:  The treatment really depends on the reason for the decrease in bone density.  We might change the patient’s current medications to different medicines that are safer and have less risk for decreasing bone mineral density.  Correcting a patient’s thyroid, parathyroid or testosterone imbalance may improve their bone density without the need for other medications.  We usually try to ensure that they are getting adequate dietary intake of calcium and vitamin D and may due some lab tests to look for excessive loss of calcium in the urine.  We might test the patient’s vitamin D levels along with the hormone levels mentioned above.  If there has already been a hip or vertebral compression fracture we will also usually check a bone mineral density (DXA or DEXA) scan to confirm the level of osteoporosis.

The DEXA scan gives us a numerical value that corresponds to the degree of osteopenia (low bone density) or osteoporosis (greater risk of fracture).  A normal bone density is when the T-score (measured on the bone density test) is between 0 and 1 standard deviation below the mean.  A normal T score may be reported as a T-score of +1 to -1.  If the T score is -1 to -2.4 the patient is said to have osteopenia which means that they have a risk of developing osteoporosis if not treated.  If the T score is -2.5 or less, the patient is diagnosed with osteoporosis.  The lower the T score (higher the negative number), the greater the risk of fracture.

Medical treatment of osteoporosis:

1)  Calcium – at least 1200 mg of calcium/day but no more than 2000 mg/day.

2)  Vitamin D – at least 800 international units/day – sometimes very high doses such as 50,000 IU/week may be prescribed if your levels are measured to be very low.

3)  Bisphosphonates such as Fosamax , Actonel  or Boniva are medications that slow the breakdown and removal of bone (bone resorption).  These are taken first thing in the morning on an empty stomach with an 8oz glass for still water.  There has been some concern about the use of bisphosphonates in people who require invasive dental work – it may lead to avascular necrosis or osteonecrosis.  Most experts do not think that it is necessary for most people to stop bisphosphonates before invasive dental work (tooth extraction or implant) because the risk is very small for those people who take bisphosphonates for osteoporosis treatment or prevention.  People who take a bisphosphonate as part of a treatment for cancer should consult their doctor before having invasive dental work however.

There is some concern about atypical (stress) hip fractures associated with long-term use of bisphosphonates.  Patients who have been taking them for more than 5 years may need re-evaluation to see if further continuation of the medication is recommended.

4)  Selective Estrogen Receptor Modulators (SERMs) produce estrogen-like effects on the bone.  They include Evista and tamoxifen.  In addition to osteoporosis treatment/prevention there is a decrease in the risk of breast cancer in women who are at high risk.  These medications are not recommended for women who have not started menopause.

5)  Calcitonin is a hormone produced by the thyroid gland that, together with parathyroid hormone, helps regulate calcium concentrations in the body.  This may be administered via nasal spray or injection.  Nasal administration is usually preferred due to ease of use and less chance of nausea and/or flushing.  It’s not clear if calcitonin improves bone in places in the body other than the spine.

6)  Parathyroid hormone (PTH) – (prescription preparation name Forteo) produced in the parathyroid glands(non-prescription form) stimulates bone resorption and new bone formation.  Clinical trials suggest the PTH therapy is effective in both prevention and treatment of osteoporosis in post-menopausal women and men.  It has been proven to reduce spine fracture risk more than any other treatment that we know about.  It does, however require a daily injection and is expensive so it’s usually reserved for patients with severe hip or spine osteoporosis with a T score of  less than -2.5 (higher number) and osteoporosis-related fracture.

When taking Forteo, we often check a blood uric acid and calcium level at the start of the medication, after 6 weeks, 6 months later and then after 12 months of therapy.

We generally do not use this medication in pediatric and young children whose bones are still growing or in patients with bone cancer,  Paget’s disease of the bone and extreme caution is needed in patients who have a history of recent calcium kidney stones.

7)  Prolia is a medication that helps improve bone mineral density and reduce fracture in postmenopausal women with osteoporosis.  It is an injection under the skin once every 6 months.  It’s usually well tolerated but can have side effects such as skin infections or eczema.  It should not be given to patients who have a low blood calcium level.

For more information, please check out the following resources:

National Library of Medicine

Osteoporosis and Related Bone Diseases National Resource Center

National Osteoporosis Foundation

National Women’s Health Resource Center (NWHRC)

Osteoporosis Society of Canada

The Hormone Foundation

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

So what is a Stroke?

shutterstock_78690082I saw a patient the other day who was in her 30’s and was brought in the other day because she suddenly stopped speaking (we call this aphasia) and became weak and confused.  Patient’s sometimes come to the urgent care with symptoms of stroke or meningitis and these symptoms can be extremely anxiety provoking.

Stroke or CVA (Cerebral Vascular Accident) is the term that medical providers use to describe an event where part of the brain goes without blood for too long.  There may be permanent damage to the brain as a result.  The blood supply to the brain can get cut off if an artery in the brain or neck gets clogged or closes off or if there is an artery in the brain that starts bleeding.

Sometimes a patient may have a stroke and there are no permanent effects, while other people may lose important functions in their brain permanently.  The individual that I saw the other day became unable to speak and it was unclear if she was able to understand what was being said.

Symptoms:  The symptoms of a stroke depend on which area of the brain is affected.  Some symptoms of stroke may be recognized by the acronym FAST –

Face – Does the person’s face look uneven or droop on one side?

Arm – Does the person have weakness or numbness in one or both arms?  Does one arm drift down if the person tries to hold both arms out?

Speech – Is the person having trouble speaking?  Does his or her speech sound strange?

Time – If you notice ANY of these signs of stroke, call 9-1-1.  You need to act FAST because the sooner the treatment begins, the better the chances of recovery

Diagnosis:  Stroke is usually diagnosed based on the patient’s symptoms and specialized studies such as a CT scan (Cat Scan) of the brain, or perhaps an MRI of the brain.  Other tests might include ultrasound of the arteries in the neck and echocardiogram (ultrasound of the heart).

Treatment:  The type of treatment depends on the cause of the stroke.  For patients who are having a stroke due to clogged arteries to the brain, they might receive medication to break up the clot or have a procedure to remove the blood clot.  They might also start medications to prevent future clogged blood vessels such as aspirin, Coumadin or Plavix.  Patients who have damage in the brain that make it difficult for them to walk might be treated with physical therapy to help them regain mobility. Sometimes it’s necessary for these patients to spend some time in an assisted care facility where there are nurses, physical therapists, occupational therapists and speech therapists available to help in the recovery process.  An assessment may be done at the patient’s house to look for possible safety problem areas and give the patient devices and tools to help the patient be able to retain independence in their home.

Prevention:  You can lower your risk of stroke by:

1)   If you have high blood pressure, keep your blood pressure in the normal range

2)   If you have diabetes, keep your blood sugar under good control

3)   Check your cholesterol and make sure your bad cholesterol and triglycerides are not elevated

4)   Avoid smoking

5)   Exercise for 30 minutes a day or longer on most days

6)   If you are overweight – work on weight loss

7)   Do not drink more than one alcoholic drink/day if you are female or more than two if you are a male

8)   Make sure you take your medications as directed by your physician

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Proper Use of Asthma/Reactive Airway Inhalers

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Today a patient came into the clinic and said that his asthma inhaler wasn’t working.  He’d been diagnosed with mild asthma last week and his primary care physician gave him an albuterol inhaler to use when his asthma flairs and he starts coughing.  He had his inhaler with him, so I asked him to demonstrate how he uses it.  He promptly put the inhaler to his lips and sprayed the inhaler into his mouth and then took a big breath in.  I was able to see that he wasn’t getting the medication into his lungs efficiently, and since this is a common problem when using inhaled medication, I decided that the subject needed some attention.

Using an inhaler can actually be quite challenging, and I find that most patients medications are only effective if they are used properly.  If you use the inhaler correctly the medication is delivered to the lungs where it works to control your symptoms.  If you are not using your inhaler correctly, little or no medication reaches your lungs and your asthma or reactive airway symptoms will not be adequately treated.

Asthma inhaler types:  Most asthma inhalers are meter dose inhalers (MDI’s) and deliver a small spray of liquid medication such as albuterol (aka Proventil or Ventolin).  Since 2008, new inhaler canisters have come out that use a propellant that does not damage the ozone layer.  They are known as HFA inhalers and have a different taste compared to the previous inhalers and are also more expensive. The spray is also softer, but works just as well as the older inhalers.

The other type of asthma inhaler is called a dry powder inhaler (DPI).  This type of inhaler has a small amount of powder that you breath in.  It has less taste, but the powder can fall out if you tip the device down towards to ground.  This type of inhaler is used commonly with medications such as the Advair diskus.

Spacer devices:  A spacer is a device that is basically a small tube that allows the medicine to have a little extra time and space to get down into your lungs rather than be deposited in the back of your mouth or on your tongue.  It is not required to use a spacer, but it is highly recommended.  If you don’t have a spacer to use with your inhaler, you can make one using an empty cardboard toilet paper roll.  You put the spacer over the mouthpiece of the MDI and then put the other end of the spacer in your lips and inhale the medication from the metered dose inhaler through the spacer and into your lungs.

Before using a metered dose inhaler MDI for the first time:

1)   Prepare the inhaler by shaking it for 5 seconds

2)   Prime the inhaler by pressing down on the canister with the index finger to release the medication.  Hold the inhaler away from your face to prevent the medication getting into your eyes.  Press the canister down again 3 more times

3)   After using for the first time, it does not need to be primed again unless you don’t use it for more than 2 weeks.

Technique for using a metered dose inhaler (MDI):

1)   Shake the canister for 5 seconds

2)   If you have a spacer (recommended), insert the MDI into the spacer and hold the MDI upright with the index finger on the top of the medication canister and the thumb supporting the bottom of the inhaler.  Some people find that using the other hand to hold the spacer is easiest.

3)   Breathe out normally

4)   Close your lips around the spacer.  If your spacer has a mask, hold the mask tightly to the face.  If you do not have a spacer, close lips around mouthpiece or hold at a position about 4cm from your mouth.

5)   Keep your tongue away from the spacer opening/mouthpiece area

6)   Press down on the top of the medication canister with the index finger to release the medication

7)   At the same time as the canister is pressed, inhale deeply and slowly through your mouth until your lungs are completely filled – this should take about 4-6 seconds

8)   Hold your breath in for as long as possible – 10 seconds is recommended before breathing out.

9)   If a second puff of medication is recommended, wait about 15-30 seconds before repeating the procedure for the second puff. Remember to shake the canister before each puff

10)  Recap the mouthpiece

11)  Rinse your mouth with water rather than swallowing after the treatment.  This is recommended especially after using an inhaled cortisone medication to prevent developing thrush

*Tip:  If you’re having difficulty timing your breath while spraying the medication, there are inhalers that automatically release the medication when you take a breath.  An alternative is to use a spacer or a dry powder inhaler (DPI).

Cleaning your MDI:  Your inhaler must be cleaned at least once a week to prevent blockages.  The manufactures recommend cleaning the mouthpiece at least once per week.

1)   Remove the canister but do not wash the canister or put it in the water

2)   Run warm water through the top and bottom of the plastic mouthpiece for 60 seconds

3)   Shake off the excess water and allow the mouthpiece to dry completely overnight

4)   If you need to use your inhaler before it is dry, shake off all the water, replace the canister and test spray (away from your face) two times before using

5)   Remember to clean your spacer

How to determine when your inhaler is empty:  You can’t always know when your inhaler is empty by shaking it because some propellant remains in the canister when all the medication is gone.  Some inhalers have a dose counter (Ventolin-HFA and Proventil) to track how much is used.  If your inhaler doesn’t have a counter but you use it regularly (2 puffs twice per day), you will need a refill in 30 days.  Write the date you will need a refill on the canister with a permanent maker to remind yourself.

If you don’t use your inhaler very often, write the date you start using it on the canister in permanent maker and consider getting a refill in 3-4 months.

Dry powder inhalers (DPIs):  These types of inhalers have a small dose of dry powdered medication in them.  They deliver a very fine powder to the lungs when you breathe in.  The advantage of using a DPI, is that you do not need to coordinate the squeezing of the canister with your breathing.  You must be able to breath in more forcefully with a DPI than with a spray type inhaler to ensure that the powder gets into the lungs.  These types of inhalers might be more difficult for patients who cannot breath in very deeply.  It’s also important not to exhale into the device before breathing in so that you don’t scatter the powdered medicine before it’s inhaled.

How to use a DPI:

1)   For single use devices, load a capsule into the device as directed

2)   Breathe out slowly and completely (but not into the mouthpiece or you will scatter the powdered medication before you have a chance to breathe it in).

3)   Place the mouthpiece between your lips

4)   Breath in through the mouth quickly and deeply over 2-3 seconds

5)   Remove the inhaler from your mouth and hold your breath as long as possible – 10 seconds is recommended

6)   Breathe out slowly

Cleaning a DPI:  Do not use soap and water.  The mouthpiece can be cleaned with a dry cloth.

For more information about asthma, here is a list of resources:

Center for disease control and Prevention 

American Academy of Allergy, Asthma and Immunology

American Lung Association

 

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

What to do about Anxiety

shutterstock_86293354Today a patient came in because she’s been feeling anxious because she’s had some heart palpitations.  She’s seen a cardiologist (heart specialist) and learned that the abnormal heart rhythm is intermittent atrial fibrillation (a usually non-dangerous rhythm) that has likely been brought on by the increased stress and lack of sleep lately.  When she gets the heart palpitations, she becomes more anxious, and the more anxiety that she experiences,  the more heart palpitations she has.  To her, it feels like an endless cycle that will never end.

This patient’s anxiety is understandable.  We all experience stressful or potentially anxiety provoking details that occur in our lives.  How we deal with these thoughts and events is critically important because it often determines how we function from day to day.

Feeling anxious can be a normal response to a stressful situation.  The adrenaline rush after we learn that a bear is in our campsite might help us escape the dangerous situation.  Feeling anxious for most of the day for long periods of time however is not normal.

Symptoms:  Excessive worry or feelings of dread or being “on edge” may contribute to daily fatigue, and muscle tension.  Other common symptoms may include headaches, hives, heart burn, constipation, diarrhea, abdominal pain, chest tightness, difficulty sleeping, memory problems and an increase or decrease in appetite.  Sometimes a patient might have depression along with anxiety.

Often patients come in to talk with me about treatment for their anxiety with medications.  I understand that feeling anxious is not particularly desirable, however in many circumstances, it’s normal.  Treating the anxiety is often most effective by addressing the anxiety provoking situation rather than masking the symptoms with medication.  Once the medications wear off, the anxiety returns and the cycle repeats itself.

I think it’s important to distinguish the difference between anxiety and an anxiety disorder.  People who have “normal” anxiety may have worries from time to time, but these feelings do not interfere with daily life.  An example might be a parent worried about their child who is late coming home from a date.  I’m sure you can think of many other examples.  People with an anxiety disorder are often worried or anxious about a number of events or activities and these worries are out of proportion to the situation.  A parent might worry excessively about their child’s safety even when the child is at home with the family.  An anxiety disorder can make routine activities difficult to complete.  There are certain criteria that need to be met in order to make a diagnosis of an anxiety disorder and it’s my opinion that only a qualified health mental professional with training in anxiety disorders such a psychologist should make this diagnosis.

Treatment:  Usually we tailor the treatment to the individual patient and what is causing the anxiety.  If the anxiety is caused by a certain life event, then learning how to address the feelings and concerns related to the event is often the most helpful way to decrease the anxiety.  Individuals who suffer from an anxiety disorder often require more treatment than those who have anxiety from stressful life events.  Some possible treatments for anxiety might include:

1)   Cognitive Behavioral Therapy (CBT): CBT focuses on the person’s behavior and patterns of thinking.  The therapist helps teach you how your thoughts contribute to your anxiety and how to decrease these negative or unpleasant thoughts when they occur.

2)   Eye Movement desensitization and reprocessing (EMDR): A particularly effective technique being used by psychologists who have had specialized training.  One of the procedural elements is “dual stimulation” using either bilateral eye movements, tones or taps. During the reprocessing phases the patient attends momentarily to past memories, present triggers, or anticipated future experiences while simultaneously focusing on a set of external stimulus. During that time, clients generally experience the emergence of insight, changes in memories, or new associations. The clinician assists the client to focus on appropriate material before initiation of each subsequent set.

3)   Medications: If medication is used to treat anxiety, you will need to see a primary care provider or psychiatrist.  If a patient has an anxiety disorder however, my opinion is that the patient should also be treated by a mental health provider such as a psychologist and/or psychiatrist.  Medications used to treat anxiety may include:

  1. Antidepressant medications such as SSRI or SNRI.  Examples of these medications include Fluoxetine, Citalopram, Paroxetine, Fluvoxamine, Sertraline, Escitalopram, Venlafaxine, Duloxetine, Desvenlafaxine, and Milnacipran.
  2. Buspirone is an antianxiety medication used to treat anxiety disorders
  3. Herbal medications such as kava kava and valerian have been used.  Kava Kava however has been linked to liver failure and is not recommended.  There is not enough evidence to show whether herbal medications are effective or safe for treating anxiety disorders.  Make sure to tell your medical provider if you are taking herbal medications
  4. Benzodiazepines such as Alprazolam, Chlordiazepoxide, Clonazepam, Clorazepate, Diazepam, Flurazepam, Halazepam, Lorazepam, Oxazepam or Prazepam are sometimes prescribed for short-term use only.  Because of the addictive nature of these medications, and because of safety concerns, I generally do not prescribe these medications frequently

If you or someone you know is suffering from an anxiety disorder (in contrast to experiencing anxiety as part of a life event), I strongly recommend that you seek help from a qualified mental health professional. Sometimes it can be challenging to know whether the anxiety you experience is the result of a “life event” or an actual disorder.  Most primary care providers can help you determine this or refer you to a mental health professional if further diagnosis is needed.

To find a Psychologist in your area, you may use the American Psychological Association Psychologist Locator website:  http://locator.apa.org/

Helpful links for additional reliable anxiety related mental health information:

National Library of Medicine (www.nlm.nih.gov/medlineplus/anxiety.html)

National Institute of Mental Health (www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml)

National Mental Health Association (www.nmha.org)

Anxiety Disorders Association of America (www.adaa.org)

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com