Question: "I recently got the sap of this succulent plant on me and it burns like white hot fire. What do I do?"

Answer: 

• If this is Euphorbia tirucalli then you are in for some pain. However, the following general suggestions would probably work for many different types of toxic plant sap. 
• Of note, this topic really wasn’t covered in medical school and it is not in any of my major textbooks.  Therefore, I am using some common sense here as well as insight from my own personal experience.  
• The best first step is to get the sap off of you as best as you can. The faster the better b/c Euphorbia tirucalli sap dries fast and is harder to remove.
• Removing Euphorbia tirucalli sap is difficult b/c it acts a bit like glue and dries clear.
• Even when you think it is gone, trace invisible residue can cause major symptoms. Therefore wash for at least 15 min... more like 30 min. 
• Soap, water and time.
• Don't wash over dirty dishes in the sink-you don't want to ingest even a tiny amount of residue from this powerful toxin.
• Discard anything that you think might have sap on it.  It can cause problems later even if you don't see it.  
• Throw away whatever you used to clean with when you are done.
• IMPORTANT, if you are in the shower, be careful how the water drains off the area you are washing. You could easily wash the sap residue from one place to another place downstream on your body. You definitely don’t want to damage your extra sensitive body parts.   
• If you get the sap on your skin, or worst, in your eye or ingest it, see your doctor/go to the hospital asap... But don’t drive yourself there because the pain is very distracting-making it unsafe to drive. If the sap is in your eyes it can cause blindness (obviously not good while trying to drive either).
• Benadryl may help with the redness but the main thing is to get the sap off you.

My Story:

• Unfortunately, that was me who asked myself the above question after a rude introduction to this toxic “ornamental” plant.
• Shortly after I just bought a house I noticed a huge succulent bush in my back yard with pencil like stems. It seemed interesting and harmless enough so I cut a branch to grow the cutting.
• Not a good idea.
• When I cut the branch, this white sticky latex sap spurted out. It acted like a bottle of Elmer’s glue under pressure. Most of it missed me but a few drops got on my arm and hand.
• Because I heard that some plant saps can be harmful, I immediately went inside and washed my arm for about 5 min.
• At first nothing happened to me.
• Then at about 2am I awoke to a terrible pain on my arm. It felt like white-hot-fire.
• I immediately washed my arm again and went to the internet.

http://www.plantzafrica.com/

This is what I discovered in my search:

• Many people sell this plant b/c it is easy to grow and looks cool.  However, no every seller will tell you that this plant is dangerous.
• It goes by name different names. (Firestick Plants, Indian Tree Spurge, Naked Lady, Pencil Tree, Rubber-Hedge, Sticks on Fire or Milk Bush)
• But the scientific name is:  Euphorbia tirucalli (you-FOR-bee-uh teer-ooh-KAL-eye)

 

http://www.wikimedia.org/

Where it lives:

• It is originally from Eastern and South Africa but has adapted all over the world.
• In some areas, such as Brazil, it is grown it as a fence. It is very effective as a fence b/c no one wants to touch the thing.
• The plant grows very well in dry environments.
• Some websites discuss how the plant can be trained and shaped. But that requires putting yourself in major danger. My advice is to stay clear and don’t touch it.

Problem:

• The sap is the big problem and is extremely toxic.
• It causes burns, and can cause blindness if it gets in the eyes.
• I have also read some articles implicating the plant as a cause of an aggressive type of lymphoma. This cancer may in part be a result of ingesting the sap as part of folk “herbal remedies.”
• More acutely, many have died after a minimal amount of sap ingestion.

Where is it now?:

• I never really noticed the plant before, but now I see it everywhere.
• I have seen smaller potted Euphorbia tirucalli plants for sale at most major home improvement/garden stores. However, I have not seen a warning label on any of the plants. In fact, in one nationwide-chain home improvement a plant pamphlet in the garden center talked about the benefits and care for the plants they sell and not a word about this dangerous plant that was profiled on its own page. Truly amazing and irresponsible.
• So beware, stay away and keep it from kids and animals.
• If you must have it, don’t plant this thing in your yard. It grows fast, is dangerous and hard to get rid of.  Now I have a big Euphorbia tirucalli from a previous home owner and no one wants to remove it.

Here's some more info I found useful/interesting online:
http://en.wikipedia.org/wiki/Euphorbia_tirucalli

http://www.nature.com/bjc/journal/v88/n10/full/6600929a.html

http://www.homegrownevolution.com/2010/04/least-favorite-plant-euphorbia.html

http://www.hort.purdue.edu/newcrop/duke_energy/euphorbia_tirucalli.html

http://plantsarethestrangestpeople.blogspot.com/2009/01/cigarette-smoking-man-euphorbia.html

Question: What are your thoughts on avoiding dairy? do people become intolerant as they grow older? i love it so much but I'm wondering if it is the key to my weight problem? ...

Answer: Yes, but perhaps not in the way you think.


Dairy has a lot of good stuff in it, but it is not good for everyone.

• In fact, we as mammals were only meant to eat it for a very short amount of time in our early youth.
• Yes; people can become intolerant to dairy. But this usually involves indigestion associated with lactose intolerance. This can be a big deal, but you would probably know it if you had it.
• People can also develop allergy to milk products, just like anything else. If you think you have an allergy to any food see your doctor. However, I don’t think this is the issue that you are asking about either.

Yes! Dairy will put on the pounds.

• Think about it. How do you make a little calf into a big cow in a short amount of time? 
• The solution is milk; a highly nutritious and highly caloric drink.  

In general, your weight is all about in's and outs:

• If you are taking in more calories than you are using, your body will store it in the form of fat.
• Some types of food have more calories per bite than others.
• If you are eating a lot of dairy and if you are no longer growing in height... you will grow in width.

Milk and milk products are basically glorified fat. Therefore, your body does not need to do much to it to store it. With dairy, it can be a very efficient transfer from eating to storage.  There is little energy lost in the process of metabolism.

You need to limit dairy products as part of any successful diet and exercise plan to lose weight.

Question “I heard that if I stop smoking that I will gain weight, is this true?”

Answer:  I don't know where to begin.  Don't smoke.  Please read the following. 

Smoking is one of the worst things you can do to yourself. If you want to do one thing to improve your health, the best thing you can do is stop smoking.

In regards to your specific question:

• Although not universal, many have people have reported weight gain with smoking cessation. Reasons for this relate to various potential factors.
• Smoking ruins a lot of your taste buds and ability to smell.  Therefore the joy of eating is diminished.  Less food = less weight.
• If you have a cigarette in your mouth you don’t have food in your mouth, so less food.
• When trying to quit, people replace smoking with snaking.
• Nicotine is an appetite suppressant and stimulant.
• If you get cancer or emphysema from smoking you will definitely lose weight, but probably not the kind of weight loss you are looking for.
• The health benefits of being tobacco free far exceed the problems associated with even moderate weight gain. Smoking is not a viable option for weight control. 
• Overall weight control is a simple equation of, "in's and out's."  If you can control what goes in (food) and counteract that with what goes out (exercise), you are golden.

Please ask yourself why you want to resort to smoking to lose weight/keep from gaining weight:

• In my experience it can generally be broken into two major reasons why people what to lose weight.
• Some want to lose weight for health reasons.
• Others want to lose weight for looks.
• Regardless of your motivation to lose weight, smoking is not a viable strategy.
• Let me elucidate the reasons.

Lose weight for appearance:

• If you are concerned about appearance, smoking is not the way to go. Smoking will decrease your beauty on every level.

Skin: 

• Smoking will accelerate skin ageing. The toxic chemicals in the smoke go throughout your body and damage just about everything it comes in contact with, (this includes your skin).
• The blood vessels that feed your skin (and other organs) are also damaged. No wonder why smokers have prematurely old looking skin.
• Speaking of skin: Smoking is linked to a 2 X increased risk of developing psoriasis.

bupropion-150mg.com

Teeth:

• The yellow/brown stain on your teeth is only part of it.
• Smoking also damages your salivary glands. A major cause of tooth decay is low saliva (xerostomia). One of the many bad things smoking does is that it causes tooth decay by causing xerostomia.
• Smoking also significantly increases risk for many other dental problems: including oral cancer and gum disease.
• It will take longer for your dentist to clean your teeth. Who wants to spend any more time at the dentists than they need to?
• Smokers do not heal as well after surgeries (tooth extractions, and periodontal procedures included).

www.nyc.gov

Breath:

• You may think that others can’t tell you smoke because you cover it up with mints/deodorant/perfume, etc.  Or you think no one will notice because you only smoke at home at night on the back porch. But guess what? You can’t smell as well as others because you smoke. We can smell that nasty.  Even if you are lucky and it is very subtle, we can still tell something is off.

Fingers:

• Got that yellow on your fingernails yet? I guess you can put nail polish on. It is hard to cover up the skin stains though.
• Skin just looks old everywhere.
• In addition, some people will have a change in the shape of their fingers because of smoking. The finger tips get a bulbous look from smoking (digital clubbing).

www.wellsphere.com

Bones:

• Smokers have weaker bones than nonsmokers. Who wants to be shorter and bent looking?

Hair:

• Smoker's are three to six times more likely to go prematurely gray than nonsmokers.
• A smoker's hair is more brittle, older looking.

Cancer:

• I have seen a lot of head and neck cancer and surgery for tobacco related tumors. I have seen a lot of bad things in my career and the nasty head and neck cancer always gets me. Even a small cancer (if you’re hoping for the best) will result in a major scar. You ever worry about a pimple? That is nothing. Head and neck surgery is majorly disfiguring (it is the, 'you don't ever want to ever go out of the house kind-of bad').

tobaccofacts.info

 

http://www.simcoemuskokahealth.org/

http://www.dh.gov.uk/

General:

• Smokers are four times as likely to report feeling unrested after a night's sleep. In regards to appearance, most people look/feel like crap after a bad night’s sleep.

So then you ask yourself, “Why do I want to lose weight-look good.”

• For most it is because they want to have a relationship. Or to be in a position to have/stay in a relationship.
• A 2005 survey of Canadians found that more than half of people surveyed would not date a smoker.
• No one wants to kiss a prematurely ageing, cancer prone, smelly ashtray.
• But if you do get into a relationship beware. Smoking affects circulation; with less blood flow to your genitals, arousal for both men and women can be more difficult. And yes impotence. Bummer.
• Cigarette smoking is a risk factor for developing diabetes. Diabetes causes impotence. Double bummer.

You want to lose weight for health:

• It is almost a joke to explain why smoking is not a healthy way to attempt to lose weight.
• You know tobacco causes lung cancer, emphysema and heart disease.  But there is so much more…

Some more tobacco related health badness you might not know:

• Not just lung and mouth cancer. Also significant increased risk of cancer of the throat, Esophagus, Pancreas, Kidney, Bladder, Cervix, etc.
• Smoking also significantly increases the risk for stroke, hypertension, and spontaneous head bleed.
• Tobacco smoke contains four thousand-plus chemicals… most of them bad (cyanide, lead, ammonia, carbon monoxide, etc).
• What did you say? Smokers have a nearly 70% greater likelihood of developing hearing loss than nonsmokers.
• A study in the Netherlands showed that smokers took an average of 11 more sick days a year than nonsmokers.
• Peninsula Medical School surveyed 10,000 and found that smokers reported below average pleasure and satisfaction with their lives than the nonsmokers.
• Smoking increases the risk of depression.
• Smoking = earlier menopause by several years.
• People are allergic to cigarette smoke. Smoking worsens allergies.
• The Canadian Journal of Public Health reported that smokers got into car accidents 1.5x more often than nonsmokers.
• Cigarette smoke doubles your risk of macular degeneration, which is a leading cause of blindness.
• The journal Neurology studied 7,000 people and found that smoking also increases the risk of dementia. What is going on?
• Women who smoke take longer to become pregnant and are more likely to miscarry.
• And by the way: if you're on the Pill and smoke beware. Mixing the two is an extra major risk for acute blood clots, pulmonary embolism, heart attacks, and strokes.
• If you were to take a medical school test and the question was: “what is the one best thing you can do to improve your health” the answer will always be Quit smoking. It doesn’t matter what the other options are.
• Smoking is estimated to be the single largest cause of preventable deaths in the United States.

The health benefits of being tobacco-free far exceed the problems associated with even moderate weight gain. Lung damage and heart disease are irreversible — weight gain is not.

American Cancer Society

Quit smoking: Every cell in your body will benefit.

Question "…He loses his balance, I was thinking because of his failing eyesight or there is more to it?"

Answer: There are many possible causes of balance problems, but yes the eyes play a big part.

 

• As was mentioned in the last blog entry (for someone else with vertigo). The system that gives you balance is a complicated one. Many different sensory factors are taken into account by your brain and interpreted to let you know where you are in the world. The last blog entry concentrated on the middle ear part of balance. That is a big part. However, the two other big parts are your vision and nerves in your limbs, especially your feet and legs (proprioception).  
• As you know, uncontrolled diabetes ruins your eyes. Unfortunately, diabetes also ruins the peripheral (nerves in your feet). So with bad diabetes, you are only working with 2/3 or the normal balance system. Working with 1/3 is hard enough. For example, as a normal person, try keeping your balance on one leg with your eyes closed. It’s hard. That is only removing one part of your balance system (your eyes). In this scenario your leg nerves and your semicircular canals are trying to figure it out on their own. Now imagine you take away another factor… No eyes and no feet nerves... very hard to keep balance.  
• Of course there are other potential causes for balance problems. However, for this person I would think that diabetes is a big factor.
• Regardless, see your doctor to make sure that there is nothing else going on.

 

Question: “A friend of mine has been housebound for 2 months with Vertigo… Do you know anything about a virus that can cause Vertigo?”

Answer: Yes vertigo can be very debilitating and can be caused by a virus. However, there are other potential causes of vertigo, each with different implications.

I recommend going to an ENT specialist or neurologist to help determine the specific cause and therefore the appropriate treatment.  

Definition:

• Vertigo is a term that is sometimes inappropriately used as a synonym for dizziness. In reality vertigo is a relatively specific symptom that refers to the sensation of spinning and/or rotation (vertigo is from the Latin verto which means to turn).
• Dizziness on the other hand is an imprecise term that is often used by patients an attempt to describe a variety of symptoms including light-headedness, faintness, confusion, tingling, unsteadiness, trouble walking, giddiness as well as a spinning sensation. Each of these potential symptoms have dizzying list of far reaching implications. Because of the lack of specificity and potential associated diagnostic confusion, doctors generally don’t use the term dizziness. As you can imagine, interchanging the term vertigo and dizziness can lead to erroneous conclusions and treatments.

Overview:

• There is a complicated series of parts in your head that work together to give you balance and self orientation. This set of parts is known as the vestibular system. When a part of this system is damaged or disturbed it can give you the symptom of vertigo.

Vestibular system:

• There are many parts to this complicated system, but I think it is easiest to think of it as two major parts: Let’s call it the 'inside part' and the 'outside part.'
• The more 'outside part' is a labyrinth of tiny tubes in your middle ear that include the semicircular canals.
• The 'inside part' includes the nerves that carry the sensory information from the labyrinth to the brain, and the brain itself.
• Each part of this system can be damaged in different ways.

What it looks like:

• I did some medical art of the labyrinth recently for a friend’s text book. I guess since I created the image, it is safe for me to put it up here in order to help with the description (see picture below).
• The whole thing is really tiny and imbedded in the skull bone.
• Most people have two of them; one set in each middle ear.
• The semicircular canals are the three different long loop looking things in the picture.
• The curly thing is the cochlea which is the hearing part of the middle ear.
• The whole labyrinth is hollow and filled with fluid. The fluid is called endolymph.
• The inside walls are covered with millions of tiny sensory hairs.

Artwork by Thomas Osborne, MD.

In the next edition of "Head and Neck Imaging" by Peter M. Som and Hugh D. Curtin

How it works:

• When you move your head the fluid moves around inside the labyrinth.  This fluid motion triggers the tiny sensory hairs inside. Moving your head right to left will cause fluid to move in one area more than another area. Front to back movement will cause other areas to have more fluid movement. Etc.  
• Now looking back at the image (above) you can see that the semicircular canals are set up at right angles to each other. This orientation is the most efficient design to decipher 3D spatial angulations.
• Fluid motion triggers the sensory hairs in the different parts of the labyrinth. That information is sent to the brain via a specific nerve (the eighth cranial nerve aka the vestibulocochlear cranial nerve).
• The eighth cranial nerve then plugs into the brainstem where a lot of other vital information is processed. Additional nerves connect back and forth from the brainstem for additional processing and verification with other sensory input.

Problems:

• An injury to any part of this system can cause vertigo. There is a long list of potential causes each with subtle and profound differences.  I will address some of the more common causes.

Infection:

• Many different types of infections can target the labyrinth; a general term for infection or inflammation of the labyrinth is called labyrinthitis. However, most causes are thought to be viral.
• An infection can cause abnormal activation of the nerve hairs in the labyrinth. This haphazard activation will be interpreted by the brain as motion when there is no motion.
• This can further confuse the brain when sensory input from the eyes do not verify that spinning is actually occurring. To this end, vertigo can be worse when you close your eyes and there is less correct sensory input from the eyes to combat the incorrect input coming from the labyrinth.

Benign paroxysmal positional vertigo (BPPV):

• This is a common problem which is typically made worse by a particular head position.
• There are tiny calcium crystals known as otoconia (stones) in a part of the labyrinth known as the utricle. In patients with BPPV, the crystals migrate into one of the semicircular canals and cause problems when they abnormally trigger the sensory hairs in their new abnormal location.
• Specific movements of the head can diagnose the problem (Dix-Hallpike maneuver).
• Other specific head maneuvers can guide the stones away from locations in the labyrinth that cause problems (Epley maneuver, and the liberatory or Semont maneuver).
• These maneuvers can be taught to the patient or patient’s spouse/partner/friend so it can be done at home if/when symptoms come back.

Drugs:

• Some toxins such as drugs or alcohol can target the labyrinth. One common class of drug are aminoglycoside antibiotics.

Injury:

• A fracture that goes through the temporal bone and labyrinth can disturb the delicate balance and cause vertigo. However, if you did something to fracture that hard bone, the diagnosis should not be a dilemma.

Ménière disease:

• Although there is some controversy as the exact cause of Ménière disease, most believe it is caused abnormal/impaired drainage of endolymph.
• Symptoms are somewhat variable but classic symptoms include vertigo, symptoms of ringing in the ear, hearing loss and a sensation of fullness in the ear.
• Attacks of vertigo can be severe, incapacitating, and unpredictable.  However, with Ménière disease symptoms of vertigo rarely last up to 24 hours.
• Ménière disease is usually a diagnosis of exclusion (only diagnosed when all other causes have been ruled out).

Tullio phenomenon:

• Tullio phenomenon is sound induced vertigo.
• This is caused by a bony defect that results in abnormal flow of endolymph.
• Loud noises causes pressure changes in the labyrinth and when there is a bony defect, fluid moves more than it should. Abnormal endolymph motion = vertigo.

Schwannoma:

• A schwannoma is a specific type of slow growing tumor that can press on the eighth cranial nerve and therefore cause nerve malfunction. This process usually causes a slower onset of more mild vertigo, often with additional symptoms of hearing problems.

Brian injury:

• Injury to the brainstem or cerebellum (where the sensory information is processed) can also cause vertigo. A stroke will result in acute systems which needs to be treated as an emergency. Other diseases such as multiple sclerosis, Lyme disease and tumors can cause acute or slower onset of symptoms.

Vertebrobasilar insufficiency:

• Decreased blood flow to the brainstem and/or cerebellum without a stroke can also cause vertigo. This can be a warning sign of a potential future stroke.

Psychogenic vertigo:

• Psychogenic vertigo is vertigo in public places. This is often associated with Agoraphobia (fear of open spaces, crowds, leaving home).

Treatment:

• Treatment depends on the specific type of problem causing the vertigo. Example: BPPV can be treated with specific head maneuvers, Lyme disease is treated with antibiotics, schwannoma can be treated surgically, etc.
• The right diagnosis will lead to the right treatment. A through neurologic exam from a qualified doctor is essential. I recommend going to an ENT specialist or neurologist. Additional testing may also be needed to confirm suspicions or rule out other possibilities.
• Obviously the ideal goal is to fix the root cause; however, sometimes this is not possible. 
• Medications that treat the symptoms of vertigo can help patients cope during and after the medical evaluation. The following medications may help.
• -Antihistamines: Meclizine, dimenhydrinate, promethazine
• -Anticholinergics: Scopolamine
• -Tranquilizer: Diazepam

Question: “I've come to understand that not all doctors are created equal. What are some things I can do to pick a good general physician for myself?”

Answer: This is a very important question, but not an easy one to answer for many reasons.

   

There is some good news and some bad news for you in your quest:

• The good news is that all medical doctors in the US must meet rigid qualifying criteria to be able to practice.
• The bad news is, as you said, not all doctors are created equal. As in any profession, there are some people who are better at their job than others.
• So how do you separate the wheat from the chaff? Unfortunately, I do not have a magic formula; however, I do have some thoughts that may help.
• There are some things that you can work out before you see a physician but other things will have to wait until you actually step foot in the doctors office.

Before you step foot in the office:

Medical insurance:

• Many health insurance plans will require that you choose a primary care physician from their approved list of providers. Start with this list and save yourself some time.

Minimal requirements:

• I would recommend that your physician has at least met the basic residency requirements of an ACGME certified medical specialty and is board certified.

Ask around:

• Ask other people you know about their PCP. If a trusted friend likes their doctor, then that is definitely something to explore. Be sure to ask them why they like their doctor because their reasoning may not apply to your needs. This admittedly is not a perfect solution; what some people perceive as good is not necessarily going to work for you, but this is a great start.
• If you like your current doctor, but can’t see them anymore for geographic or insurance reasons, then ask your doctor if they can recommend a referral.

Background search:

• Some people believe that the prestige of a physicians medical training will reflect the quality of the doctor. The rational being that the better the medical school/internship/residency/fellowship, the better the doctor that is produced.
• Another perspective is that high level medical training programs will select for the best candidates.
• It is hard to prove if this is a legitimate argument and I don’t think that this method has ever been tested to be a valid strategy for selecting the best physician. In addition, I have known some great physicians from little known medical programs. I have also heard stories of subpar physicians form the most prestigious medical institutions.

Seek a specifically trained physician for a specific situation:

• Some primary care physicians are more experienced in some medical situations than others and will therefore be in a position to provide better care for that specific circumstance.
• As we all know, the more someone (anyone) does something the better they will be at that task. Some of these are obvious; you don’t go to your kid's pediatrician to have your gallbladder removed, and you shouldn’t go the ER for a routine mole check. Etc.
• To this end, consider that some doctors may have additional training in a medical field specific to your needs. This additional training may not always be designated with a certificate of merit or fellowship but may just be an area of particular physician interest.
• If you are an athlete/weekend warrior, then a doctor with additional training in Sports Medicine might be a big plus.
• If you are older, then additional training in Geriatrics will help.
• If you are often sick or have an immune disease then you would be lucky to find a PCP with additional Infectious Disease training.
• Additional Women’s Health training can provide a physician with insight into problems that a general trained physician may not have experience with.

Physician age:

• Some people think that an older doctor will be a better doctor because they have more experience.
• However, others believe that a younger doctor will be better equipped because they have more experience with the latest medical advances.
• I don’t think there is a good answer here. The quality of a doctor in my opinion can’t be determined by their age.

Look around: 

• There are several online physician rating sights out there. However, I wonder who is writing the opinion on the websites or if anyone is policing the entries. I am skeptical about the usefulness of these sights.

Logistics:

• Beyond a doctor’s medical talents, you will need one that works for you schedule.  Consider:
• Office location
• Office hours
• Emergency availability
• How long does it take to get an appointment
• Average wait during appointments
• Number of patients booked per hour
• Is the doctor affiliated with a local hospital? If you prefer a specific hospital, is your doctor associated with it?

After you step foot in the medical office:

Physician personality:

• Some people will think their doctor is the best because they are nice. While, I would expect all doctors to be personable, I would not say that this automatically equates to good medical care. None the less, you definitely want a physician that:
• Listens to you, doesn’t interrupt you, and seems to be paying attention.
• Does not make you feel rushed.
• Is willing to listen to your theories on what's going on and is open to you getting a second opinion without making you feel guilty or ashamed.
• Perhaps most importantly, I would caution against an arrogant physician. Ego can and has clouded judgment. I have seen many unfortunate cases where a self-righteous physician has not allowed themselves to see significant medical issues because someone else proposed an alternative diagnosis or treatment.
• In my opinion, a great physician is one who does everything they can to be at the top of their field and at the same time is open to alternative explanations/care.
• The paternalistic (doctor tells patient) model of medicine needs to change to a more productive partnership between patient and physician.

Medical office:

• Beware if the office/exam rooms are not clean. Cleanliness is a necessity in medicine and may be a reflection of the quality of care in general.
• The doctor’s office and nursing staff should be courteous and respectful of your privacy.

The bottom line, if something doesn’t feel right, don’t hesitate to move on or get a second opinion.

Question: "My husband was given a prescription for fungal nails… and has been prescribed Lamisil… could this be dangerous to take with other meds?"

Answer: Good question. The answer is yes it could be a problem to take Lamisil with other drugs, but it depends (see below).

Background:

• Fungal infection of the toenails or fingernails is known as onychomycosis. This is a common but hard to treat infection.
• The following text is not intended to be a complete review of the onychomycosis or medications. You should see your doctor and discuss your condition and how it relates to you specifically.

What it looks like?

• Onychomycosis can have different appearances.
• Early on, the infection can be subtle and hard to detect.
• The infection can cause the nail to look yellow, green, or cloudy.
• The nails can become thick, rough and crumbly.  The nail can also separate from the nail bed. 
• Other diseases can look similar to onychomycosis, so you will need a doctor to evaluate and diagnose.

Photo credit: http://wikipedia.org/

Why does the fungus grow in the toenail?

• Since onychomycosis is a fungal infection, it will thrive in conditions where fungus do well; dark/moist places. Under the nail is one of those spaces. Tight fitting old sweaty shoes are also optimal living conditions for toe fungus.

How do you get it?

• Onychomycosis is a common infection and can be spread from person to person via floors or other surfaces.
• Therefore, some things that can help reduce your chance of getting the infection are: Don’t go barefoot in public bathrooms. You should ware flip flops in public showers. Don’t share nail files or emery boards.

Onychomycosis and diabetes:

• Onychomycosis can be a big problem for people with diabetes. 
• People with diabetes can get the infection easier than other people, the infection can be harder to treat and it can lead to more serious infections.
• Treating onychomycosis will decrease the risk of getting other/secondary infections that can lead to toe or foot amputation.

Treatment:

• There are several medications available.
• Topical medications have few side effects but are not very effective.
• Lamisil is the oral medication that your husband has been prescribed. The generic name for Lamisil is terbinafine (ter BIN na feen).
• Studies have shown that oral medications are more effective than topical medications. Some physicians advocate both oral and topical medications to increase effectiveness.
• There are even some promising drug-free treatments that use laser light. http://abcnews.go.com/Health/OnCall/story?id=7113863&page=1

Preexisting conditions:

• Lamisil is a medication that has a predisposition to adversely affect the liver. Therefore, people with liver problems should take this medication with caution.
• Kidney disease and autoimmune disease such as lupus may also be a particular problem with Lamisil. 
• As with any medication, there are potential side effects that can have a negative effect on some people regardless of preexisting health conditions.  It can be difficult to tell who will experience those adverse reactions.

Lamisil with other drugs:

• Lamisil can alter the livers ability to process/metabolize other medications.  Therefore, Lamisil can alter the concentrations of other drugs in the body. This can result in too much or too little of a particular medication. Not all medications are affected in this way and some are more vulnerable to body concentration alteration than others.
• This does not mean you should not take Lamisil.  However, you should have your liver evaluated before taking the medication.  You should also be sure that your doctor knows about all the other medications you are taking (prescription/nonprescription/herbal or otherwise).

Take as prescribed:

• Treatment for onychomycosis is long; It may take several months for your nails to return to normal.
• If you stop taking this (or any) antimicrobial medication before the prescription is complete then the infection may become resistant to that medication.

When you are taking Lamisil:

• Call your doctor at once if you have symptoms of liver damage. Signs of liver damage may include:
• Nausea, abdominal pain, loss of appetite, fatigue.
• Itching, dark urine, clay-colored stools.
• Jaundice (yellowing of the skin or eyes).

There is more in-depth information about Terbinafine (Lamisil) at: http://www.drugs.com/pro/terbinafine.html

Question: "How do you become a radiologist in the US?"

Answer: Many years of blood sweat & tears, (and a little luck).

Overview of a 7 step program

1). College or University:

• Graduate from a 4 year college or university with excellent grades.

2). Pre Med:

• Try to get into Medical School during or after college by jumping through multiple hoops. Regardless of who you are you have to excel in the many prerequisite science classes (biology, chemistry, organic chemistry, biochemistry, physics, calculus, etc). These classes are usually taken during college but can be taken after. Get superior scores on the MCAT exam. Get excellent letters of recommendations. Demonstrate success in extracurricular activities. Doing all of these things won’t guarantee acceptance into medical school, it is just the minimum. It would help to win the Nobel Prize. 

3). Medical School:

• Graduate as a Medical Doctor from a 4 year medical school. The amount of information to learn in medical school has been likened to "Drinking from a fire hose." Obtain superior scores on local and national medical examinations. Get more excellent letters of recommendations.

4). Internship:

• Complete a rigorous 1 year ACGME internship in internal medicine or surgery. These generally entail long hard stressful hours with little sleep.

5). Residency:

• Get accepted into a 4 year ACGME radiology residency program. It’s competitive; more doctors want to get in than there are available positions. Once you are in, you soon realize that you have much more to learn than you ever imagined. Willpower, commitment and fear will help to fight exhaustion.

6). More exams:

• Pass a series of challenging written and oral national examinations throughout the training.

7). Graduate from radiology residency:

• Take a moment to contemplate what happened to your youth and wonder how to pay back your student loans.

Additional training:

• Some radiologists will go on to do more in-depth advanced training/fellowship in a subspecialty field of radiology such as Neuroradiology, Neurointerventional Radiology, general Interventional Radiology, Musculoskeletal Radiology, Body Imaging, Nuclear Medicine, MRI, Ultrasound, Women’s Imaging, Pediatric Radiology, etc.
• These optional training programs last an additional 1 to 3 years.

Total time investment:

• For someone such as myself, the total higher education time commitment was 15 years.
• Each medical specialty has different training requirements which reflects the unique challenges of the specific individual field. As a comparison, a general pediatrician or family doctor only needs to complete a 3 year residency program after medical school.

Question: "What is a radiologist?"

Answer:  A radiologists is a highly trained physician who utilizes the latest medical technologies to diagnose illness and direct medical care.

Diagnostic Radiology:

• Radiologists are the only doctors who are specially trained to interpret medical images which include x-rays, ultrasound, computed tomography (CT), nuclear medicine, positron emission tomography (PET) and magnetic resonance imaging (MRI). In doing so, radiologists are able to provide other physicians with lifesaving information about their patients. Because of this essential relationship, radiologists have often been referred to as, “A doctor’s doctor.”
• Radiologists are central to patient care and their expertise is indispensible in every medical subspecialty. 

Interventional Radiology:

• Radiologists are also trained to perform minimally invasive image guided surgical procedures such as biopsies, paracentesis, thoracentesis, myelogram, lumbar puncture, kyphoplasty, vertebroplasty,  vascular surgery including aneurysm repair, uterine fibroid embolism, as well as many different infection and cancer treatments.
• Most patients will not see their radiologist unless there is a question or if the radiologist is performing a procedure.

Who is the person who takes my x-ray?

• The people who take your x-ray, MRI, CT, etc are technologists.
• Radiology technologists have completed separate training but did not go to medical school.
• Radiology technologists are not doctors or radiologists.
• However, sometimes a radiologist will help a technologist to obtain medical images.

Question: "What is sepsis?"

Answer: Sepsis is basically a really bad type of infection.

More specifically, sepsis is an infection that causes whole body inflammation via the blood.

• The infection is usually caused by bacteria.
• Often the infection starts in a specific location such as the kidney, bowel or a heart valve and then spreads to the rest of the body via the blood.
• However, sometimes a primary starting point of the infection is not identified and the major problem is a blood infection that then causes infection elsewhere.
• Sepsis is a serious problem that needs to be treated with lots of IV medications in the hospital.
• There is much more to this story. Let me know if you have a specific question.

Question: "I have terrible pain going down my leg that they say is radiculopathy from disc disease. What can I do about it?"

Answer:

• Unfortunately, this is a very common problem.
• I recently posted a blog about the mechanics of nerve impingement and radiculopathy (see Feb 2nd posting for details).
• With your question, I will expand on information from the prior posting and go through some potential treatment options. This should give you a good foundation from which to discuss treatment strategies with your PCP.

Surgery:

• Surgery can be a definitive treatment for pain arising from degenerative disc disease. When appropriate, surgery can be a miracle cure.
• However, even when the cause of pain is clear on MRI and physical exam, surgery is not always successful at alleviating symptoms. Up to 40% of patients have persistent and sometimes worse pain after surgery. This is the so called “failed back syndrome”.

Surgery risks

• There are many different types of back surgery. Regardless of the approach, spinal surgery is not a minor endeavor.
• There are short term risks with surgery such as anesthesia complications, bleeding, nerve injury, infection, and death. These risk factors are exaggerated with concomitant health problems such as heart disease and diabetes.
• There are also potential long term complications with surgery such as chronic pain, recurrent or worsening pain from surgical scar tissue, decreased mobility, fracture, infection, etc.
• Because of these factors and because radiculopathy symptoms may subside on their own, surgery may be delayed.
• However, there are times when surgery is the only solution to avoid potential paralysis. Qualified medical examination and MRI will be needed to direct appropriate clinical care. Don’t try to do this on your own. If you have paralysis or other problems such as trouble urinating this may indicate a more serious problem such as cord compression. This blog entry information is for radiculopathy and not for the more serious problem of severe spinal stenosis, cord compression and/or cauda equina syndrome. See your doctor regarding your back pain or other related symptoms because without appropriate medical care it may lead to permanent disability.  

Primum non nocere (first do no harm):

• After a disc has ruptured, several specific immune cells (such as macrophages) will arrive at the scene to start to remove the diseased material. These immune cells are small and therefore the removal of disc material is slow. If there is not an additional or recurrent disc rupture, then over time the diseased disc often gets smaller and the amount of inflammatory mediators will decrease. This process will lead to a marked improvement or resolution of symptoms for many patients. There are some papers that suggest the long term outcome for radiculopathy is similar for patients who wait to have surgery compared to patients who have immediate surgery.

Finding out about other pain treatment options: 

• It is important to know your audience. Don’t expect to get a full list of nonsurgical pain treatment options from your surgeon.  Surgeons like to do surgery and they get paid to do surgery. Most surgeons think about surgery all the time and do it very well. In general, surgeons like to face a problem head on with the tools they know. Another words, everything looks like a nail if you only have a hammer.  There are other less invasive options to consider for back pain that your surgeon or PCP may not even know about (see below).

Noninvasive or minimally invasive treatment options for radiculopathy:

• In general, radiculopathy is not an easy problem because is not a normal kind of pain and does not respond to well to standard pain treatments. In addition, pain is only part of the story because nerve injury also affects muscle function.

I am in favor of:

1. Pain Clinic: Many major hospitals have a dedicated “pain clinic” or “pain center.” There you will find people who are trained specifically in the art of treating different specific types of pain. These are usually run by or in conjunction with anesthesiologists. They should know the subtleties of pain treatment better than an average surgeon or PCP. This is a relatively new field and sometimes you won’t know about this option unless you ask about it specifically. If I were in your position I would definitely explore this alternative.
2. Diet and reasonable exercise with the goal of reaching a healthy weight and developing strong back supporting muscles. This should be done under the supervision of a medical professional. 
3. Neurontin (gabapentin): This is an underused medication that has a low side-effect profile and is particularly good at neuropathic pain. The only major problem with neurontin is that it takes a long time to start working and doesn’t work for everyone.
4. Acetaminophen: Low side effects and works fairly well for neuropathic pain.
5. Capsaicin cream: This is a relatively new one on the market and I like it for several reasons. First it is effective. Second it has a low side effect profile and third it is the active hot ingredient in chili peppers. Muy caliente! It is used topically. When it is applied to the skin, capsaicin cream has been found to deplete the pain neurochemical known as substance P.  Less substance P = less pain. Use gloves when applying because this stuff is hot and can burn sensitive parts.
6. Lidocaine patch: This is also applied topically and will numb the skin. This is basically the stuff the dentist injects but is used topically with the patch, so no injection pain.
7. Nontraditional approaches: These include acupuncture, biofeedback, meditation, etc. Acupuncture is covered by many insurance plans for the indication of pain. These options have no real side-effects and in some journal articles, the positive results for acupuncture have been reported to be up to 90%. They can be used in conjunction with other pharmacologic treatments without cross side effects.
8. Physical therapy: A dedicated medical physical therapy program is important for long term function and may also help in the short term, but should only be done by qualified individuals with specific knowledge of the nature and extent of disease.
9. Nerve root blocks: This can be helpful in some patients. Some studies have reported success as high as 60%.  However, in some patient's symptom relief can be short lived. The procedure is semi-invasive and the risks are less common than surgery. Risks include bleeding, nerve damage, vascular damage, infection, transient weakness/paralysis, spinal cord infarction and stroke. Most physicians will limit the procedure to a total of 3 separate treatments attempts because of potential steroid side effects, however this limit is controversial.

Options that I have mixed feelings about (treatment will depend on your specific clinical situation):

1. NSAID’s (such as aspirin) are better than opiates for this type of pain, but chronic use increases the risk for side effects such as a bleeding stomach ulcer. This is risk is exaggerated for someone like yourself who should already be on NSAID’s for heart disease or with chronic illness.
2. I am not a fan of narcotics but when the pain is intolerable it may be an option. Vicodin is a better option than oxycontin and oxycodone because Vicodin is a mixed drug containing both acetaminophen and hydrocodone. The mixture allows a lower dose of hydrocodone (narcotic) but long term use can result in similar problems (cause constipation, can alter level of awareness, and are addictive). In general, narcotics are not particularly good at this type of pain.

I am unsure about these options:

1. I have heard that electrical stimulation has been helpful in some uncontrolled studies; however, I have no experience with this myself.
2. Mechanical traction seems archaic, but it apparently works for some.

Treatment options that I would view with caution:

1. I am not a fan of a chiropractor. I have seen some unnecessarily bad outcomes, particularly after manipulation if the neck. However, some people swear by it.
2. I would avoid stronger opiates such as oxycontin and oxycodone. Opiates are not particularly good at this type of pain; they cause constipation, can alter your level of awareness, and are addictive.
3. Some people advocate bed rest. I do not think this is a viable option because in the long term this will weaken already compromised muscles. Weakened muscles will not be able to support your spine and therefore accelerate the degenerative process. Disuse will also lead to limited motion from muscle/tendon tightening. Extended bed rest will also lead to accelerated osteoporosis, potential spinal/hip fracture, pneumonia and other bad things.

Questions: "He seems depressed and was having trouble breathing. He has been in constant pain for months. Now he has shingles on his scalp face and eye. He takes pain killers every day and his Dr does not offer any type of pain management that I know of. I think he needs a new Dr. and then you would probably need to wait months to see a new Dr. I asked if he would just call the ambulance - and that way he could get right in ... and maybe they could tell him what to do. I want to set up some apts and go this week or next.”

Answer:  It is obviously hard to know what exactly is going on from this limited information. Please see the following remarks regarding the issues you brought up. The bottom line he needs to see a doctor today.

Breathing:

• Trouble breathing can mean a lot of different things and needs to be addressed by a qualified physician in person. The list of possibilities for shortness of breath goes on for volumes; however, I will address a few potential causes.
• Trouble breathing can represent an acute life threatening illness such as pneumonia or pulmonary embolism. Pneumonia usually has associated symptoms of fever (but not always) and pulmonary embolism usually presents with symptoms of acute chest pain (but not always). Sudden onset or worsening of symptoms needs to be addressed immediately in the ER.
• However, trouble breathing can be a chronic problem such as emphysema.
• Knowing his personal history of prior heart attack, one contributing factor that I would consider is congestive heart failure (this may not be the only cause; sometimes there are many causes for shortness of breath at the same time).
• Congestive heart failure happens when the heart is not strong enough to push the blood/fluid away from the lungs and therefore fluid backs up in the lungs. Congestive heart failure can be mild and treated with medications on an out-patient basis. However, congestive heart failure can also be severe with large pleural effusions which requires management in the hospital.
• Again, any shortness of breath needs to be addressed by a qualified physician; the range of potential possibilities is enormous and there is no way I can evaluate them over the internet. If symptoms are severe and or new he needs to go to the ER.

Depression:

• There are numerous causes of depression. The severity of depression also ranges significantly from mild to severe. As you know, severe depression can also be life threatening, which needs to be addressed in a hospital. 
• Seasonal affective disorder is a possible contributing factor that gets everyone down this time of year. In addition, being sick, especially with a chronic illness will depress almost anyone. Depression also runs in the family. Again, this needs to be addressed by a qualified physician in person. 

Shingles

• Shingles is a painful, blistering skin rash due to the varicella-zoster virus. This is the virus that causes chickenpox. After you have had chickenpox (most of us have), the virus goes dormant, living quietly in your nerves for most of your life. However it can wake up again in the form of shingles. It is not clear why this happens but it often occurs in times of severe stress or illness.
• Shingles often disappears on its own. It usually clears in 2 to 3 weeks and rarely recurs.
• Shingles can also be treated with antiviral medications such as acyclovir, famciclovir, and valacyclovir which can shorten the time of illness. The earlier you start the medications the better.
• Infection in-and-around the eye is an emergency because it can cause permanent blindness. If there is eye involvement, this needs to be addressed immediately in the hospital and treated with IV medications.
• Shingles is also very painful because it is an infection of the nerves. Pain can also be managed with various pain medications. Other medications such as prednisone may reduce swelling in some patients. Antihistamines such as Benadryl can help to reduce itching. Some have used nontraditional methods such as meditation and acupuncture. The list goes on but one of the most important things is to keep the area clean and dry to prevent a secondary infection. 

A different primary physician?

• Knowing the person you mentioned with the above illnesses (name left anonymous for the blog), I could imagine he may not have told his doctor all of what is going on. It is also possible that he may not have shared with you all that his doctor is doing for him.
• However, if he doesn’t like his current doctor, for whatever reason, he can get another doctor. The availability of doctors varies from place to place. However, it shouldn’t take months to get an appointment to see a new primary physician.
• Regarding finding a new physician; an ambulance driver would not know what primary physician to send him to.  This is not their training or role.
• In the short term, he needs to see someone about the shingles eye involvement and the shortness of breath today.
• In the long term, he needs to thoroughly address his many medical problems with a primary physician he is comfortable with. He might want to consider a university doctor.
• If I was looking for another doctor, I would first see who is on my insurance approved physician list. I would also ask around to see who is happy with their doctor and go from there. If you want to help out with this, you don’t have to be in his town. It can all happen over the phone and on the internet. I wouldn’t wait till your visit to do something about getting him a new doctor if you think it is important. I am sure that your other sister who is in his town would be happy to help out with information and transportation.

Question: "They found a pulmonary nodule on a CT scan, what does this mean?"

Answer: This is a very common question/issue. What a pulmonary nodule means to you depends on a lot of factors.

What does a pulmonary nodule look like?

• A pulmonary nodule is basically a small focus of tissue in the lung. It is usually round but can often be oval, irregular, or speculated. Sometimes is can be calcified or have fat density.
• By definition a nodule is less than 3cm in size. If the lesion is greater than 3cm, it may be the exact same tissue etiology, but it is now called a mass.

What could it mean?

• Fat density in a nodule is considered benign.
• If calcifications are seen within a pulmonary nodule it is almost always benign as well.
• Calcifications are associated with prior or chronic inflammation/infection. In this scenario, the nodule is the tissue that is left over after your immune system has taken care of the problem. It is kind of like a scar.
• These “scars” do not always calcify and a non-calcified nodule can be more difficult to evaluate. None the less, a noncalcified-nodule can still represent the benign residue of a prior infection, but it is hard to tell for sure. So that is usually the major question; is the nodule cancer or not?

So how can you tell if it is cancer?

• The good news is that the vast majority of lung nodules are benign.
• The bad news is, if the nodule is not calcified or does not have fat, it can be difficult to impossible to tell on one CT scan if a nodule is cancer or not.
• Because cancers grow and scars generally do not, a follow-up scan can help. Scans at different times provide a reference point to evaluate if it increases in size over time. Some types of cancers grow very slow and therefore a long follow-up may be necessary to feel comfortable that the nodule is benign.
• Other factors play a role in the likelihood that a nodule is a cancer or not. The chances that a nodule is malignant increases with nodule size. Some other common factors that increase the likelihood that a nodule could be cancer is; patient age, history of other cancers, smoking history and history of other carcinogen exposure.

How often do you re-scan with CT and for how long?

• This is a major issue that is debated by many.
• In the last decade several articles have been published in major peer reviewed medical journals to try to establish a safe and rational approach to the management of this common issue. Most recently, in 2005 a consensus guideline was created and adopted by the major medical society on chest imaging (the Fleischner Society). Their follow-up algorithm is very helpful but remains general and many other individual factors will dictate management. The article is online:
• http://radiology.rsna.org/content/237/2/395.full

November 2005 Radiology, 237, 395-400.
• As you can see from this guideline, nodules less than 4mm are considered benign in low risk patients.
• I believe this is the size of the nodule you have on the CT scan (reference to the person asking the question).  However, a 4 mm nodule is not considered benign in high risk patients.
• The type of cancer you are dealing with (desmoid fibroma) is not known to metastasize to the lungs and therefore it is questionable if you should even be in the high risk patient category.
• These guidelines have been used by many, but not by all. For example, at MGH, they have a slight modification to the Fleischner Society recommendations based on their own experience.

This algorithm was used when I was at MGH. However, things in medicine often change with medical advances and it is possible that it has been updated since.

Question: "I have a question about by mammogram. Since I went to a new facility for my last mammo, they did not have comparison films from my previous, they think that my mammo is abn… do you know where I can have copies made?"

Answer: Get your prior mammograms sent to the new place.

• It is very important for a radiologist to have prior mammograms when reading current mammograms. It is one of the most important things needed to accurately read a mammogram.
• At least a 2 year old prior mammogram is best.

Explanation:

• There are many large textbooks on mammography, and the details of interpretation are way beyond the scope of this entry.
• Overall, reading mammograms is difficult because there is a wide range of what normal looks like. In addition, there is overlap between what disease and normal looks like.
• Looking at a mammogram reminds me of looking at the sky; there are all kinds of different possible patterns.  Because mammograms often look amorphous, one of the most powerful tools a mammographer has when reading a mammogram is the prior exam to see if there is a change.
• For example, on initial review a pattern in the breasts may look concerning.  However, if it is found to be stable for many years it may be deemed as benign. This is because cancers grow over time and stability would unusual for a cancer.  Old biopsy changes often cause breast distortion that can look concerning. However, biopsy changes should be stable or resolve over time. A cancer will grow. 
• On the other hand, a subtle asymmetry on a mammogram could be a cancer that will only be noticed if you see there was nothing there on the prior exam.

What do you need to do?

• You need to get your prior mammograms sent from the older facility, to the place where you just had the mammogram.
• You can get copies at the place you had the mammogram, but film mammograms usually don’t copy well. The original is best.  However, if you had a digital mammogram done, then a CD copy is just as good.
• Once you have your old mammos sent to the place of your recent mammogram, the facility radiologist should reinterpreted your mammogram at no additional cost and provide you with an updated final report.

(image credit from Society of Breast Imaging, sbi-online.org)

Can you tell if this is abnormal or not?

It is really hard to say. 

A comparison would definitely help.

Question: " I was told I have radiculopathy. What is this?"

Answer:

• The name is derived from Latin and Greek
• In Latin, radicula refers to root.  In medicine, radiculo- refers to a spinal nerve root.  
• In Greek, pathos refers to suffering. In medicine, -pathy at the end of a word is a general way of saying there is disease there.
• Therefore, radiculopathy is disease of the spinal nerve root. 

Background anatomy (Spine, Disc, Nerves):
I have some great anatomy pictures from my anatomy textbooks. However, I apparently have to get copyright permission to post the images. I’ll draw something if my description doesn’t do the trick.

-Spine (bone):

• In the lower back (lumbar spine) the five bones are labeled L1, L2, L3, L4, and L5.
• The “L” is short for Lumbar, and the following number is the vertebra (from top to bottom).
• The 5 bones stack up like toy wooden blocks.
• There is a disc between each vertebra (this is often the cause of the problems).
• The spinal nerves pass through a narrow apace between each vertebral body.  This space is known as the neural foramina.

-Anatomy (disc):

• There is a disc between each vertebra which acts like a shock absorber and allows for some movement. This disc space is a type of joint.
• The disc itself is looks a bit like a ¼ inch section of a tree branch. However, this cut branch of soft wood has a round sphere of jelly in the center.
• The outside of the disc, (the part with the wood-like looking rings), is called the annulus fibrosis.
• The central jelly part of a disc is called the nucleus pulposus.
• In total; the disk with two adjacent vertebral bodies is like a jelly donut between two blocks of bone (vertebra).

-Anatomy (Neurologic):

• The best way to think of the spinal cord is a bundle of electrical wires.  These wires connect your brain to the rest of your body and then and back again to your brain.
• The spinal cord carries many different types of wires in a space called the central canal.  The central canal is a tube in the middle of your back surrounded by bone.
• The wires that branch off the spinal cord are called a spinal nerves which innervate (connect to) both muscles and skin.
• A pair of spinal nerves branch off from the spinal cord and travels outward between each vertebra through the space known as the neural foramina. 
• The nerves are labeled in the same way the vertebral bodies are labeled; L1... through L5. 

-Anatomy (Neurologic more specific):

• Each pair of nerves has a specific job(s) and takes care of a specific area(s).
• When something happens to a specific spinal nerve, you will have symptoms/disability in the territory that that nerve innervates.  This can cause the symptoms of radiculopathy.
• Specific maps of spinal nerve-skin intervention are called dermatomes. For example, a map of the area that the L4 spinal nerve innervates is of an area of skin from the back to your leg and knee, down to your foot.
• Specific muscles are also controlled by spinal nerves and when injured there can be associated decreased leg strength and atrophy.

There are several causes of radiculopathy but most of them are either the result of an injured disc, bone (or both).

Disc causes:

• When a disc gets worn out many things can happen.
• Sometimes the disc will just bulge out like a beer belly.
• In another scenario, a tear forms in the annulus fibrosis.  This creates an opening for the jelly like center nucleus pulposus to squeezes out through the tear. Commonly this is called this a “ruptured disc.” This process is similar to jelly doughnut being squeezed with the jelly squirting out of one side. This jelly nucleus pulposus is thick and can squish whatever is in its way.
• If there is adequate room for the adjacent nerves, and if the rupture is small, then symptoms may be minor. However, when the disc material pins a spinal nerve or the spinal cord against bone, the symptoms can be severe.

Anatomic cause (bone):

• The spinal cord is protected from outside injury by the surrounding vertebra-bone.
• The nerve roots leave the central canal of the vertebra through openings called neural foramen.
• A possible outcome of the degenerative repair process is large bony callus formation which narrows the neural foramen and central canal. This is callus formation process is similar to a callus that may form on your foot in response to repetitive use. However, in the case of degenerative disc disease, the callus is made of bone.
• This bulky bony callus can get in the way and narrow the central canal and/or neural foramen.
• This callus generally grows relatively slowly and is not thought to be the cause of acute pain.
• However, a nerve within a critically narrowed space will be venerable to the presence of anything extra in that compromised area.  In this scenario, even the smallest disc bulge can completely narrow an already compromised opening.
• When the nerve gets pinched, you feel pain it in the area where that nerve was programmed to work.
• As discussed above, this can result in pain in a specific dermatome band and/or weakness of a muscle supplied by that nerve.

Diagnosis:

• Physical exam and symptoms often point to the problem.
• Anatomy and function are intimately related. The 3D imaging capability of MRI and CT can provide exquisite detail of the anatomic problem.
• As a result, imaging with MRI and CT can both confirm the cause of symptoms and quantify the extent of disease.  There is usually a direct correlation between the severity of the visible anatomic problem and symptoms. Imaging not only diagnoses the cause of symptoms, but also directs the type of treatment; the need for surgery or conservative therapy.

Question: “Every time I leave my doctor I have all of these questions. He talks so fast and I feel like I am being pushed out the door. What can I do?”

Answer: Unfortunately, this problem is becoming more and more common (details below).

Why it happens:

• There are many reasons why this happens and detailing all of the issues would take many volumes. However, for the most part it comes down to economics.
• Health insurance companies and the government (Medicare/Medicaid) continue to cut reimbursements and malpractice insurance premiums are always increasing.
• As a result, doctors are taking an economic hit on both ends; less money coming in and more money going out. As with any business, this squeeze means less money to keep the lights on, pay employees, etc.
• The problem has gotten so bad that some doctors have found that it is more economical not to work.
• The other alternative for a physician is to work more efficiently. That means a physician needs to see more patients in a shorter amount of time to get the same or less reimbursement.

What can you do?

• Learn more about the problem and become politically active… Ok, so no one seems to have time for that.

What can you do to help yourself?

• Knowing that your doctor only has a limited amount of time to see you, make the best of it. Be efficient yourself. Be clear about all of your concerns and problems.

How can I be more efficient?

• Be ready to answer questions about the what, where, why and when of your problem/illness. What makes it better or worse?
• Everyone does a better job at remembering things in a relaxed environment. Therefore, make a written list of your symptoms at home and bring it with you. Keep a medical diary of symptoms if it is an ongoing problem. In addition, the more time you prepare before your visit, the more accurate and complete you will be.
• More accurate patient information = more accurate medical diagnosis.
• Don’t rush in the doctor’s office, just be prepared.

“I never seem to get all my questions answered”

• Being more efficient/prepared will leave more time for you to ask questions at the end of your doctor’s visit.
• However, if you are like me, you often leave a situation such as this and think, ‘Ahh, I forgot to ask about XYZ.’ The solution is simple, bring a list of your questions with you and go through them one by one.
• Do some research beforehand so you can make the most of the time you have with your physician-medical expert. However, be warned, the internet is filled with all kinds of misinformation. Therefore, doing this type of research before your visit will give you an opportunity to have things confirmed/clarified by your physician.

I strongly believe that patient care should be a team approach between physician and patient. The older model of a passive patient with a dictatorial physician telling the patient what to do is becoming less viable, and was probably not the best approach to begin with. Do your part, be organized and educate yourself. Understanding a problem will lessen the fear/anxiety of uncertainty and will allow yourself to make more intelligent-informed decisions.

Question/Statement: "I saw the internist yesterday. She has ordered an ultrasound of the thyroid just for good measure..."

The "just for good measure" part kind of concerns me.

• In general, there should be a good reason to order any test. Just ordering a test or an exam without a significant indication can get you down the wrong path and can lead to additional tests or unnecessary complications.

Every test has it’s +/-

• No test is perfect and therefore it can’t be interpreted in a vacuum.
• Every test has different degrees of sensitivity and specificity.
• Sensitivity refers to how good a test is at finding something subtle.
• Specificity refers to how much you can rely on a positive result being real.

So what’s the problem?

• A positive test result has more meaning if the disease was suspected to begin with. However, if the same test came back positive on someone healthy, then you got to ask yourself, is it a real result or a false positive?
• A better question would be, why order a test that is not indicated, because then you will not know what to do if the result comes back positive.
• Or worse, if you ignored everything else about the healthy patient except the positive test result, you might inappropriately treat them for something they don’t have.

Thyroid ultrasound:

• Unfortunately, thyroid ultrasound is one of those tests that is rather nonspecific. A thyroid ultrasound is nonspecific because you often can't tell what lesions are begin (good) or malignant (bad) just by the ultrasound appearance. Don’t get me wrong, I am not saying that thyroid ultrasound it a bad test. This is just one type of tool that works well for a particular job. You dont use a hammer when you need a screwdriver (unless you are going to make a mess of things).  Thyroid ultrasound, needs to be used appropriately to be relevant.
• So be warned, most people have abnormal looking thyroids on ultrasound. However, a few years back a bunch of doctors got together and created a consensus guideline to help sort out who should get a biopsy.
• Depending on what things look like on ultrasound, a biopsy may be recommended. This happens quite a bit.
• I use to do ultrasound guided thyroid biopsies all the time. Ill fill you in more if it comes to that.