Thursday, April 28, 2011

Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) affects 3-6% of adults and is the most common entrapment neuropathy. Symptoms are due to compression of the median nerve in the wrist, which results in pain, numbness and tingling.  More than half the patients with CPS have symptoms in both hands.

CTS is often associated with over-use type injuries caused by repetitive motion. Other causes include obesity, pregnancy, arthritis, diabetes and thyroid disorders.

The pain, numbness and tingling typically occur in the thumb, index and middle fingers and may radiate to the forearm. Patients will often notice loss of grip strength and may be awakened by pain at night. The patient may try to shake the hand or flick the write to alleviate the discomfort.

In patients with mild disease, six to twelve weeks of splinting and anti-inflammatory medication may lead to relief. Patients who are not better with conservative treatment or who have severe symptoms may need surgical management.  

Even better than treating CTS is preventing it. I recommend avoiding repetitive motions.  Use ergonomic equipment to keep your wrist in the neutral position, such as wrist rests and ‘fat’ pens, and avoid vibrating tools. Take frequent breaks. Smoking lessens the blood supply to the median nerve; this may exacerbate symptoms. A uniquely suburban recommendation: don’t clutch the steering wheel – we all have power steering.

There is little evidence that dietary supplements will either prevent or cure CTS.

Monday, April 25, 2011

Cardiology Update

The current issue of Annals of Internal Medicine published summaries of ten cardiology articles from the past year that the editors selected for their novelty, quality and potential impact on clinical practice. Cardiovascular disease remains the leading cause of death worldwide.

Statins are the most commonly prescribed drugs in the United States and there is consensus that they should be used in patients with multiple risk factors who are at high risk for heart disease. However, there is little data that statins are beneficial in primary prevention. A meta-analysis (data from many trials aggregated and reanalyzed) failed to demonstrate that prescribing statins (such as Lipitor, Zocor, Crestor) to prevent heart disease actually leads to lower mortality in low-risk patients without demonstrated coronary artery disease.

Even in patients with diabetes, a group in which cardiovascular events are common, there are questions about how vigorously physicians should pursue lower lipid levels and lower blood pressure. The new recommendation is that blood pressure goals in the diabetic should be the same as in other patients, since very low blood pressures can have adverse events. Another article refutes the assumption that using additional medication (fibrate plus statin) to achieve a more favorable lipid profile is associated with reduced cardiac events in the diabetic. The best way to reduce risk in the diabetic populations is the same as for all other patients: increased physical activity, increased intake of fruits and vegetables and reduced sodium intake.

Medical imaging has rapidly increased in the past decade and the per capita dose of medical radiation in the United States has increased six-fold from 1980 to 2006. More than 10% of the radiation exposure (excluding radiation therapy) is from myocardial perfusion imaging. In one New York teaching hospital, one-third of the studies were on patients without symptoms. Another article reviewed coronary angiography; here too one-third of the patients were asymptomatic. No research suggests that invasive procedures help patients without symptoms.

The number of procedures that use ionizing radiation (CT, myocardial perfusion imaging, coronary angiography) is increasing and the use of medications to lower lipids and blood pressure is increasing despite little evidence that were are benefiting our patients. We can clearly help our patients by emphasizing life style changes: diet, exercise and smoking cessation.

Ann Intern Med. 2011;154:549-553.

Monday, April 11, 2011

When Losing Weight is Not Good

The annual meeting of the American College of Physicians took place in San Diego this past week. Alas, I was not able to attend but through the magic of the internet I was able to catch up with some of the more important discussions. Dennis Sullivan, MD of the University of Arkansas spoke about weight loss in the elderly.

Weight loss in the older patient is different than in the younger person. From the ACP Internist summary: “A group of healthy young and old people were deliberately underfed for 21 days. Not surprisingly, all lost weight. But when the participants were taken off the diet and encouraged to eat anything they wanted, the young people gained back all the weight they had lost and then some, while the older participants did not. “The older individuals, even when they were encouraged to eat more, were unable to increase their food intake to regain the weight that they had lost,” said Dr. Sullivan.”

Dr. Sullivan also pointed out that in the elderly a weight loss of 5-10% in the prior year is associated with an increased risk of death in the present year. Late life weight loss is both linked to illness (infection, gastrointestinal disorders, metabolic problems) and inadequate intake. Poor intake may be due to prior medical advice to limit certain foods as well as social isolation, lack of exercise and depression.

Difficulty swallowing and dental problems can also limit food intake. The best approach is to modify the consistency of food – NOT to substitute products such as Ensure or Boost. A variety of real food is the best option. Older patients need more protein in their diet, but some treats can be included to increase the calories. Ice cream is a favorite – delicious and easy to eat.

A patient that does not feel well may enjoy grazing more than three large meals. Dr. Sullivan does not recommend vitamin supplements with the exception of vitamin B12 (cheap and effective). Dr. Sullivan’s recommendation for the elderly: eat like a teenager – frequently and enjoy some junk food.

Wednesday, April 6, 2011

Men's Health

I try to have a good assortment of magazines in the waiting room – and we regularly patrol the rack to make sure that they are current. Who wants to read the Christmas issue at the end of February? The magazines cater to all constituencies – young families, fashionistas, gear heads, travelers and design mavens. I also include the all time classic: the New Yorker, as well as an assortment of alumni magazines.

My favorite magazine, the one that I read cover to cover, is Men’s Health. The articles are a terrific combination of nutritional advice, career guidance and general interest. I can’t give an expert opinion on the career counsel, but the medical information is accurate, timely and well written.

Every month I turn right to the “Belly Off! Club” and “Eat This Not That.” The April 2011 issue has a book excerpt from The Men’s Health Diet. The discussion on visceral fat (belly fat) is lucid, precise and contains less jargon than the medical press. The weight loss advice is healthy, makes sense and is based on sound scientific principles.

Some of the magazines that we receive don’t make it to the waiting room, but are immediately recycled. The main reasons for exclusion are advertisements that don’t meet my standards. I must admit that I am not too fond of the ads in Men’s Health, but the editorial content is an effective counterweight. I still prefer magazines over websites, but is worth a look.

I applaud both the editorial and the medical advisory boards of Men’s Health – they put together a great general interest magazine.