Peripheral Neuropathy

    Peripheral neuropathy refers to any disease or dysfunction involving  the peripheral nervous system. The peripheral nerves are the nerves outside the brain and spinal cord. These nerves are involved in the sensory input from the extremities and in movement of the extremities. The different types of neuropathies are often classified as sensory or motor neuropathies. Another way of classifying the neuropathies is based on the number of nerves involved. Involvement of just one nerve is called a mononeuropathy while the term polyneuropathy refers to the involvement of more than one nerve.  Peripheral neuropathies affect 4-7 % of the general population but in the diabetic population this number may be as high as 30%.

Peripheral neuropathy affects both the sensory and motor fibers of the nerve. However, weakness is rarely a symptom of the neuropathy. This happens because as the muscle fibers lose their nerve connections they undergo a compensatory reinervation (reconnection) from the surrounding muscle fibers. Sensory nerve endings cannot utilize this same mechanism to stay connected to the central nervous system. This is the reason that most peripheral neuropathies initially present as burning, tingling or numbness. Weakness may become obvious only as the neuropathy markedly worsens. Most neuropathies progress slowly over months or even years. However, there is one important type of neuropathy that can rapidly progress and usually involves the motor fibers initially. This type of neuropathy is called Guillain-Barre syndrome. It often starts with weakness and numbness and rapidly progresses to paralysis and respiratory failure. If not promptly treated it can be fatal. This type of neuropathy is rare and almost always follows a respiratory or gastrointestinal viral infection. The sensory neuropathies involving the hands and feet are the most common type. They almost always present with pain often described as a tingling, burning,  buzzing or prickling sensation. Patients often describe a tightness or cold/burning sensation.

There are many causes of neuropathy.  Finding the underlying cause of the neuropathy is often much more difficult the making the diagnosis.  Toxicity from metals such as lead, arsenic and iron overdose can cause neuropathy. Organic solvents used in the chemical industry have been shown to cause some neuropathy. Exposure history and job history are often useful in finding these causes.  However, these are not extremely common causes and can be easily overlooked. Both viral and bacterial infections can cause certain types of neuropathies.   Autoimmune disease and cancers have been implicated as possible causes of peripheral neuropathy. Treatments of some conditions with medication and radiation have been associated with neuropathy. However, diabetes, alcohol abuse and hypothyroidism account for well over 50% of all peripheral neuropathies. Entrapment syndromes such as carpal tunnel syndrome and cubital tunnel syndrome are other relatively  common causes of neuropathy.

Diagnosis of peripheral neuropathy and its underlying cause is often very difficult. The medical history is the most useful diagnostic tool. Electrical testing of the nerves provides objective data that the history and the physical exam may not reveal. The electrical nerve tests give more precise information on the extent and distribution of involvement of the neuropathy. Laboratory testing may be useful in obtaining the exact etiology of the neuropathy. This is important because some of the identifiable causes are treatable.. Common laboratory tests useful in the evaluation of peripheral neuropathy are fasting blood sugar, vitamin B12 level, folic acid level , thyroid panel and complete blood count.

Treatment of peripheral neuropathy starts with treatment of the underlying medical condition if identified. Protection of the extremity from injury due to the numbness  is very important. This includes checking the extremity daily for any signs of early injury. Proper fitting foot wear and proper treatment of any pressure points or skin breakdown is extremely important. Since peripheral neuropathy often involves pain to the extremity pain management is vitally important. Several groups of medications have shown usefulness in treating neuropathic pain. However, no one group is always successful and often finding the best treatment requires some trial and error effort. In some patients combinations have been shown to be more successful than a single agent. The anticonvulsants are the most successful group for treating the neuropathic pain. This group includes Neurontin (gabapentin), Lyrica, Tegretol and Lamictal.  The antidepressants are also extremely useful in treating neuropathic pain. This group includes Elavil (amitriptyline), and Pamelor (nortriptyline). These are older types of antidepressants belonging to the tricyclic antidepressant family. This group of medications commonly cause sedation and should be cautiously in the elderly. A newer class of antidepressants called the SSRI (selective serotonin reuptake inhibitor) group is much safer but is less consistent in helping with neuropathic pain.  Cymbalta is a newer dual acting agent that has recently been shown to be very effective in treating chronic pain.  Some of the opioid pain meds such as Vicodin are  still useful for treating the pain associated with the peripheral neuropathies.  Tramadol is a safer general pain medication that has been shown to be useful in the treatment of chronic pain. Topical agents such as the Lidoderm  patch and capsaicin are useful in the controlling the pain of peripheral neuropathy.

In conclusion, peripheral neuropathy is a relative common problem associated with significant pain and dysfunction. There are multiple causes but diabetes alone causes about 1/2 of the reported causes. The history usually makes the diagnosis but  electrical  nerve studies are extremely useful in determining severity and extent of the neuropathy. Treatment is difficult, but several medications have been shown to be useful in treating the pain associated with the neuropathy.

Osteoporosis Prevention and Treatment

Osteoporosis

Osteoporosis is a disease that affects ten million Americans of which 8 million are women. One in two women and one in eight men over age 50 will get osteoporosis related fractures.
It is a decrease in the density or thickness of your bones. The bones get thinner and weaker as we get older. Unfortunately, there are no obvious warning symptoms. It is therefore known as the “silent disease”. Having weak bones means they may break after a minor injury or fall. It may happen without any injury.

Prevention

Osteoporosis is a preventable disease. The best way to prevent weakened bones is by having enough calcium and vitamin D in your diet and regular exercise.

1. Follow a diet with enough calcium and vitamin D.
a. Women need 1000 to 1500 mg/day of calcium.
b. It means at least three 8 ounces glasses of milk per day. You can also eat three ounces servings of yogurt. Other choices are dark leafy vegetables, orange juice and cereals. If you don’t have this much calcium in your diet, ask your doctor if you should take supplements.
c. A natural source of vitamin D is sunlight. In only 15 minutes each day, you can get enough sunlight to keep a healthy vitamin D level.  However, sunlight exposure does increase your risk of skin cancer.
2. Exercise
Try to do weight bearing exercises three times a week. It helps the uptake of calcium by your bones. Examples are walking, jogging, stair climbing and hiking.
3. Medications
a. Estrogen- oral estrogen can be combined with oral progestin to prevent osteoporosis. If a woman has had a hysterectomy, only estrogen is given. With the recent studies of Prempro having an increased risk of breast cancer, stroke and heart attacks, and other problems, you need to ask your doctor if estrogen is safe for you to take. You doctor might consider non-estrogen alternatives for prevention.
b. Evista (Raloxifene)- approved to be used for both prevention and treatment of postmenopausal osteoporosis. It is a “selective estrogen receptor modulator”. It can cause hot flashes or increase the risk of blood clots in some women.
Risk factors
a. Postmenopausal status
b. Premature menopause (before age 45)
c. Caucasian race or Asian ethnicity
d. Thin, small body build
e. Family history of osteoporosis
f. Certain medications, e.g., steroids
g. Use of tobacco, excessive alcohol or caffeine

Screening tests
Bone densitometry or DEXA scans can be ordered to check the thickness of your bones. It will tell you what your risk for a fracture is. Consult with your doctor to see if this test is indicated.
Treatment
Some medications can stop bone loss of calcium. They will keep your osteoporosis from getting worst.
a. Biphosphanates- there are two medications called alendronate (Fosamax) and risedronate (Actonel). They can be used for treatment and prevention of osteoporosis. Consult with your doctor to see if treatment is indicated.
b. Calcitonin (Miacalcin)- This is a hormone that is given via a nasal spray. You do one “puff” every day.
c. Teriparatide (Forteo)- is an injectable hormone that stimulates new bone. Side effects are nausea, dizziness and leg cramps. Only approved to be used for 2 years.

Information
1. National Osteoporosis Foundation offers a 22 page free booklet about osteoporosis (1-800-223-9994).
2. National Institute on Aging offers free facts sheet about menopause, osteoporosis and preventing falls (1-800-222-2225).
3. Public library and bookstores have books about osteoporosis.
4. Websites: www.ahrq.gov- Agency for Healthcare and
Research Quality
.
www.nof.org- National Osteoporosis Foundation.
www.nia.nih.gov- National Institute of Aging.

Hepatitis A

Hepatitis A

Hepatitis A is a viral infection that multiplies only in the liver cells and the lining of the gastrointestinal tract. Hepatitis A is a hardy virus that may survive for several months in sea water, fresh water, waste water and the soil. It is resistant to freezing and may be spread in ice cubes.

Infection occurs primarily from close person to person contact via hands or sexual contacts. Ingestion of contaminated food is a common source of Hepatitis A outbreaks. The potential spread by IV drug use or blood transfusion is believed to be extremely low. The incubation period is 15 to 50 days with an average of 25 to 30 days. Approximately 70% of infected adults will develop symptoms such as jaundice, nausea and vomiting. However, only about 30 % of infected children will develop symptoms. The problem is that these asymptomatic individuals will shed the virus and continue to spread the disease. Children may shed the virus in their stools for up to 6 months. This is often a major factor that perpetuates community wide outbreaks.

Due to childhood immunization practices the number of reported cases of Hepatitis A has dropped from 32,000 in 1990 to 7,700 in 2003. Childhood vaccination and vaccination of higher risk groups including close personal contacts with an infected person, bisexuals, gay males, travelers outside the USA and IV drug abusers could markedly reduce the remaining 7,700 cases in the United States.

The main signs and symptoms of Hepatitis A are abrupt onset of fever, malaise, decreased appetite, nausea, vomiting, abdominal pain and headache. Occasionally individuals manifest muscle aches, diarrhea, joint aches, cough, hives or intense itching. Physical signs include a tender swollen liver, a tender swollen spleen, tender swollen lymph nodes and jaundice. About 10 – 20% of Hepatitis A infections will develop a prolonged relapsing course that may last several months. Approximately 1% of adults with the infection will develop fulminant liver failure. The overall fatality rate is low but does approach 2% in adults over the age of 40.

There is no specific treatment for Hepatitis A. Treatment is supportive and includes rest, adequate nutrition and avoidance of agents toxic to the liver such as alcohol and Tylenol. Caregivers and close contacts should be given the Hepatitis A vaccine (a series of 2 vaccinations, given 6 or more months apart) and immune globulin if not already fully vaccinated. Administration of immune globulin is not contraindicated in pregnancy or while breast feeding.

Mark Smith, MD

Genital Warts, What You Need to Know

Genital Warts

Genital warts are usually small, skin-colored bumps that look like flat domes or small cauliflowers. They are not tender and typically do not bleed with contact. They can be on the inside or outside of the genital areas including the vagina, vulva, cervix, urethra, penis, scrotum, and anus. They are caused by a virus called Human Papillomavirus (HPV). This virus is very different from the common wart virus seen in other areas of the body. Not everyone exposed to HPV gets genital warts. Studies have shown that _ of Americans ages 15 to 49 years old have the antibody to HPV. Why a certain percent develop genital warts is unclear, but it may have to do with the individual’s immunologic response and the serotype of the HPV.

You can get the infection by having oral, vaginal, or anal sex with someone who is infected. HPV can live inside your body for weeks, months, or even years before the warts appear. This makes it impossible to know exactly when exposure to the virus occurred. Certain kinds of HPV may increase a women’s risk of getting cervical cancer. Other risks of cervical cancer are smoking, many difference sex partners, having sex at an early age, and developing another sexually transmitted disease. A Pap Smear is the best way to detect early cervical cancer or its precursor, dysplasia. It is extremely important that women with a history of HPV (treated or untreated) or who have had a sexual partner with a history of HPV (treated or untreated) keep their Pap Smear up-to-date. HPV in males may slightly increase the risk of getting cancer of the penis or anus.

Treatment of genital warts is more complicated that treating simple warts that develop on hands, arms, feet, etc. Genital warts are treated by your doctor. Do no use over-the-counter treatments for genital warts. Basically there are two ways to treat genital warts. The first is ablative (destructive) therapy with surgery; laser or freezing with liquid nitrogen. The second is chemical treatment. Some are patient-applied and some are physician-applied. The chemical methods take up to several weeks to work. The most popular patient applied treatment is condylox (podofilox). This is applied twice a day for three days then off for four days. This cycle may be repeated for up to four cycles. Please see your physician for further advise as to which treatment is best for you and your situation.

Mark Smith, M.D.

Fibromyalgia

Fibromyalgia

Fibromyalgia is a syndrome characterized by widespread pain and tenderness at specific points across the body. It occurs most commonly in the 4th and 5th decade and affects women 10 times more commonly than men. Overall about 3-4 % of the US population is affected. Associated symptoms include fatigue, stiffness, insomnia, headache, abdominal pain and poor concentration. Fibromyalgia is often associated with other chronic conditions such as  Temporomandibular Joint Syndrome (TMJ), Irritable Bowel Syndrome (IBS), Chronic Fatigue Syndrome (CFS)  and depression.

The cause of fibromyalgia is unknown but there appears to be  a problem with the central pain processing center in the brain. This problem results in the sensory signals coming to the brain being magnified. It is this magnification that turns a relatively innocuous sensation  into a painful sensation. Thus, a sensation with a 2-3 (out of 10) pain level become a 8-9 level. How this happens is unclear but does appear to involve some of the deeper sensory centers of the midbrain. The American College of Rheumatology has published a set of criteria used to make the diagnosis of fibromyalgia. The criteria are :

  1. History of widespread pain for greater than 3 months duration
  2. Pain along the spine and in all four quadrants of the body (right/left and above/below the waist)
  3. Tenderness in at least 11 out of 18 standard points throughout the body to pressure of 4 kilograms (9 pounds).

Testing for fibromyalgia with lab and radiological testing is unnecessary and not part of the diagnostic criteria used to make the diagnosis. However, these tests are often very useful in excluding other painful disorders. Appropriate testing may include:

  • Complete Blood Count (CBC)
  • Thyroid Panel (TSH and free T4)
  • Sed rate
  • Rheumatoid Tests (RA or CCP)
  • Antinuclear Antibody (ANA)
  • C-reactive Protein (CRP)
  • Creatinine Phosphokinase (CPK)

Radiological testing has a very limited use in the diagnosis or treatment of fibromyalgia.

Treatment of fibromyalgia is difficult due to the diffuse presentation of the symptoms. Also, there is no treatment for the underlying cause of fibromyalgia. Psychotherapy is useful in dealing with the emotional response people have to the pain and limitation in function.  Physical therapy and exercise programs with a graded program that slowly increases the intensity and the duration of the exercise is extremely useful. Patients should set realistic but progressive goals. A flexibility and stretching program is useful in maintaining function. A patient log to monitor progress is useful to demonstrate improvement or identify a problem.

Medications have been shown to useful in most patients with fibromyalgia.  However, the degree of pain reduction with medication alone is 35-50%.  The main groups of medication used for treatment are:

  1. Tricyclic antidepressants – Elavil and Pamelor
  2. Selective serotonin reuptake inhibitors  (SSRIs)- Zoloft, Celexa, Prozac and Lexapro
  3. Selective serotonin and norepinephrine  reuptake Inhibitors – Effexor and Cymbalta
  4. Anticonvulsants – Neurontin and Lyrica.

Many of these medications are now available generically (7 of the 10 medications listed.)

Narcotic pain medications are seldom suggested for use in fibromyalgia due to their high addiction potential. These medications may worsen cognitive function and increase depressive mood changes. However, there are certain patients for which the antidepressants and the anticonvulsants are inappropriate or simply do not work. These patients may need pain medications to maintain their activities of daily living especially as the disease progresses. Tramadol is a medication that works in  a similar fashion to the narcotics. However, it is not a true opioid narcotic and not as physically addicting as the narcotics. Tramadol appears to a slightly beneficial effect on serotonin and norepinephrine.  It is a useful medication in the treatment of fibromyalgia. The nonsteroidal anti-inflammatory medications are marginally useful in this condition but are cheap and nonaddicting.

Fibromyalgia is a common chronic pain syndrome that has the potential to incapacitate people. There is no cure for this problem and response to treatment varies from patient to patient. The best treatment appears to be multifactorial ,  often requiring psychotherapy, physical/exercise therapy, education, a supportive family, motivation by the patient’s doctor and appropriate medication.