Sophie, in her mid-50s, came to see me because her menopausal symptoms were out of control. She had fibroids, and had heard that estrogen often caused fibroids to increase in size, so she hadn’t wanted to take hormone replacement therapy. But she was having a rough time of it without supplemental hormones, so we discussed her options. I explained that fibroids would not grow with the over-the-counter phytoestrogen ipriflavone; or the natural progesterone cream sometimes recommended to combat menopausal symptoms; or testosterone, which sometimes relieves menopausal symptoms; or Evista, the newest drug being sold to treat osteoporosis, which had many estrogen-like properties. My belief is that fibroids are unlikely to grow with estriol and estrone, either, though I haven’t seen any official studies on the matter as yet. Many of my patients with fibroids, or heavy uterine bleeding at menopause, or on Premarin, have had success by changing the type or form of estrogen they use, so I suggested that option to Sophie as well. I encouraged her to look for a way to balance her hormones that would relieve her symptoms and protect her heart and bones, as I was sure we could find one that wouldn’t make her fibroids any worse, though it might take a bit of experimenting to hit on the best one. Finally, I explained that though estradiol (the usual prescription at menopause) is likely to make fibroids grow, not all fibroids are estrogen sensitive, so you could always try it and see, dropping estradiol if you did develop unwanted side effects.

Sophie—a nurse—was most comfortable with the most mainstream option, and decided to try an estrogen patch, with an oral progestin, despite the risk of aggravating her fibroids. She also started taking calcium and vitamin D, and took up a regular program of weight-bearing exercise to protect her bones. She had no side effects from the hormones, including no bleeding (a common sign of large fibroids). I monitored her fibroids via sonogram, which confirmed they did not change in size. And the menopausal symptoms that brought her into my office in the first place also disappeared.

*136\228\2*

Another popular self-poisoning game evolves from the Judeo-Christian philosophy that we are all born in sin and can only hope and pray for redemption. There is an infinite variety of patterns to this particular game, all of which consist of the central attitude that misery, misfortune, and unhappiness are permanent when they occur and the likelihood of change for the better is at best remote. On the other hand, any state of well-being is considered a temporary interlude before the next catastrophe. When the person feels depressed, he sincerely believes his depression will last forever. If he is a salesman and business is bad, he is convinced he will never again earn a living. If he is rejected once, he is convinced that no one will ever love him. Even when he feels contentment, this kind of self-poisoner is on the alert for approaching disaster. If business is good, he hushes up any expression of this fact: why get excited when financial ruin may be just around the corner? When he is involved in an emotionally gratifying relationship, he is certain it will soon deteriorate. After all, he “knows” that the real meaning of life is tragedy, misery, and unhappiness.

The refusal to reach out for the joys and excitements of life is frequently a refusal to face the pain of possible disappointments and rejections.

*65\350\8*

The first phase (aura) of a migraine attack is vasoconstriction of the intracranial circulation. To prevent any possibility of damage to the brain due to cerebral ischemia, the attack should be aborted before this phase but, once the first symptoms appear, vasoconstriction has already started. Occasionally people may get (prodromal) feelings the day before warning of an impending attack; these are sometimes related to gastric upsets, e.g. some people feel hungry, and eating sugar may abort the attack. In the majority of cases, the aim is to stop the headache coming and to prevent nausea and vomiting.

Pain itself has an effect on the cerebral vasculature; even mild pain causes activation in the area of brain representing the painful area of the body and there is a slight increase in blood flow in that region. As pain increases, there is a more generalized increase in blood flow through the whole brain, caused by vasodilatation which in turn causes more pain. This cycle can be stopped by altering the appreciation of pain by means of analgesic (pain-killing) drugs; the feedback can also be broken by sedation using tranquillizing drugs such as Valium. Vasodilatation can be reversed using a short-acting vasoconstricting substance.

Nausea and vomiting are not only disturbing in themselves but they also upset and prevent the administration of remedies by mouth. These symptoms are partly due to chemical transmitter acting on the ‘vomiting centre’ of the brain and partly due to the stomach becoming sluggish in its action (hypotonic). This means that the contents of the stomach, including tablets, do not readily pass down into the small intestine where most foods and medicines are absorbed. The reason why tablets taken during an attack of migraine do not help may be because they do not get into the blood stream. Sufferers often say: ‘nothing helps the attacks; I just have to lie quietly in a darkened room and wait for it all to pass’.

Although the migrainous aura need not be very troublesome in itself, if it can be stopped, the full-blown attack may be prevented.

Most sufferers prefer to lie down during an acute attack. This is partly because it is difficult to function or concentrate as well during this time and also because lying down provides some relief of headache and nausea. Because light and sound are upsetting, a quiet darkened room is preferred.

*52/152/5*

Veena was lying on her bed motionless, looking towards the ceiling not even winking her eyes, totally unconcerned with what went around her in the room. She did not notice me when I entered the room, and I doubt if she was even “seeing” the ceiling towards which her look was addressed.

Her daughter who had arranged my visit slowly removed the bed cover from her leg to show me a vicious-looking boil which gave her unbearable pain when touched. I gave her 3 doses of Hepar sulf-6 to assist suppuration and opening of the boil, and a combination of Clematis (for lack of attention and interest in the surroundings) and Cherry Plum (for unbearable pain) to be taken every 3 hours till the trouble lasted. In 3 days Veena was up and doing her normal duties.

*94\308\8*

Ideally, the kneecap should lie directly under the quadriceps in the center of the knee. In some people, however, the kneecap sits slightly off to one side or the other. In women, for example, the kneecap sits off to the side toward the center of the body, making women somewhat knock-kneed. To accommodate a woman’s wider pelvis, the femur is angled toward the other leg and the tibia is angled outward. On the other hand, many men are bowlegged, in which the femur angles inward as does the tibia. In fact, between 30 and 40 percent of the population—primarily women—has some kind of an abnormal knee alignment. In some cases, a malalignment of the kneecap can pull it off track. However, a trauma such as a twisting injury can also knock the kneecap off its track. If the kneecap partially comes off its track, its called a subluxation. If the kneecap is entirely off track—for example, it sits way off to the side instead of in the center—it’s called a dislocation. Although some people may not be bothered at all by irregular alignment, others may experience discomfort. Very often, the problem can often be corrected by strengthening the surrounding leg muscles, thus improving their shock-absorbing ability. I advise patients to try a well-supervised rehabilitation program for 6 months before seeking further treatment. However, if the patient is in a great deal of pain and a good rehabilitation program has not helped, surgical correction may be considered.

*30\185\2*

In treating Type II diabetes, specialists now advise that a doctor first try a controlled diet and exercise, especially for people who are overweight. If this works, it will keep weight down, and the person’s own insulin will be able to keep things running properly, which is the best possible situation.

If diet and exercise don’t bring Type II diabetes under control, oral drugs may be tried, either alone or in combination with insulin or other drugs. (Today, 30 to 40 percent of those with Type II diabetes in the United States and as many as 50 percent worldwide use oral hypoglycemic drugs. Insulin may be necessary at the beginning of the treatment program. Eventually it may be possible to change to a program of diet alone. Oral agents are most effective for those whose diabetes began after age forty and who have had diabetes less than ten years.

The oral hypoglycemic drugs used today are chemicals called sulfonylureas. The first to be marketed for the treatment of diabetes was tolbutamide, sold under the trade name Orinase. Today, a second generation of highly effective sulfonylurea drugs is available, including Glucotrol (glipizide), and Diabeta (glyburide), which have fewer side effects. These drugs are not insulin substitutes. They work by stimulating the pancreas to increase its secretion of insulin, and by helping to prevent insulin resistance.

A bad thing about the oral antidiabetic drugs is that they falsely lull people (both doctors and patients) into believing that control of diabetes is easy, and that worrying about diet and control of blood sugar is unnecessary. But diet is even more important for those using oral agents, and it may mean the difference between successful blood glucose management and uncontrolled diabetic complications.

*36\268\2*

The basic cause for approximately 90 percent of myocardial infarctions is arteriosclerosis, or “hardening of the arteries.” This word, arteriosclerosis, is the family name describing several disease processes. You may, at times, run across the term atherosclerosis, which is the specific member of the family that is affecting your blood vessels. For our purposes, however, we can consider that arteriosclerosis and atherosclerosis are synonymous.

This disease can affect blood vessels in several ways, but the common result is the narrowing of the arteries and therefore a decrease in the amount of blood that can flow through the arteries in a given time. Arteries in many different parts of the body may be affected by atherosclerosis. If the primary area involved is in the coronary arteries (the two arteries that feed the heart), a myocardial infarction or angina pectoris may develop, the former, if actual death of heart muscle has occurred. If the process involves primarily the blood vessels supplying the brain, a stroke may be the outcome. The same disease may affect the blood vessels of the legs and result in symptoms ranging from pain in the muscles of the calf on walking to gangrene of the toes or a greater portion of the foot or leg.

An easy way to visualize the effect of this disease of blood vessels is to think of the problem that results inside water pipes that have carried hard water for many years. The inside of the pipe becomes coated with a limey substance, and the opening or bore of the pipe becomes progressively narrower. Obviously the amount of water that flows through the pipe is progressively diminished. Atherosclerosis does not cause such a uniform narrowing of the blood vessel. The process occurs in distinct patches. It may be easier to visualize this if one were to think of a garden hose that had lima beans glued to the inside of the hose at intervals. The diameter of the hose would be narrowed at each spot where a lima bean was found, but in between the beans the diameter would be normal. Such intermittent narrowing of the blood vessel does not necessarily decrease the effective blood flow because the blood flow may merely speed up as it passes each obstruction.

A person could therefore have a considerable amount of atherosclerosis in his blood vessels without producing any symptoms. As a matter of fact, persons in their fifties and sixties who are examined after death frequently are found to have significant amounts of atherosclerosis in their heart or in the blood vessels that lead to their brain or to their limbs, but they may never have had any symptoms that suggested disease in these areas. You might say that Lady Luck had a great deal to do with the determination of who would or who would not have angina pectoris or a heart attack. If the atherosclerosis in your blood vessels is not of a critical degree or if the patches do not occur in critical areas, you may get away with a great deal of blood vessel damage without ever being aware of it.

In this general area of disease, several things may happen to produce the startling event that we know as a heart attack. In about 50 percent of cases of myocardial infarction, a thrombosis has occurred which completely blocked a blood vessel. A thrombosis is a medical term for a blood clot. The blood clot frequently forms on or near one of these patches of atherosclerosis. In some cases, a patch of atherosclerosis becomes detached from the wall of the artery and is carried further down the blood vessel until it completely occludes the artery. In some instances, for unknown reasons, a small hemorrhage develops beneath the plaque and pushes it out to obstruct the lumen (passageway) of the artery. The end effect in all these instances is obstruction of the artery with an obvious deficit of blood flow to the muscle that lies beyond the area of obstruction.

*9/309/5*

Leukemia is a cancer of the blood-forming tissues that leads to proliferation of millions of immature white blood cells. These abnormal cells crowd out normal white blood cells (which fight infection), platelets (which control hemorrhaging), and red blood cells (which prevent anemia). As a result, symptoms such as fatigue, paleness, weight loss, easy bruising, repeated infections, nosebleeds, and other forms of hemorrhaging occur. In children, these symptoms can appear suddenly.

Leukemia can be acute or chronic in nature and can strike both sexes and all age groups. Chronic leukemia can develop over several months and have few symptoms. Although many people believe that leukemia is a childhood disease, leukemia struck many more adults (28,200) than children (2,600) in 2000. The 5-year survival rate for patients with leukemia is 38 percent, due partly to very poor survival for patients with some types of leukemia. Over the last 30 years, however, there has been a dramatic improvement in survival of patients with acute lymphocytic leukemia – from a five-year survival rate of 4 percent for people diagnosed in the early 1960s to 28 percent in the early 1970s to 59 percent in the mid-1990s. In children, the improvement has been from 4 percent to 81 percent.

*29/277/5*

People with BDD sometimes avoid taking a job they’d really like. Jobs that involve a lot of interaction with others, especially if the defect will be exposed, are especially avoided. I’ve seen many people who had a solitary job, such as a night watchman. As one person told me, “I can’t do any kind of job where I have to be up close to people. I don’t want people to see my facial abnormalities. I think they’re noticing how ugly I am, and I worry that they’ll think less of me because of it.”

Tony took jobs he didn’t really like because he didn’t want other people to see him. He had always longed to be a high school teacher and football coach, but he hadn’t pursued these jobs because of his chin. Instead, he’d worked at office jobs where he sat in a back room doing solitary work. “I’ve been underemployed because of my appearance problem,” he said. “I haven’t met my potential or gone after the kind of job I’ve really wanted. When opportunities for advancement came along I turned them down because they always involved being around people more. I didn’t want a job where people would see me. I would have felt too ashamed.” Another man said something similar: “I could have a much better job if it wasn’t for this problem. I haven’t been able to get promotions to positions that involve more social interaction. I’ve stuck to more technical jobs. I would have liked to advance.”

Use of camouflage can also interfere with work. One young man, who wore a hat to cover his hair, told me, “I’m a pretty smart guy, and I should have a much better job than I do. But I can’t look for a decent job with this stupid hat. I can’t dress up in a jacket and tie and wear this ridiculous thing on my head!” Another man, who thought that his nose was crooked and covered his face with long hair, didn’t look for jobs because he couldn’t remove the curtain of hair from his face.

*125\204\8*

Septic arthritis is classified as a “rheumatologic emergency” warranting hospital admission and the initiation of parenteral antibiotics to prevent permanent damage to the joint. After obtaining synovial fluid and peripheral blood for cultures, empiric antibiotics should be started. The choice of empiric antibiotic therapy is initially based on Gram stain, age, history of sexual activity, and synovial fluid culture results. Once a specific pathogen is identified, the empiric antibiotic regimen can be suitably narrowed.

For treatment of S. aureus infection, a parenteral beta-lactam, such as nafcillin (typically 2 g intravenously every 4 hours) or cefazolin (500 mg intravenously every 8 hours) is recommended. If the patient is penicillin-allergic or at risk for infection with methicillin-resistant S. aureus, vancomycin should be substituted (1 g intravenously every 12 hours). The recommended total duration of treatment for S. aureus septic arthritis is 3 weeks.

Streptococcal infections should be treated with intravenous penicillin (12 to 18 million units/day administered every 4 hours). Alternative antibiotics include vancomycin and cefazolin. The recommended treatment course for streptococcal septic arthritis is 2 weeks.

For gonococcal septic arthritis, the initial drug of choice is ceftriaxone (1 g intravenously every 24 hours). Response to treatment is typically rapid, and parenteral administration should continue until 48 hours after symptom resolution. Oral medications, including cefixime (400 mg twice daily) or ciprofloxacin (500 mg twice daily), can then be initiated to complete a total course of 7 to 10 days. Doxycycline (100 mg twice daily) should also be given to treat presumed chlamydial co-infection.

For some patients, the initial Gram stain may not be helpful in directing the course of therapy, and broad antimicrobial coverage must be initiated. Treatment for infection with gram-negative rods consists of 3 weeks of a parenteral antibiotic chosen according to culture susceptibility results. In cases in which the initial Gram stain is negative, broad coverage with ceftriaxone for gonococci, streptococci, and staphylococci can be started and altered based on culture results. Patients in whom tissue culture confirms mycobacterial or fungal infection should be referred to an infectious disease specialist for initiation of the appropriate course of therapy.

Repeated needle aspiration of the affected joint may be necessary for any fluid re-accumulation within the first week of treatment. If the patient fails to clinically respond to antimicrobial therapy and repeated aspiration, surgical drainage may be required. Infections of the hip and shoulder typically require open drainage.

*137/348/5*