Friday, July 20, 2012

Skin Tags

Skin tags, known in medical terms as "acrochordons" or "fibroepithelial polyps", are very common benign skin growths affecting over half of the general population at some time in their lives.  They most commonly occur in skin folds, especially in the neck region, armpits, and groin.  Other common areas for the development of skin tags include the eyelids and upper chest, particularly under  female breasts.  They are usually flesh colored and may appear similar to a small piece of hanging skin. Inspection often shows them to be "pedunculated", that is, projecting from the surrounding skin from a narrow stalk.  While usually quite small, a millimeter or two across, on occasion they can be as large as a grape.

Who gets skin tags?  The reasons that skin tags develop are not well understood.  Although they occur frequently in perfectly normal people, they are even more common in the following circumstances:
  • From chaffing and irritation from skin rubbing together or against clothing
  • Accompanying aging, with most developing in those who are middle-aged or older
  • During pregnancy, due to hormonal influences
  • In diabetics, particularly those with Type 2 (adult onset) diabetes
  • In people who are overweight or obese
Do skin tags cause any symptoms?  Skin tags are usually noticed coincidentally, since they do not cause pain or any other symptoms.  They can, however, become irritated and may even bleed from rubbing against adjacent skin, jewelry, or clothing.

How are skin tags treated?  As long as the skin tag is not growing or changing in appearance, it is acceptable to just leave it alone.  A biopsy to determine the exact cause should be considered for skin tags-like growths that are getting larger, bleed, or that are darkly pigmented.  People sometimes choose to have them removed if they are cosmetically unacceptable or if they become irritated, for example, when rubbing against the collar.  In the doctor's office, these growths may be removed by freezing (cryotherapy), electrical burning (cautery), or by cutting the lesion off at its base.

Can I remove skin tags myself?  A number of lay medical websites offer information for self-treatment of skins tags.  These treatments include tying a string around the stalk to cut off the blood supply and use of OTC solutions for removing warts.  In most cases, however, it's best for a doctor to take care of skin tags.  Since they can be located in areas of the body that would be awkward to take care of oneself, self-treatment can be difficult.  Some of the self-care methods mentioned, e.g. snipping the skin tag at its base, could lead to complications including bleeding, infection or scarring.  Additionally, there is the possibility that the skin tag is something more serious, such as skin cancer.

Will removing a skin tag cause more to grow?  There is a common belief that skin tag removal will result in the development of more skin tags.  There is no evidence, however, that removing a skin tag will cause more skin tags to grow.

Monday, July 16, 2012

Exercising in the Heat

This summer has seen record breaking heat, particularly in the northeast part of the U.S. Based on news reports, this summer may set a record for heat-related illness and deaths also.  Heat-related illnesses (e.g., heat cramps, heat exhaustion, heat syncope, or heatstroke) can develop when high temperatures overwhelm the body's natural ability to dissipate heat.  Despite the heat, many people try to maintain their exercise habits. With some modification of one's exercise practices, this can often be done safely.

There are, however, times when exercising outside is not advisable.  For example, if the temperature is above 80° F and the humidity above 80%, the body's natural cooling system is severely impaired.  Sweat evaporates very slowly, if at all, and the body heats up.  Under these conditions the best choice may be to work out in an air conditioned gym, swim, or walk in a mall.  If you must exercise outdoors in the summertime, the following suggestions will help make your experience safer and more pleasant.
  1. Slow Down.  Exercising in the heat increases body temperature, which places an additional workload on the heart.  For every degree the body's internal temperature raises, the heart rate increases by approximately 10 beats per minute.  By reducing your pace or speed, you will decrease internal heat production and moderate the increase in heart rate.  If you are accustomed to using a heart rate monitor, you should pay attention to the heart rate rather than trying to maintain a certain pace or speed.

  2. Go early or late.  Try to avoid exercising during the hottest part of the day in order to minimize thermal stress on the body.  This usually means starting early or waiting until the sun is setting.  Follow weather reports and be alert for heat warnings which could alter your plans for when or where you exercise.  Whenever possible, select walking or running routes that include shade.  Natural surface paths through a treed area are preferable to sun-exposed concrete or asphalt roads or trails.

  3. Drink, drink, drink.  On hot days, drink fluids before, during, and after exercising.  As a guide, drink around 16 oz. of water 20–30 minutes prior to exercise and 6–10 oz. every 30 minutes while exercising to help prevent dehydration.  In most cases, plain water is an acceptable fluid replacement.  For exercise sessions exceeding an hour or two, a sports drink that includes electrolytes may be a better choice.  Monitoring your weight before and after exercising is one way of determining if you are drinking enough.  A weight loss of one pound during exercise implies that you are behind in your hydration by approximately a pint.

  4. Get used to it.  To some degree, the body is able to adapt to heat stress.  Some of the changes that allow this to occur include an increase in perspiration rate, a reduction in the amount of sodium lost in sweat, and an expansion of the blood plasma volume.  Acclimatization to the heat takes approximately 2 weeks during which time workouts should become gradually more strenuous.

  5. Dress the part.  The choice of clothing when exercising in the heat has a major bearing on comfort as well as safety.  Synthetic fabrics that "wick” sweat away help with evaporative cooling and are generally the best for exercising in the heat.  Dark colors should be avoided since they absorb sunlight and heat.  A light colored, wide-brimmed hat will help keep the head cooler.  Sunglasses don't help keep us any cooler but they do provide protection against harmful ultraviolet rays.  The other thing to remember to "wear” is sunscreen.

When exercising in hot or humid conditions, heat-related illness can occur in spite of taking precautions.  Heat-related illnesses include heat cramps, heat exhaustion, and the most serious form, heat stroke.  Signs to watch out for include muscle cramps, dizziness, nausea, and rapid heart rate. Should any of these occur, stop exercising, rehydrate, and seek a cooler environment immediately.  Certain medical conditions or medications can make heat-related illness more likely to occur.

Monday, July 9, 2012

Parkinson's Disease

What do Michael J. Fox, Mohammed Ali, and more than a million people in the U.S. have in common? All have a degenerative disorder of the central nervous system known as Parkinson's disease. It is named after the English doctor James Parkinson, who in 1817 called the disease "shaking palsy", after one of the condition's most prominent symptoms. Since most people develop Parkinson's disease after the age of 60, and with life expectancy increasing, we can expect it to be more prevalent in the future.

What causes Parkinson's disease?  Parkinson's disease results from the death of brain cells that produce a substance known as dopamine.  Dopamine is a neurotransmitter, a chemical that is responsible for sending messages to other nerve cells (neurons) of the brain.  It has a role in controlling a number of functions, including voluntary movement, thinking, and mood.  The cause of this cell death is unknown, although it has been linked to genetic mutations, head trauma, and exposure to environmental toxins.

What are its symptoms?  The four primary symptoms of Parkinson's disease are:
  • Tremor, or shaking, affecting the hands, arms, legs, and face
  • Rigidity or stiffness of the limbs and trunk
  • Slowness of movement (bradykinesia)
  • Impaired balance and coordination
Initially, the symptoms of Parkinson's disease are subtle and develop gradually.  The most common early symptom of Parkinson's disease is known as a "pill rolling tremor" in which the thumb and fingers move involuntarily in a manner resembling the rolling of a pill between the fingers.  As the disease progresses, the tremor can cause problems with activities of daily living, such as use of the hands for fine motor activities.  Many people with Parkinson's will have a characteristic gait, taking small steps or "shuffling" with the feet close together.  With the loss of movement in the muscles in the face, an expressionless stare, often called the "Parkinson's mask", may be present.  Other symptoms of Parkinson's disease include impairment of speech and swallowing and depression or emotional instability.

How is Parkinson's disease diagnosed?  There are currently no blood or laboratory tests available to diagnose Parkinson's disease.  The diagnosis is made based on the medical history and physical examination.  In some instances brain scans or laboratory tests may be performed to rule out other diseases.

Is there an effective treatment?  Descriptions of Parkinson's disease treatment date back many thousands of years.  In ancient India the disorder was called Kampavata and was treated with the seeds of a plant known as velvet bean or cowitch.  This plant, with the botanical name Mucuna pruriens, was later found to contain levodopa or L-dopa, a substance that is converted into dopamine in the brain.  Today, administration of levodopa, usually in combination with a second drug known as carbidopa (trade name Sinemet), has become the standard treatment for Parkinson's disease.  Carbidopa delays the conversion of levodopa into dopamine until it reaches the brain.

In addition to levodopa/carbidopa, a variety of other drugs are approved for treating Parkinson's disease.  A class of drugs knows as monoamine oxidase B inhibitors prevent the breakdown of dopamine in the brain.  These medications include selegiline (Eldepryl) and rasagiline (Azilect).  Other drugs, such as bromocriptine and ropinirole, mimic the role of dopamine in the brain.  A common drug used to treat influenza, amantadine, also appears to reduce symptoms.

Since symptoms tend to wax and wane and all of the medications used to treat Parkinson's disease are associated with side effects, it is typical for the treating physician to have to adjust medication dosages and regimens periodically.

Is surgery an option for treating Parkinson's disease?  Deep brain stimulation (DBS) is a procedure in which surgeons implant electrodes connected to a device to deliver electrical impulses to a part of the brain affected by Parkinson's disease.  It is used primarily in individuals with severe, otherwise unmanageable motor symptoms.  DBS can reduce the involuntary movements that are a common side effect of levodopa as well as reducing tremors, slowness of movements, and gait problems.  The transplantation of dopamine-producing stem cells is also being investigated.

What is the prognosis?  While offering relief of many symptoms of Parkinson's disease, treatment of Parkinson's disease with levodopa or other medications, does not represent a cure.  The death of dopamine producing cells continues despite treatment.  The severity of Parkinson's disease symptoms is variable, with some people becoming completely disabled while others experience only mild motor symptoms.  It is impossible to predict how quickly the disease will progress but in most cases, the average life expectancy is similar to someone without the disease.

Tuesday, July 3, 2012

Heart Murmurs, Part 2: When a murmur points to a heart condition

Heart murmurs are sounds made by blood moving through the valves that control the flow of blood between the chambers of the heart or to the major blood vessels leaving the heart.  They are usually described as a "whooshing" sound, occurring at a certain point during the "lub-dub" cycle of each heartbeat.  Last week we learned about "innocent" heart murmurs, those that do not pose a risk to one’s health.  Heart murmurs can also be associated with serious conditions affecting the heart muscle, the valves that control the flow of blood between the heart’s chambers, or with the blood vessels that carry blood from the heart.

Innocent heart murmurs are typically discovered during routine physical exams.  Usually, the individual with an innocent murmur has no physical problems that would have prompted the doctor to listen for a murmur.  In the case of heart murmurs due to a structural problem or disease affecting the heart, symptoms are typically present.  For example, in newborns, a murmur along with blue-tinged skin (cyanosis) alerts the doctor to the possibility of congenital heart disease.  A heart murmur in an adult along with chest pain, palpitations, shortness of breath, or swelling of the extremities often points to the presence of a serious heart condition.  The following are some of the most common heart conditions that are associated with murmurs:

Congenital heart disease includes a number of problems with the heart's structure and function that are present at birth.  Septal defects, holes in the wall (septum) that separates the chambers of the heart, are one of the most common congenital heart conditions.   A septal defect between the upper chambers of the heart is known as an atrial septal defect and one between the lower chambers is a ventricular septal defect.  These may or may not be serious depending primarily on the size of the hole.  Other congenital heart problems associated with murmurs include patent ductus arteriosus and aortic coarctation.  In patent ductus arteriosus, a small artery that is important in fetal circulation but not needed following delivery, fails to close.  Coarctation of the aorta is a narrowing of part of the major artery leading out of the heart.  Many congenital heart murmurs resolve spontaneously without special treatment while others may require surgical repair.

Mitral valve prolapse is a heart problem in which the valve that separates the upper and lower chambers of the left side of the heart does not close properly.  Up to 10% of the population has some minor form of mitral valve prolapse, and most of these people have no symptoms related to this condition.  A small number of people with valve prolapse, however, will have symptoms that include palpitations, chest pain, difficulty breathing, and fatigue.  In a small number of cases, the prolapse can cause blood to leak backwards, a problem known as mitral regurgitation.  Over time, this can weaken and/or enlarge the heart and lead to heart failure.  In the past, people with mitral valve prolapse were given antibiotics before certain dental or surgical procedures to help prevent an infection called bacterial endocarditis (BE).  Currently, however, the American Heart Association no longer recommends routine antibiotics before dental procedures or other surgical procedures for patients with mild mitral valve prolapse.

Aortic sclerosis:  Aortic valve sclerosis involves thickening and stiffness of the valve that controls the flow of arterial blood out of the heart.  Up to 30% of elderly people, most of whom have atherosclerosis (hardening of the arteries), will have this condition.  Mild aortic sclerosis usually does not cause significant heart problems.  Severe narrowing of the aortic valve, on the other hand, is known as aortic stenosis and can be a very serious problem.  Symptoms of aortic stenosis include breathlessness with activity, fainting, palpitations, and chest pain that can mimic a heart attack.  Although rare today, in the past, rheumatic fever was a common causes the development of aortic stenosis.

Endocarditis is an infection of the inner lining of the heart that may also involve the heart valves.  It usually develops from a bacterial infection elsewhere in the body.  Bacteria entering the bloodstream at the site of the infection travel to the heart causing the infection.  If not treated, endocarditis can damage heart valves with the development of a murmur.  The presence of a new murmur, along with signs of infection (fever, chills, sweats, etc.) would alert the doctor to the possibility of endocarditis.  This condition usually occurs in people with a previous underlying heart abnormality.  People with endocarditis usually require hospitalization and treatment with antibiotics through a vein.  In severe cases, surgery to replace the involved heart valve may be needed.

It is important to understand that heart murmurs are not a disease.  In fact, most murmurs are harmless and don’t produce symptoms.  In a minority of cases, however, a murmur can point to the presence of a serious heart condition.  The outlook and treatment of an abnormal heart murmur depends on the type and severity of the underlying heart problem causing it.