A shot in the knee?

A lot of us develop osteoarthritis (“wear and tear arthritis” – though the process is not that simple) as we age.

If it is truly disabling, surgery may be the only way to reduce pain and increase mobility, but there are many less invasive options. Do any of them work?

Let’s get one myth out of the way first. Many people see an orthopedic surgeon and are told “your knee(s) are bone-on-bone, and nothing will work but surgery.” This is very often an exaggeration. There may be complete loss of cartilage in a portion of the knee, but rarely does this involve the whole knee. If it is on one edge, a brace may give great relief. The decision to have surgery should almost never be based on an X-ray.

The most time-tested non-surgical approach is an injection of a cortisone-type product into the knee, usually accompanied by a local anesthetic. This injection generally starts working in 2 days, and the effect may last 3-4 months. I had patients who got these shots 3-4 times a year for several years with good relief.

Like any treatment, cortisone shots do not work for everyone, and there is a worry that the drug may hasten deterioration of cartilage. The treatment is universally covered by Medicare and commercial insurance plans.

Hyaluronic acid is a lubricant that mimics the body’s natural joint fluid and injecting it into the knee is another “standard” procedure that is covered by insurance. Since most of the product leaks out of the joint within a few days, it is unclear how it works, and recent studies have suggested that it has largely a placebo effect.

Newer treatments are available that are considered experimental and typically NOT covered by insurance.

One is injection of platelet-rich plasma (PRP), drawn from your own blood, centrifuged to separate the PRP from the rest of the blood and injected into the knee. These seem to work by reducing inflammation and may provide relief for as long as a year. Be prepared to pay several thousand dollars out of pocket if you go this route.

Widely advertised is the use of stem cell injections, which can theoretically grow new cartilage. The jury is still out on this, but most studies show benefit lasting only 3-4 months. The cost, in the thousands, will almost certainly not be covered by insurance.

The newest kid on the block is radiofrequency ablation (RFA) of the pain nerves in the knee. This treatment has been shown to give pain relief for up to six months. It is minimally invasive and has few side effects, but is often not covered by insurance, at least not without prior approval from your insurance company.

Knee replacement surgery is generally, but far from always, successful. If you opt for this surgery, know that you must be committed to doing a lot of physical therapy for many months to get the best result.

Do not forget weight loss! Whether through use of the newer drugs or old-fashioned diet, significant weight loss will usually help your knees.


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Do you feel safe at home?

Domestic violence has been a plague throughout human history, but only in recent decades has it come to the forefront of medical and legal concerns.

Domestic violence or "intimate partner violence", is a pattern of behavior in any relationship that is used to gain or maintain power and control over an intimate partner. Abuse can be physical, sexual, emotional, or psychological.

While domestic violence most commonly involves a male against a female, the victim can be of any gender or age.

How common is domestic violence? Nearly 3 in 10 women (29%) and 1 in 10 men (10%) in the US have experienced rape, physical violence, and/or stalking by a partner and reported it having an impact on their functioning. In the United States, more than 10 million adults experience domestic violence annually.

Since the abuser is a spouse or companion, and often repeatedly apologizes and promises to stop, the victim is often reluctant to call the police, and the pattern continues.

If there are children, the victim may be even more reluctant to separate, and the children become emotionally (if not physically) traumatized.

Once thought of as a problem among lower socioeconomic classes, we now know that domestic violence is prevalent in every community, and can affect anyone regardless of age, socioeconomic status, sexual orientation, gender, race, religion, or nationality.

If you are the victim, or you know someone who is a victim, what can you do? First, know that it is NOT your fault. Disagreements among spouses or other domestic partners are normal and common, but never justify violence.

If you feel you are in immediate danger, call 911 and get help getting away from your abuser.

Find someone you can trust and seek their help. This may be your physician, pastor, or a close friend or relative. You almost certainly cannot solve the problem yourself.

For anonymous, confidential help, 24/7, call the National Domestic Violence Hotline at 1-800-799-7233 (SAFE) or 1-800-787-3224 (TTY). Almost every state has 24/7 hotlines and most offer immediate help with shelter and legal resources.

If you suspect a friend or relative may be a victim, you can help. Be aware of clues such as bruising, cut lip or emotional withdrawal. Listen – let them know you want to help – but do not offer concrete advice until asked. Believe them – you may find it hard to believe but know how common the problem is.

Reassure them that you believe them, that it is NOT their fault and that they do NOT “deserve” what is happening. Help the victim create a safety plan that can be put into action if violence occurs again or if they decide to leave the situation.

This should include a safe place to go in an emergency, or if they decide to leave, a way to let family or friends know what is happening and an "escape bag" with cash, important documents (birth certificates, social security cards, etc.), keys, toiletries, and a change of clothes that can be easily accessed in a crisis.

Domestic violence will probably never disappear, but you do not have to accept it.


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We are having a heat wave...

The U.S. and most of the world experienced unprecedented heat waves last summer, and this summer promises more of the same. The Northeast is set to experience it’s first official heat wave as I write. Extreme heat can cause serious health issues, including death, so prepare – prevention is much better than treatment.

The body is generally quite good at maintaining a normal internal (or “core”) temperature. We get rid of excess heat by increasing blood flow to the skin, where it can be removed by air flowing over us, and by increasing sweating, which dissipates heat as it evaporates.

In extreme heat conditions, these mechanisms may be inadequate, and our core body temperature rises. The heart feels the stress – it works much harder trying push more blood through dilated blood vessels.

The first sign of heat beyond the body’s ability to cope are cramps and “heat exhaustion:” dizziness, weakness, nausea, headache, and an unsteady gait. If the sufferer is moved to a cool environment, these symptoms will usually pass.

If the core body temperature exceeds 104 (40C), you may go on to experience “heat stroke.” This life-threatening condition begins with confusion and can go on to seizures, delirium, coma, and death if untreated.

While everyone can experience these heat-related emergencies, certain people are at higher risk: children and the elderly, those doing physical work outdoors and those taking medications that impair the body’s response to heat (such as diuretics – fluid pills - many psychiatric drugs and anticholinergics, used for some urinary and bowel problems).

How can you prevent heat-related illness? The most obvious is the most important: stay cool! Keep blinds down to lessen indoor heat; use your air conditioner, and if only 1 or 2 rooms have AC, stay in those rooms. If you do not have AC, use public places that do, such as the library or official cooling sites.

Avoid doing physical work in the heat of the day; if you MUST run or cycle, do it in the early morning. Hydrate! You are going to lose water by increased sweating, so push the water and electrolyte drinks.

If you are experiencing any of the symptoms noted above, stop physical activities and get to somewhere cool. If you do not improve, call 911. An emergency home remedy is to get in a cold tub or to put ice bags under the armpits, behind the neck and in the groin.

Check on any neighbors who may be at risk. Since an early sign of heat-related illness is confusion, they may not react properly.


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Symptoms and cancer

Most cancers eventually cause symptoms, but usually only when the cancer has been there a long time, and often when the optimal time for treatment has passed. This has led to the recommendation behind many “screening tests,” tests done in people with no symptoms.

Colonoscopy, Pap smears (often combined with HPV virus testing), mammograms and low-dose chest CT are among the recommended tests done routinely in people with no relevant symptoms.

Do symptoms have any role in cancer detection? Yes, in both directions.

Let’s start with men. Many men worry they may have prostate cancer when they begin noting urinary urgency and frequency, and feel that if they have no urinary symptoms cancer is unlikely. In fact, urinary symptoms reflect growth of the central part of the prostate, which surrounds the urinary passage out of the bladder, while most cancers begin in the outer part of the gland. So, counting on symptoms to prompt a search for prostate cancer is unwise.

Whether screening for prostate cancer saves lives remains controversial, but if you want to find it early, get tested regardless of any symptoms.

For both men and women, both kidney and bladder cancers are usually heralded by blood in the urine, though this may be small enough to only be seen when the urine is checked by a lab. Since a small amount of blood in the urine is common, and most often due to something else (infection and stones lead the list), there is tendency to overlook it. Don’t.

If your patient portal shows you that you have any amount of blood in your urine, be sure your doctor stays on top of it. At a minimum, get this rechecked. If it is still there, the next test is usually an ultrasound – both safe and harmless, so not to be feared.

Uterine cancer is becoming more common, for reasons not entirely clear. This cancer almost always announces itself early, with abnormal bleeding. If caught early, uterine cancer should be nearly 100% curable, but diagnosis is too often delayed because the bleeding is attributed to something else. Don’t accept a diagnosis of fibroids or endometriosis or hormone imbalance without at least discussing having a sampling biopsy. If you have been through menopause and then bleed, demand a biopsy.

Finally, for women, is ovarian cancer. This, like pancreatic cancer, is often found only after it has spread. It has been taught that early ovarian cancers do not cause symptoms, but a recent study found that 72% of women with early-stage cancer had one or more symptoms. The leading symptoms were abdominal and/or pelvic pain, fullness or bloating and urinary frequency. Most often these symptoms are not due to ovarian cancer, but do not ignore them. You know your body, and if these symptoms are new, persist and do not have another explanation, push your doctor to check for ovarian cancer, typically with a pelvic ultrasound. Catching it early may save your life.


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Here comes the sun - cover up!

After a cool rainy spring, at least in the northeast, summer has finally arrived, bringing promise of beach time, sailing, cycling and other outdoor activities.

As good as the sun is for the soul, it is hard on the skin. The sun’s UV (ultraviolet) rays age the skin, contribute to skin cancer and can cause painful burns. A good protective sunscreen lotion should be a key part of your outdoor gear.

There are 3 types of UV rays:

• UVA. These rays go into the skin more deeply than UVB rays. They play a major part in skin aging and wrinkling. They also contribute to the growth of skin cancer.

• UVB. These rays are the main cause of sunburn. They tend to damage the skin's outer layers. These rays also play a key role in the growth of skin cancer.

• UVC. These rays do not reach our skin. The Earth’s atmosphere absorbs them before they reach the surface.

Sunscreens are labelled with their SPF – skin protective factor – a measure of how much of the UVB rays, the rays that cause sunburn, they block. An SPF of 30 blocks some 97% of these rays. Going above 30 adds very little additional protection.

Since it is the UVA rays that most contribute to skin cancer, you should look for a product labelled “Broad spectrum,” indicating protection against both UVA and UBV.

There are two main types of lotion – chemical-based and mineral-based. Chemical sunscreens absorb UV rays while mineral sunscreens reflect them as well as absorbing them.

It has been found that the chemicals in sunscreens are absorbed and can be measured in the blood. To date, there is no evidence of harm, but this has only been studied recently. The zinc oxide and titanium dioxide in mineral sunscreens are not absorbed but can leave white residue on the skin and this may discourage use. The best sunscreen is the one you will use!

The ingredients in sunscreen degrade when hot, so leaving the bottle in a hot car or beside you on the beach is not a good idea. Keeping the sunscreen bottle in your cooler is wise.

Despite claims to the contrary, very few sunscreens are “waterproof.” Water resistant sunscreens will only work on wet skin for an hour or two and should be reapplied every 2 hours if you are sweaty and after you get out of the water if you swim.

Don’t forget to protect your ears, lips (with a sun-protective lip balm), feet and ankles and along clothing/swimsuit edges.

So…

Buy a broad-spectrum sunscreen with an SPF of 30 or higher, apply it liberally every 2 hours (sooner if you go in the water) and be sure to protect all exposed skin. Keep the bottle cool if possible. Do not forget the option of protection with a hat and light-colored clothing.




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