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Medical Conditions

Posts about medical conditions, presentations, and/or treatments

What is an Aneurysm?

The kids took out a hose to wash our cars. We have several hoses, but the kids like the cheap nylon hose for most of the jobs around the house because it is light and easy to move around. They used the cheap nylon hose to fill up a bucket with some soap and water, got some sponges, and had a lot of fun cleaning the cars. Then they put a spray nozzle on the hose to rinse the cars off. That’s when my daughter came into the house dripping wet to give me some bad news. “Dad … there’s something wrong with the hose.” I went outside and the hose was in bad shape. “The hose has an aneurysm. Not going to last much longer.” “What’s an ann-you-rism?” My youngest daughter asked. Light bulb! What a perfect idea for a blog post! I went to get my camera. At this point, you’re probably asking yourself what a garden hose has to do with a discussion of aneurysms on a medical blog. The simple answer is that the basic principles remain the same whether we’re talking about an abdominal aortic aneurysm, a brain aneurysm, a hose aneurysm, or even a balloon. In medicine, an aneurysm occurs when there is a weakness in the walls of a blood vessel. As the weakness worsens, the walls of the blood vessel  around the weakness begin to balloon out. As the walls balloon out, they get weaker. The cycle continues until eventually the wall breaks. Think of a balloon. When you first start blowing up the balloon, it is usually a lot more difficult to get the first breath of air inside. After that, it gets easier and easier to blow more air into the balloon until you reach the limits of the tensile strength in the balloon walls and … POP. Aneurysms almost always occur under pressure, so they almost exclusively occur in arteries. Venous aneurysms can occur, but are rare. This makes sense. Go back to the balloon analogy. If you don’t blow to put pressure inside the balloon, it won’t get bigger. Now think of the hose analogy. My kids didn’t notice the swelling in the hose initially because they didn’t have the spray nozzle on the hose and the water ran freely out of the end – therefore no pressure built up inside the hose. Once the spray nozzle was in place, the water had nowhere to drain, causing pressure to build up inside the hose and making the aneurysm bulge. Think about the human body. Higher blood pressure puts more pressure on aneurysm walls. Therefore, it’s a good idea to keep your blood pressure down with aneurysms. Blood vessels have many layers. Because arteries are under higher pressure than veins, arteries have more layers of reinforcement. See the picture above which was originally posted on Wikipedia. Note how there are more layers in the artery and how the smooth muscle layers are thicker than in the veins? Just like layers of clothing in the winter help to keep in warmth, layers in blood vessel walls help to maintain the blood vessel’s strength. There are two basic types of aneurysms. Fusiform aneurysms are similar to what happens when you partially inflate a “twisty balloon”. Fusiform aneurysms involve the entire diameter of the blood vessel. Berry or saccular aneurysms involve a bulge in the side of a blood vessel or can also occur where a blood vessel divides (often in the brain). Our hose had a berry aneurysm. Now here’s the cool part of the hose analogy (click on the pictures to enlarge). Note the yellow nylon coating ...

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Diabetic Eye Problems

One of my goals in updating this blog was to create some informational posts to help patients understand common medical problems. When the National Eye Institute e-mailed me about posting an article on diabetic eye disease, I thought it was a good opportunity to do another such post. Diabetic retinopathy is the most common cause of diabetic eye problems and is a leading cause of blindness in adults. Diabetic retinopathy affects a significant proportion of patients with diabetes: 38% of diabetic patients in this study, 26-36% of diabetic patients in this study, 27-36% of diabetic patients in this study, and 28% of patients over age 40 with diabetes (about 7 million people) according to NEI estimates. If you think of the eye as a movie projector, the outside world is the movie being projected (the large red arrow in the first picture below), the lens is the camera lens (yellow in the picture), and the back or the eye (the retina) is the movie screen (grey area to which the three red arrows are pointing). Diabetic retinopathy is caused by damage to the blood vessels in the retina throughout the back of the eye – which damages the “screen” upon which our brains view the world around us. The resulting image to our brains (as shown in the second picture from the National Institute of Health) is blurry with multiple blind spots – as if someone had burned holes in the “movie screen.” Treatment of diabetic retinopathy involves first controlling one’s glucose levels. If good blood sugar control isn’t sufficient, doctors can use a laser to coagulate some of the damaged blood vessels in the back of the eye. After laser surgery, the back of the eye has many small laser burns (see the white spots on the third picture) which limits the overgrowth of blood vessels. This is a simplistic explanation of a complex problem and an eye doctor can explain it in more depth. The bottom line, and the point that the National Eye Institute wanted to make, was that regular eye exams in diabetic patients can help find and treat any diabetic vision problems at an early stage when the prognosis is better. The message from the National Eye Institute is below. Set Your Sight on Healthy Vision if You Have Diabetes If you have diabetes, your doctors most likely have told you to keep your blood sugar under control through diet, exercise, and proper medication. But did you know that you also need a dilated eye exam at least once a year? A dilated eye exam is when an eye care professional dilates, or widens, the pupil to check the retina in the back of the eye for signs of damage. All people with diabetes, type 1 and 2, are at risk for vision loss, but certain groups are at higher risk: African Americans, American Indians/Alaska Natives, and Hispanics/Latinos. The longer a person has diabetes, the greater the risk of diabetic eye disease, which includes the following: •       Cataract (Clouding of the lens of the eye) •       Diabetic Retinopathy (Damage to the retina) •       Glaucoma (Damage to the optic nerve) In November, when National Diabetes Month is observed in the United States, the National Eye Health Education Program (NEHEP) of the National Eye Institute (NEI) recommends that all people who have diabetes reduce the risk of vision loss from the disease by having a comprehensive dilated eye exam at least once a year. “Half of all people with diabetes don’t get annual dilated eye exams. People need ...

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Otitis Externa and the Ear Wick

This is the first in a series of posts to explain some common medical problems to patients in a hopefully easy-to-understand manner. Otitis Externa Otitis externa (or “swimmer’s ear”) is an inflammation of the outer portion of the ear canal. It is different from a middle ear infection (“otitis media” or the typical “ear infection” that typically afflicts children) because otitis externa affects only the ear canal (see the red area in the picture below) while otitis media is a collection of pus behind the eardrum (see the yellow area in the picture below) that does not affect the ear canal. Patients with otitis externa often have significant pain in the outer ear and may have swelling and/or drainage from their ear canal. One of the easiest ways to tell whether a patient has swimmer’s ear is the “tragal tug” — pulling outward on the cartilage of the ear (like your mother used to do when she was mad at you). Pulling on the ear will cause traction on the skin within the ear canal. When the skin inside of the ear canal is inflamed and is stretched, it will hurt. Therefore, patients with swimmer’s ear will usually have significant pain when their ears are pulled. The pain from inner ear infections usually doesn’t get much worse with the tragal tug — unless otitis externa is also present. Mild cases of otitis externa can sometimes be treated by putting Burow’s Solution into the ear canal a few times a day. When a patient is diagnosed with otitis externa, drops containing antibiotics and steroids are often prescribed. It is a good idea to check the ear drum for signs of perforation before putting medications into the ear. If some medications get into the inner ear (the yellow area above), they can cause dizziness, ringing in the ears or even hearing loss. For example, Cortisporin Otic and other aminoglycosides have the potential to damage the vestibula with prolonged use. Quinolone/steroid combinations are less likely to cause such damage. The Ear Wick If you put drops into the ear canal and then stand upright, then the drops all collect on the bottom of the ear canal. Eventually, they either get absorbed or they drain out of the ear canal. Additionally, if the ear canal is swollen shut or nearly swollen shut, the medications may not get to the affected areas in the ear. An ear wick solves both problems. An ear wick is a piece of sponge (or sometimes a piece of cotton) that is inserted into the ear canal. Topical medications are then put onto the ear wick and then capillary action pulls the medication further into the ear canal. The wick helps to keep the medications in the ear and helps to hold the medication along all surfaces of the ear canal. As the ear heals, the wick usually falls out on its own. If not, a medical professional can easily remove it.    

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C2 Cervical Spine Fracture Xray Miss

The cervical spine x-rays were initially read as normal by the radiologist. CT scan images showed that the cervical spine was not normal. In retrospect, the lateral view of the cervical spine shows that the “ring” of C2 has been disrupted and that there is some soft tissue swelling anterior to the vertebrae. The AP view shows a fracture through the base of the odontoid, classifying this as a “Type II” fracture. Recall that there are three Anderson/D’Alonzo classifications of odontiod fractures, with the numbers getting larger as the site of the fracture gets lower: Type I: Through the tip of the dens Type II: Through the base of the dens Type III: Through the body of C2 All are treated with a halo vest.

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VA Administrators Get Bonuses As Patients Die from Legionella

When VA hospital administrators ignore government guidelines on how to treat a problem that caused multiple patient deaths AND then tried to correct the problem using an ineffective treatment AND then failed to notify patients and staff about the problem until months later, what happens? They get bonuses. Welcome to the Pittsburgh Veteran’s Administration where a Legionella outbreak killed five of our nation’s veterans and no one knew why … until water fountains were sealed off and patients stopped getting baths and showers. Turns out that the VA administrators knew why. VA Administrators reportedly knew about Legionnaire’s Disease in the hospital’s water supply but didn’t disclose it. This Inspector General report showed that the VA system did not document system monitoring for proper Legionella control for “substantial periods of time” and when the VA did learn about positive Legionella cultures in its water supply, the hospital flushed the outlets with regular hot water – which does nothing to eradicate Legioinella. What happened to the administrators who knew about the disease outbreak and reportedly delayed disclosing it to the public? VA Regional Director Michael Moreland got a $63,000 performance bonus for his excellent work. When reporters went to interview hospital officials, they were met by armed federal police who told the reporters to leave. As a side note, reading the Inspector General report on Legionella was quite informative and an interesting read. For example, I didn’t know that Legionella had not been identified until 1976 – when more than 200 people at a American Legion convention became sick and 34 of them died. Legionella lives in the biofilm that lines water pipes and thrives at temperatures between 95-115 degrees. It is difficult to culture because it is easily overwhelmed by other bacteria on the culture medium and because it has specific nutrient requirements – including cysteine and iron. Legionnaire’s Disease causes about 5% of all community-acquired pneumonias, but immunocompromised patients are most at risk for bad outcomes. Legionella outbreaks occur most commonly in the summer and the fall and are frequently misdiagnosed. Air conditioning systems, humidifiers, and spas are some sources of infection. The most common source of hospital infections is contaminated drinking water. In other words, don’t use hospital water fountains. Steaming hot water flushes with copper and silver ions is the only approved way to eradicate Legionella, but flushing a system with hot water must be done with care to avoid scalding patients and to avoid diluting the hot water with cold water in the system. A World Health Organization publication on Legionella (.pdf file) shows that a temperature of 158 degrees kills Legionella almost instantly. The Wikipedia entry on Legionella links to another article alleging that bacteria, including Legionella, are being genetically modified in order to be weaponized.

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Treating Asthma on the Cheap

For people who suffer from asthma, most treatment involves an “MDI” or “metered dose inhaler.” I won’t get into all the specifics here, but many people don’t use inhalers correctly which, in turn, significantly decreases the effectiveness of the inhaler. Putting the inhaler in your mouth and actuating it causes a substantial proportion of the medicine to be sprayed either on your tongue, on the roof of your mouth, or on the back of your throat. Ideally, patients should hold the inhaler 2 inches (2-3 finger breadths) in front of their mouth, open their mouth, actuate the inhaler, and then inhale deeply – with their mouth still open. Looks dorky, but that is what gets the most medications into your lungs. Often patients have difficulty coordinating the actions. Here is a link describing proper MDI use. Enter the spacer device. The spacer is a hollow chamber that fits on the end of a metered dose inhaler. The dose of medicine is sprayed into the chamber where it forms a mist. The patient then inhales the medicine from the other end of the inhaler so the particles get deeper into the lungs. Here’s a link about use of spacer devices. Use of a spacer device can increase the amount of medication delivered to the lungs by 300%. While a spacer device can make you better, they’re expensive. You can get them from Canada for $65. In the US, they’re more like $80 to $100. If you lose them or they crack, you’re out another $100 to replace them. So a patient came to the ED and was having trouble controlling her asthma. I recommended a spacer device to help her – in addition to adding steroids to her regimen. She told me that other doctors had recommended a spacer, but that money was tight and she couldn’t afford one. So I MacGyvered a spacer device out of the water bottle she had sitting on the bed next to her. Basically, I used a pair of scissors to cut a hole in the bottom of the bottle that would just fit the end of the MDI (this is another version I made at home where the hole is a little too big). This obviously isn’t an ideal device. Some of the medication will be deposited on the ribbed sides of the bottle. It’s probably a little bigger than it should be as well. But even if it doubles the amount of medication getting into the patient’s lungs, it’s better than using nothing at all. It would be an interesting study to determine the amount of medication delivered via traditional spacer versus this jury-rigged version. If it helps keep patients breathing, it’s worth it. UPDATE JULY 18, 2009 Thanks to the research from Allergy Notes! There were a couple of published studies showing no statistical difference between the use of homemade spacers and commercial devices. See this Cochrane review Also see this study in Lancet showing “a conventional spacer and sealed 500 mL plastic bottle produced similar bronchodilation, an unsealed bottle gave intermediate improvement in lung function, and a polystyrene cup was least effective as a spacer for children with moderate to severe airways obstruction.”

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