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Saturday, February 16, 2019
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  • Monday, February 11, 2019 4:00 AM
    We continue to see quite a few kids in our office each year with concussions. Usually this is an athletic injury, but it is commonly seen in others as well. Concussions have always been a part of sports, especially those involving high-energy collisions, most notably football, soccer, hockey and basketball. Intensive research, along with lawsuits like the one the NFL Players Association brought against the NFL, is causing research to move rapidly to help us get a firmer grasp on how to prevent and manage concussions.
    A concussion is a trauma-induced alteration in mental status that usually does not involve a loss of consciousness and does not have to be a result of a blow to the head. In fact, only ten percent of concussions are associated with a loss of consciousness. 
    A concussion is the result of soft brain tissue moving violently inside the bony skull. It is important to realize that this movement can result in varying degrees of microscopic injury to the brain, the majority of which will not show up on radiology imaging studies like CT or MRI scans. 
    Concussions alter the ability of brain cells to properly use energy to communicate – the brain’s demand for energy exceeds what can be delivered, resulting in many signs (observable by others) and symptoms (what the athlete feels). The injured brain is at increased risk of additional injury, sometimes catastrophic, until this mismatch of energy supply and demand is resolved.
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  • Stem cells have promise but are in infancy
    Monday, February 4, 2019 4:00 AM
    Last week I hope I answered the first part of our reader’s question about how DNA can be used to treat inherited conditions. This week I want to focus on stem cells - what they are, where they come from, how they might be used to treat disease and finally the social and ethical challenges surrounding their use.
    Stem cells are cells that have the potential to change into other more specialized cells in the body through a process known as differentiation. By definition, stem cells have to exhibit two properties: (1) they must be able to divide multiple times and remain unchanged, and (2) they have to have “potency,” the ability to differentiate into other cell types.
    There is a hierarchy of potency in stem cells that is important in determining what they are capable of doing. Totipotent cells have the capacity to differentiate into any of our 220 cell types. Pluripotent cells can differentiate into nearly all cells, while multipotent cells can become only cells of a closely related family of cells. There are additional levels of potency that produce even fewer cell types.
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  • Kudos to Messrs. Mendel, Watson & Crick
    Monday, January 28, 2019 4:00 AM
    I received two queries from readers asking me to address how DNA and stem cells might be used to treat inherited medical conditions. That’s a tall order for the space allotted, so I’ll tackle DNA this week and stem cells next week. 
    Modern genetics started with Gregor Mendel’s work on the inheritance of various traits in pea plants in the mid 1800s. A century later, James Watson & Francis Crick (with a lot of help from Rosalind Franklin) determined the structure of DNA in 1953. There is no doubt that the expansive scientific knowledge borne from the discovery of the structure of DNA will continue to revolutionize medical science.
    DNA is an extremely elegant molecule that carries all the instructions needed to construct a living organism. The structure of DNA is described as a “double helix” which can be represented by imagining a ladder that has been doubly-twisted along its length (see diagram).
    The “rungs” of the DNA ladder are comprised of chemical units called base pairs. Each half of a rung is comprised of a base (also known as a nucleotide) that binds in the middle of the rung to the base on the other side. DNA contains four different nucleotides. The genetic code contained in the DNA molecule is determined by the sequence of the nucleotides.
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  • Monday, January 21, 2019 4:00 AM
    Last week I had a young patient ask me what the difference is between an MRI and a CAT scan. Not long after that, I noticed an error in a newspaper article that mixed up the two technologies. 
    Radiologic imaging of the human body has revolutionized our diagnostic accuracy. However, it also has the negative effect of reducing our reliance on a good medical history and physical examination. 
    There is also a real concern about patients receiving too much radiation over their lifetimes as a result of having too many CT scans (more below). This is particularly concerning in children who may receive numerous scans over their lifetimes that may increase their risk of cancer.
    We are the only country in the world where a CT and/or MRI scanner is in the neighborhood of virtually every citizen. While this is convenient, it leads to over-utilization of these very expensive and sometimes unnecessary technologies.
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  • Monday, January 7, 2019 4:00 AM
    We are definitely living in a post-truth world. It’s not just in the political sphere that we have to be careful of facts and “alternative facts.” It also extends to the scientific world as well. The public is being constantly bombarded with scientific information through the popular media and especially the Internet. How is a non-scientist supposed to filter all this information and figure out what to believe? I want to give you some tips to use when evaluating what you see or hear.
    The most important thing to look for when reading a science article is whether the author or source is credible. Does the author have the proper credentials? Is the person addressing a subject on which he or she has training and knowledge? Just because someone has an M.D., it does not mean he/she has the expertise to comment on the subject at hand – it may be completely out of his/her specialty. 
    Does the author have a degree from a well-recognized accredited institution, or are they simply a member of an organization that has little or no credibility in the scientific community? 
    There are a number of other things to watch for in scientific articles. The first that should raise a huge red flag is if, in addition to presenting information, an article is trying to sell or promote something. Honest scientists or organizations are interested in disseminating information for scientific and public discussion – not to use it to sell a product or service. Unfortunately, doctors can fall into this trap by promoting treatments or procedures that benefit them.
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  • Dr. Roberts talks shoulder pain - part 2
    Monday, December 31, 2018 4:00 AM
    Welcome back to my two-part series on shoulder pain. First, I want to do a quick review of shoulder anatomy (see diagram of a view of the right shoulder from the front). The upper arm bone (humerus) joins to the scapula at the glenoid and is held in place by two structures: (1) a rim of cartilage (glenoid labrum) that forms a shallow cup for the head of the humerus to sit in, and (2) the rotator cuff which is made up of four tendons that wrap around the head of the humerus.
    As I stated last week, in order for the shoulder to move in so many directions, it has to be inherently unstable. Since it is so unstable, two of the most common injuries are dislocations and subluxations. Dislocations result when the ball on the head of the humerus slips out of the glenoid “cup” and stays there. This typically happens when a person’s upper arm is hit from behind when the arm is raised to the side and the shoulder is cocked and ready to throw.
    A subluxation is less severe than a dislocation. The ball does not completely come out of the cup. Subluxations are usually brief events and the ball returns to its normal position spontaneously, but can feel unstable afterward. Dislocations sometimes reduce spontaneously, but often require manipulation by a doctor to get the head of the humerus back in position.
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  • Hey Doc, my shoulder hurts! What’s the story?
    Monday, December 24, 2018 4:00 AM
    The next two weeks, I’d like to address shoulder pain and injuries. Most people experience shoulder pain at some point in their life. Doctors typically see it in athletes, people who overuse their shoulders, and others who may have fallen directly on their shoulder or on an outstretched arm.
    To understand shoulder pain, it’s important to know the basic anatomy of the shoulder joint itself (see diagram of the front view of the right shoulder). The shoulder joint is one of the most complex in the body. Most joints permit only a fairly limited range of motion. The anatomy of the shoulder joint, in contrast, allows for a vast range of movements. To be so versatile, It has to be relatively unstable compared to our other joints. 
    The easiest way to describe the shoulder joint is to picture a basketball sitting on a dinner plate. The basketball represents the head of the humerus, the round top part of the upper arm bone. The plate represents the glenoid, the part of the shoulder blade (scapula) that articulates with the head of the humerus. If you picture the ball on the plate, you can understand how unstable this joint is – the ball can slide around on the plate or even roll off of it.
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  • Monday, December 17, 2018 4:00 AM
    There is no doubt that antibiotics have saved millions of lives. But, is it all good news? I hope our readers have been noting the increasing number of news stories related to problems with the overuse of antibiotics and the development of resistant bacteria. We have known this was coming since Alexander Fleming (the discoverer of penicillin) warned of it in his Nobel Prize speech in 1945, but it has now reached a tipping point. Dr. Sally Davies, the Chief Medical Officer of the United Kingdom, has equated the critical health threat of antibiotic resistance to the risk of terrorism. 
    Each year in the United States two million people are infected with antibiotic-resistant bacteria and 23,000 die. The CDC published an excellent report in 2013 on the threat that can be downloaded here: 1.usa.gov/1n5K4VF. The primary cause of resistant bacteria is the overuse of antibiotics, both in medicine and agribusiness. This is also complicated by the fact that very few new antibiotics are being developed – there’s little profit in drugs that will become quickly ineffective as bacteria become resistant.
    In addition to the development of resistant bacteria and the infections associated with them, the overuse of antibiotics is also being identified as a probable cause of a number of other medical conditions involving the immune system. This is an absolutely fascinating and rapidly expanding area of medical research and may hold the key to putting the brakes on many of the disease trends that have been on the rise in the decades since antibiotic use has become commonplace. Researchers have hypothesized that altering the bacteria that reside in the gastrointestinal tract and elsewhere in and on our bodies can lead to the development of many diseases.
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  • Monday, December 10, 2018 4:00 AM
    My patient Jim asked me to re-run my column about warts. They are very common - it’s estimated that up to 12 percent of people worldwide have had warts and that 10 to 20 percent of school-aged children have them at any given time.
    Warts are caused by a group of viruses called human papilloma viruses (HPV). When people hear HPV they often think of genital warts that are caused by particular strains of HPV virus, some of which have been associated with cervical, mouth and throat cancers. There are over 100 known types of HPV, all of which share the characteristic of being able to infect skin cells.
    Warts are spread by direct or indirect contact with another person who has them. People can also spread them from one body location to another. They commonly attack skin that is dry, cracked or has an open wound. The incubation period from infection to development of a wart is usually one to three months, but may take years.
    The appearance of warts runs the gamut from small flat lesions to large, raised ones. Larger warts are typically seen on the palms or soles of the feet. “Planter’s wart” is common misnomer for a wart on the bottom of the foot. These warts have nothing to do with gardening or farming. The proper term is “plantar wart.” Plantar is the anatomic term for the bottom surface of the foot. These warts usually appear to have a central core or seed, hence their other common name, “seed wart.” These “seeds” are actually small blood capillaries that have clotted.
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  • Monday, December 3, 2018 4:00 AM
    An adult patient asked me to write about night terrors. While night terrors can be seen in adults, they are much more common in children. It’s hypothesized that this has something to do with brain development in these children. 
    Night terrors are a subclass of sleep patterns called parasomnias (para-, meaning abnormal, and -somnia meaning sleep). Rather than focus specifically on adults, I’d also like to talk a bit about kids. People who exhibit parasomnias often have family members who suffer from them as well. Virtually all of these conditions go away with time.
    Parasomnias are a category of sleep disorders defined by abnormal and unnatural movements, behaviors, emotions, perception, and dreams. They occur while falling asleep, sleeping, between sleep stages, or arousal from sleep. They are further classified by when they occur in the sleep cycle – during REM (Rapid Eye Movement) sleep or during non-REM sleep.
    REM sleep is very light sleep characterized by rapid eye movements and muscle relaxation. This is the stage of sleep when dreaming occurs. Babies spend about 50 percent of their sleep time in REM while adults spend about 20 percent in this stage. Non-REM sleep is comprised of three or four stages, with stage 3 or 4 being the deepest sleep.
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  • Monday, November 26, 2018 4:00 AM
    My partners and I are starting to notice an uptick in patients walking in to hospitals and imaging centers to have heart and lung CT screening tests, usually after seeing them advertised by the facilities doing the testing. The results often show up in the patients’ primary care providers’ inboxes without any prior knowledge that their patients had the examination(s). The scans typically have out-of-pocket costs in the $49 to $99 range and are not covered by insurance. They are promoted to identify early heart disease and/or lung cancer. 
    Unfortunately, many of these scans are done inappropriately, and without a prior discussion of their utility and limitations. There are definite indications for the tests, but it’s also important to know the risks including false positives (seeing things on the scans that have no medical significance, yet cause a great deal of angst for patients), false negatives (not seeing something that is actually there), as well as exposure to radiation.
    The coronary artery calcium (CAC) scoring test involves doing a CT scan to see if calcium deposits are present in the walls of the coronary arteries that supply oxygen and other nutrients to the heart. It has been shown that certain amounts of calcium can indicate a person may have coronary artery disease, with an increased risk of suffering a heart attack. 
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  • Monday, November 19, 2018 4:00 AM
    The cold weather is finally arriving and it’s time to prepare for the flu. Most people us the term “flu” in a very generic sense, meaning anything from cold symptoms to having a case of vomiting and diarrhea. The “flu” in this column refers to respiratory influenza. Since 2010, the number of deaths from influenza has ranged from 12,000 to 79,000. Hospitalizations have been between 140,000 and 960,000 and total cases between 9.3 and 49 million.
    Influenza is caused by viruses with Type A and Type B causing the majority of infections. Type B typically does not cause severe disease, whereas Type A can be lethal, particularly in the young, elderly, and those who have compromised immune systems.
    Type A virus can be broken down further into different subtypes or “serotypes” based on which proteins are found on the surface of the virus. When you read about influenza virus with a name like “H3N2,” the “H” and “N” refer to the different proteins on the surface and the numbers refer to the serotype. The serotypes are also often given common names, usually from their region of origin, such as Influenza A “Hong Kong.”
    Influenza viruses are constantly changing or mutating slightly so that each flu season brings new serotypes. Scientists make an educated guess each year on what serotypes of virus might occur the following year and formulate that year’s vaccine accordingly.
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  • Monday, November 12, 2018 4:00 AM
    A patient whose mother is having hearing difficulties asked me to write about the best way to choose someone to fit hearing aids. I’d like to begin with some background on hearing.
    It goes without saying that hearing is one of our most important senses. It is critical for our quality of life as well as for safety and social interaction. There are an estimated 30 million Americans who have some degree of hearing loss, 65 percent of whom are younger than 65 years of age. It’s very concerning that one in 14 younger adults and one in 20 adolescents have measurable hearing loss. Since 1971, the number of Americans over three years old with hearing disorders has doubled.
    The primary cause of hearing loss is environmental noise. The louder the volume (measured in decibels or dB) and/or the longer the exposure, the more likely it is for damage to occur. Repeated exposure to noise over 85 dB, produced by things such as lawn mowers, truck traffic and shop tools, can lead to gradual hearing loss.
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  • Monday, November 5, 2018 4:00 AM
    Winter cold & flu season is starting to gear up. This week, I’d like to talk about a different kid of flu, “stomach flu.” I have to start by dispelling a common misconception that all flu is the same. “Stomach flu” is not caused by the same viruses as “respiratory flu.” Flu shots, given to prevent respiratory influenza, will not protect you against viruses affecting the gastrointestinal tract that cause infections known as viral gastroenteritis.
    Noroviruses are the number one cause of acute viral gastroenteritis in America, with an estimated 21 million cases per year with about 70,000 hospitalizations and 800 deaths. The name norovirus is derived from a virus that was first identified as the cause of an outbreak of illness in a school in Norwalk, Ohio in 1968. They are a very sturdy group of viruses, able to withstand freezing and temperatures as high as 140 degrees. They can survive steaming when cooking shellfish and are even resistant to the levels of chlorine found in our municipal drinking water.
    Typical symptoms of norovirus infection include the sudden onset of nausea, vomiting, diarrhea and abdominal pain/cramping. Diarrhea is particularly common in children. These symptoms can lead to dehydration, especially in the young and elderly.
    Noroviruses are commonly the responsible pathogen in outbreaks of gastrointestinal illness on cruise ships. The viruses are highly contagious and spread rapidly in close quarters such as day cares, schools, nursing homes, hospitals, restaurants and ships. The vomit and diarrhea of norovirus sufferers can contain billions of viruses. A person need only ingest 100 of these agents to become infected.
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  • Hey Doc, My Head is Spinning
    Monday, October 29, 2018 4:00 AM
    This week I want to address a specific variant of a condition that I’ve been seeing a fair amount of lately – dizziness. Primary Care doctors in the U.S. see about six million patients a year with dizziness. 
    Dizziness means different things to different people and can be a symptom of many different medical conditions. People usually describe being dizzy when they either feel faint or lightheaded or when they feel like their environment is spinning. This latter sensation is called vertigo, from the Latin vertere meaning, “to turn.” 
    I want to touch on the most common cause of vertigo, known as benign paroxysmal positional vertigo or BPPV. Benign means the condition is not dangerous, paroxysmal indicates it occurs in a recurring pattern for short periods of time, and positional refers to the vertigo being brought on by changes in position. 
    I have to open the anatomy and physiology books to explain what causes BPPV. Hopefully many of you recall from junior high science that the organ that allows us to maintain our balance is the vestibular apparatus found in the inner ear. This is a truly remarkable and complex organ. I’ve included a diagram to hopefully help you visualize what I’m describing.
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