Tag Archives: Dr. Jerry Saliman

What if Rapunzel Lost Her Hair?

by on February 3, 2016

hair loss

The other day I was reading the story of Rapunzel to my granddaughter, and I started to wonder what would have happened if Rapunzel had a hair loss disorder. The plot of the story hinges on the prince being able to climb up Rapunzel’s hair to meet her since she was locked in a castle tower with only one window and no door. “Rapunzel, Rapunzel, let down your hair so that I may climb the golden stair.”

We often take the amount of hair on our heads for granted, that is until we start losing it. One of the most common complaints I hear from patients of any age, almost as an afterthought, is “Doctor, I seem to be losing my hair.” Normal hair loss is anywhere from 50-100 hairs per day. Hair grows in cycles, and typically lasts 2-6 years. At any given time, 90% of hair is in a growth phase, growing at one-half inch a month, and 10% of the time it’s in resting phase. After 3-4 months the hair in the resting phase falls out, and new hair grows to replace it. The glitch can be when more hair falls out than grows back in. As I was reading the story, I wondered how exceptional was Rapunzel’s hair? Let’s presume that she lived in castle five stories high (50 feet), and her hair grew at the normal rate of one-half inch a month, (or one-half foot a year), and that her hair was always in a growth phase. A quick calculation indicates that in order for Rapunzel’s hair to reach the prince on the ground, she would have to be 100 years old! She clearly lived in a fairy tale.

When patients ask about unusual hair loss, I inspect the scalp. Men sustain hair loss in two places – a pattern of receding hair line, and balding at the top of the head or crown. When women lose hair, typically the frontal hairline is preserved, and there is diffuse hair thinning of the top of the head. (If a woman sustains male pattern baldness, this leads me to suspect a medical condition where there is an excess of male hormones such as in polycystic ovary syndrome.) Around two-thirds of men develop some balding during their lifetime, but women’s hair loss is common too. Over 50% of women over the age of 80 have hair loss. Hair loss in women can be particularly devastating since it can result in low self-esteem. Perhaps the one thing that helped Rapunzel’s confidence despite her lonely imprisonment was her bountiful head of hair.

The other thing I do to evaluate hair loss is the “hair pull test.” (Unlike many medical tests which are named after obscure medical scientists, this test has an easy name to remember!) I learned this test from a dermatologist colleague, and it’s performed by grasping a lock of hair and pulling gently. As mentioned earlier, normally no more than 10% of hairs are in a resting phase at a given time, so if I pull on 20 hairs on the scalp, I should not expect more than 2 hairs to be removed. For this test to be done accurately, it’s important that the patient be instructed to not wash his/her hair for at least 24 hours before the visit, and the test should be performed over various places of the scalp.

What Are Some Of The Causes Of Hair Loss?
Other than hereditary hair loss triggered by the interplay of genes and hormones, sudden hair loss has many causes. Stress from a major illness, surgery, or fever can result in hair loss 3-4 months later, but fortunately this is temporary. Overactive or underactive thyroid disease can result in hair loss, and improves with proper treatment. “Traction alopecia” can result in hair being pulled too tightly from wearing braids or ponytails. Hair can be damaged with other manipulations such as from bad brushes, blow dryers, and brushing aggressively when the hair is wet. In most of these cases, hair grows back after the offending behavior is stopped.

It is common for women to lose significant hair three months after childbirth due to changes in hormones – one would hope that Rapunzel’s obstetrician would warn her of this possibility. Imagine Rapunzel’s surprise if she awakens from sleep three months after a pregnancy and discovers a huge pile of hair on her pillow!

Lack of iron, inadequate protein in the diet, or eating disorders such as anorexia or bulimia may result in hair loss. Fad diets or ingesting large doses of Vitamin A may also cause a problem.
Most people are aware that radiation and chemotherapy can result in hair loss, but many common medications can cause hair loss as well. The long list of medicines that can result in hair loss include anti-clotting drugs, antidepressants, birth control pills, anticonvulsants, nonsteroidal anti-inflammatory drugs, cholesterol lowering drugs, and blood pressure medications. (If you don’t do so already, read the prescription information enclosure when you get medication to see about potential side effects.) The most common medication hair loss culprit that I have seen has been due to a beta-blocker called atenolol. When hair loss does occur from a medicine, it usually starts within a few weeks of taking the medicine, and hair typically grows back on its own after the medicine is stopped.

One serious cause of hair loss is alopecia areata meaning “area baldness.” Hair is lost in patches, but may proceed to complete baldness. It can be diagnosed by inspection and positive “pull test.” This is thought to be an autoimmune disorder and affects around five million people in the United States. Anyone who has this should see a dermatologist, but fortunately the condition resolves by itself in many cases.

In children, tinea capitis, or ringworm presents with a round patch of hair loss due to a fungal infection. Careful examination reveals scaling and redness around the rim of the patch, and localized enlarged lymph nodes. If the diagnosis is obscure, a skin scraping from the border of the patch can be looked at under the microscope.

Trichotillomania is a compulsive disorder involving repetitive plucking and pulling of hair in children, but may progress into adulthood. This condition results in patchy hair loss which may become permanent due to scarring.

Medical Treatment For Hair Loss
It’s virtually impossible to prevent hereditary baldness. However, there are two medicines that have been approved by the FDA to treat hair loss. Topical minoxidil (brand name Rogaine) can be purchased over the counter for use in women and men; it should be massaged into the scalp twice a day, and has to be applied indefinitely to maintain its benefits. Minoxidil helps only the crown of the head, and the new hair is like baby hair, thin and light. In one study, 20% of women reported moderate hair growth after using it for 32 weeks. Side effects may include unwanted hair growth on the adjacent skin of the face and rapid heart rate.

The other treatment is finasteride (Propecia), a prescription medicine for men only. It is a pill taken once a day, works best on men who are starting to lose hair, acts better for the crown of the head than receding hairline, and may take at least six months to see results. Side effects may include loss of sex drive and sexual function. It needs to be taken indefinitely to maintain its benefits, and there is concern how it affects the risk of developing prostate cancer.
A novel treatment for preventing hair loss in patients undergoing chemotherapy is using scalp hypothermia, or “cold caps.” The theory behind this is by cooling the scalp, blood vessels become constricted, hair follicles receive less chemo, and hair loss is prevented. The downside may be that stray cancer cells lurking in the scalp could survive so the long term safety of this technique is unknown.

A laser device called HairMax Laser Comb has been approved by the FDA for use in men, but published research on the effectiveness is lacking. Don’t waste your money since it’s too early to tell if it actually helps.

Common Sense Things To Do For Your Hair
Choose a gentle shampoo. “Revitalizing” shampoos which promise to restore hair do not regrow hair. If you use a hair dryer, use the low setting. Use a comb rather than a brush, particularly if your hair is thinning. If you do use a brush, do so when hair is dry. Avoid any brush or comb that pulls your hair, and preferably find one that has rounded edges or natural bristles. Avoid bleaching, straightening, excessive sun exposure, or anything else that can damage your hair. Consult with a hair stylist to camouflage or hide thinning hair. Perms and hair coloring are thought to be safe as long as no bleach is used. Hair transplantation surgery is an option for both men and women after thorough pre-operative assessment and discussion of realistic expectations.

Summary
It is extremely unlikely that any of us will ever have hair like Rapunzel. However, with better understanding of some of the conditions which can result in hair loss, and knowledge of how to care for our hair properly, it’s possible to enjoy the way we look for many years.

Jerry Saliman, MD is a volunteer internist at Samaritan House Medical Clinic in San Mateo. He retired from Kaiser South San Francisco after working there more than 30 years. While at Kaiser SSF, Dr. Saliman was also Chief of Patient Education. He received the 2012 “Lifetime Achievement Award” given by the Kaiser SSF Medical Staff.

Editing acknowledgement: Ellen Saliman

Neither the PJCC or our guest columnists provide medical advice, diagnosis, or treatment. Please make your health care decisions in partnership with your health care provider.

 

 

 

Singing For Your Health

by on January 5, 2016

singing for health

Many people sing in the shower, others sing in choirs or at their place of worship, and some do karaoke. Other than the joy singing brings us, does singing provide any health benefits? I consulted with Billie Bandermann, the choir director of Hashirim, a Jewish community choir, to get some answers.

In addition to conducting, Billie has been teaching voice for more than four decades, including instructing octogenarian singers. According to Billie, proper breathing is a requirement for good singing. Specifically, “Inhale deep and wide to fill the lungs from the bottom upwards while Continue reading

Prayer Rx

by on October 8, 2015

prayer rx

I had recently returned from a medical conference, and the first patient I faced at 8:30 AM on a Monday morning was a woman who the physician in chief of the medical center wanted me to see because she was a problematic patient. She had been visiting the Emergency Department monthly for vague neurological complaints for more than half a year. Despite many negative brain scans and other tests, she was convinced she had multiple sclerosis, and she insisted on treatment with high dose intravenous steroids. When steroid treatment was denied her, she Continue reading

CPR: Are You Prepared to Help?

by on September 17, 2015

cpr

May 16, 2003, 7:50 AM. 
My wife and I enter the quad at a Midwestern university.  There are orderly rows of white chairs on the lawn, and on each one is a bottle of water labeled with the university logo, and a program for the commencement ceremony.  Scores of people are hurrying to the seats, streaming in from all sides of the quad with the graduates penned off to the side.  I am looking forward to witnessing the first of my three daughters graduate from college, and to hearing the commencement speaker, Madeleine Albright.  Suddenly my wife notices people gathered around a woman on the ground.  My wife encourages me to see if I can be of assistance. I identify myself as an internist to the woman and she responds with halting, labored breathing that she is having chest pain.  I grab her wrist and realize her skin is cold and clammy, and find her pulse weak and fairly rapid.  It was immediately apparent that she is having a heart attack, and her condition is critical.  I ask the bystanders and the security guard if paramedics had been summoned, and they assure me this was the case. Another physician is at the scene too, a pediatric endocrinologist, and she informs me that she too had requested paramedics.

7:55 AM. 
The woman’s pulse becomes weaker, her breathing shallow, and she loses consciousness. Her acute heart attack has led to cardiac arrest.  I start CPR.

According to a recent New England of Journal Medicine study of June, 2015, there are 420,000 cases of out of hospital cardiac arrests each year in the U.S, which corresponds to 38 people experiencing one every hour. Odds are that you know a friend or family member who has had one.  Survival chances decrease about 10% for every minute following a cardiac arrest, but less than half of persons with a cardiac arrest receive bystander CPR. When CPR is performed before paramedic arrival the thirty day survival improves from 4% to 10.5%.

Many people assume that cardiac arrests take place outside the home where there will be a willing bystander to initiate CPR.  Surprisingly, 88% of cardiac arrests occur in the home, so if you are called upon to initiate CPR at home, the life you save could be a spouse, parent, child or friend.  Since 2008, the American Heart Association has offered hands-only CPR for adult cardiac arrest as an alternative to chest compressions plus breaths because the outcomes are similar.  Although, a CPR course is advised, the instructions are simple: call 9-1-1, and push hard and fast in the center of the chest to the tune of “Stayin Alive.”  Here is the link: http://www.heart.org/HEARTORG/CPRAndECC/HandsOnlyCPR/Hands-Only-CPR_UCM_440559_SubHomePage.jsp

The San Francisco Unified School District has a reason to be proud. Starting this school year, SF is the largest school district in the country to add hands-only CPR to its ninth grade health curriculum.  Improvement in rates of bystander initiated CPR is a critical public health issue and it is encouraging to see this initiative.

8:00 AM. 
Paramedics have not arrived yet.  I continue chest compressions, and the pediatric endocrinologist administers mouth to mouth breaths.  Oxygen and an AED, or automated external defibrillator, are unavailable.

8:15 AM.
Paramedics finally arrive!  They had trouble navigating through narrow crowded roads into a congested space.  Initial evaluation by them reveals the woman has a heart rate but absent blood pressure.

When I returned home, I wrote the chancellor of the university expressing my dismay over the lack of emergency medical support for this large gathering of people.   Four years later, when we returned for my youngest daughter’s graduation from the same university, it was gratifying to see a paramedic vehicle right on site.

Sadly, as I learned later, the woman who we tried to resuscitate died at a nearby hospital.  She was the grandmother of a graduating classmate of my daughter.  If resuscitation had been successful, the grandmother could have been expected to continue to live a normal life. Although bystander CPR improves the odds of survival by more than 2.5 times, probably too much time elapsed before advanced paramedic resuscitation was begun.  One never knows when you may need to perform CPR so I “heartily” encourage you to take a CPR course near you: http://www.heart.org/HEARTORG/CPRAndECC/FindaCourse/Find-a-Course_UCM_303220_SubHomePage.jsp

Jerry Saliman, MD is a volunteer internist at Samaritan House Medical Clinic in San Mateo.  He retired from Kaiser South San Francisco after working there more than 30 years.  While at Kaiser SSF, Dr. Saliman was also Chief of Patient Education.  He received the 2012 “Lifetime Achievement Award” given by the Kaiser SSF Medical Staff. 

Editing acknowledgement: Ellen Saliman

Neither the PJCC or our guest columnists provide medical advice, diagnosis, or treatment. Please make your health care decisions in partnership with your health care provider.

 

 

Airplane Emergency

by on August 6, 2015

airplane emergency sick

“Is there a doctor on the plane; is there a doctor on the plane?!” The urgent sounding voice rang over the loudspeakers on the jet about thirty minutes into our flight from Frankfurt, Germany to San Francisco. My wife nudged me just as I was trying to arrange my body for sleep in preparation for the fourteen hour voyage. I pressed the call button unsure what emergency I was volunteering for. The next thing I knew I was face to face with the flight attendant who had recently served me orange juice. She explained to me that she was the one who needed medical attention, and she escorted me toward the tail section of the plane where we ascended into a private sick-bay alcove. She proceeded to tell me her story. A year prior to this, she had been hospitalized for a week with a kidney infection, and she was experiencing similar symptoms once again. She had back pain and urinary symptoms, and was desperate for help. I suspected that for her to have been hospitalized for so long previously, the kidney infection must have been complicated by septicemia (bacteria in the bloodstream). When she came to work this day, she had mild urinary symptoms which she thought she could ignore, but now she had a full blown problem. She handed me the emergency medical briefcase that airlines carry onboard, but all it contained were cardiac medicines and injectable opiate analgesics. No antibiotics. What was I going to do to help her? Soon we would be crossing the ocean and there would be no option for emergency landing.

In a New England Journal of Medicine study published on May 30, 2013, it was estimated that there is one in-flight medical emergency for every 604 commercial airplane flights, and overall, there are approximately 44,000 medical emergencies each year world-wide. Serious illness is infrequent, and death rare (3 per 1000 cases). The most common illness causes in order of frequency are fainting and near fainting, respiratory symptoms, nausea or vomiting, cardiac symptoms, seizures, abdominal pain, and infection (such as in my patient). Other in-flight emergencies include agitation or psychiatric symptoms, allergic reactions (better not bring peanuts onboard), stroke, trauma, diabetic complications, headache, arm or leg injuries, Ob-Gyn symptoms, ear pain, cardiac arrest, and lacerations.

You can never be certain that a physician or other medical professional will be on your flight if a medical situation arises. If you feel moderately sick before you start a long airplane trip, chances are that you will feel even worse during the journey so it would be wise to cancel and request a written note from your doctor. If you take medicines, bring them in your carry-on, not in your packed luggage. If you have a past history of a serious infection which required hospitalization, bring antibiotics with you. My flight attendant patient was totally unprepared.

For cardiac emergencies, the airplane I was on was well equipped. There was an automated external defibrillator (AED), oxygen, epinephrine, and a variety of other cardiac medicines. I was dismayed that there were no medicines for infections. In order to help my patient I needed a strong antibiotic that I hoped a well-organized passenger had brought along. I asked nearby passengers for Cipro 500 mg, and fortunately someone volunteered the medicine. All we needed were two doses. Meanwhile, my patient’s kidney infection was causing her significant pain, so I also asked if there was a nurse on board to administer an injectable narcotic. Luckily a kind Kaiser dialysis nurse offered his expertise.

The pilot of the plane spoke to me. We would be flying over Reykjavik, Iceland soon, and this would be our last opportunity for an emergency landing. The pilot put me in touch with a United Airlines land physician in Chicago. I explained to him that everything was under control now that a passenger had donated Cipro. Normally, when one presents to the ER with a serious kidney infection, IV Cipro is administered because it is a faster way to get the medicine into the body. Whether Cipro is given IV or orally, it should have equal efficacy which I discussed with the airline’s physician. I did not think diverting the plane for emergency landing was indicated, and the airline’s physician concurred. During the reminder of the flight I checked my patient every two hours to make sure her vital signs were stable and that she was comfortable. With the help of the narcotic, she slept most of the way to San Francisco. –at least one of us got some rest. – I always feel elated when airplane wheels touch land, and this time I breathed an extra sigh of relief.

I didn’t ask United Airlines for any compensation for volunteering my medical care, but they sent me a $200 voucher anyway. Two weeks later I received a wonderful thank you letter from my patient. It was reaffirming to know that she had completely recovered.

Jerry Saliman, MD is a volunteer internist at Samaritan House Medical Clinic in San Mateo. He retired from Kaiser South San Francisco after working there more than 30 years. While at Kaiser SSF, Dr. Saliman was also Chief of Patient Education. He received the 2012 “Lifetime Achievement Award” given by the Kaiser SSF Medical Staff.

Editing acknowledgement: Ellen Saliman

Neither the PJCC or our guest columnists provide medical advice, diagnosis, or treatment. Please make your health care decisions in partnership with your health care provider

 

 

 

Back Pain – the Bane of Being Human

by on July 7, 2015

back pain pjcc

Back pain can be devastating. Just ask my wife. Prior to our upcoming wedding my wife decided she wanted to get in shape. She joined a gym and, in her zeal, she repeated the weight routine three days in a row. The next day she suffered severe lower back pain which subsequently has besieged her for the past 38 years. (I know this because we just celebrated our 38th anniversary.) Guess who has been destined to be the luggage shlepper and primary grocery shopper in our marriage?

My wife has not been alone in experiencing low back pain. 80% of adults suffer low back pain sometime during their lifetime. In younger people, pain is mostly due to mechanical factors – the interplay of spine, muscles, ligaments, discs, and nerves in the way of they fit together. Low back pain can be triggered by repeated straining such as at a gym, or by a fall or accident, or by a sudden action involving lifting a heavy weight or twisting abruptly. Oddly, a herniated disc can happen spontaneously without a specific injury. In older adults, the most common cause of low back pain is spinal stenosis which means narrowing of the spaces of the spine. With aging, some people develop spurs in their vertebrae, and ligaments around the spine may thicken which together may cause narrowing (stenosis) where the nerves exit the spine. This typically results in pain while standing and walking, and relief by sitting.

Red Flags
While most causes of back pain are not life threatening, there are some warning symptoms that indicate immediate attention is required. These “red flags” include history of trauma, fever, incontinence, history of cancer, unexplained weight loss, long term steroid use, and intense localized pain with inability to find a comfortable position. Coincidently, the reason there why there was a position available when I was hired at Kaiser was because my predecessor had died of back pain due to an epidural abscess, an infection near the spinal cord. While I don’t know the details of his illness, he likely had fever with his back pain, and unfortunately did not appreciate the implication. Life threatening cases of back pain with fever I have treated include pyelonephritis (kidney infection) and endocarditis (heart infection.) Back pain with fever can be a lethal combination.

The inability to find a position of comfort typifies a patient who present with an abdominal aortic aneurysm. For this reason alone, I routinely examine any older patient with back pain for the presence of a pulsating mass in the abdomen. During the course of my career, I have detected two patients with aortic aneurysms. They both were ex-smokers and were overtly grateful since delayed diagnosis is almost always fatal.

A patient with a history of cancer always raises a red flag to me even if the cancer occurred decades prior. The most common types of cancer that spread to bone are breast, prostate, lung, kidney and thyroid. While most doctors have been well educated about not doing unnecessary imaging studies, a patient who has a past history of cancer especially with any history of recent weight loss deserves x-ray evaluation.

When back pain is not spine pain
During the fifteen years I spent working part time in spine clinic at Kaiser, I was amazed the number of times a patient was referred for back pain actually had something other than a spine condition. Two of the most common conditions that can be confused with a spinal disorder especially in older adults include osteoarthritis of the hip and peripheral artery disease (PAD). Hip osteoarthritis can usually be distinguished by performing a hip examination during the visit and by getting hip x-rays. A person with good range of motion of hips does not likely have significant hip arthritis. PAD can usually be determined by checking all the pulses in the legs and feet. The other feature differentiating PAD from spinal stenosis is that patients with PAD do not have pain while standing, while spinal stenosis patients generally do. Sometimes, though, a patient might have more than one condition causing back and/or leg pain in which case more sensitive testing is indicated to evaluate circulation competency and neurological function.

Other causes of low back pain outside the spine include kidney stones, acute pancreatitis, herpes zoster (shingles), endometriosis, and fibromyalgia.

What is the scoop about MRI’s?
A common question from many people with back pain is whether they should get an MRI to pinpoint the cause of their problem. The problem is that most people even without back pain will have an abnormality on an MRI exam. Falsely alarming MRI results in patients who have back pain explain why back surgery in the U.S. is more than twice as high as in other countries. Yes, surgery corrects the problem seen on the MRI but this may be unrelated to the cause of the pain.

Treatment
Treatment of low back pain can vary depending if it is acute or chronic (more than 3 months). There are no hard and fast rules, but generally ice packs are advised for pain within 2-3 days of injury. Heat can help ease subacute or chronic pain. Bed rest after acute injury tends to delay recovery, and it is important to resume normal activity as soon as possible. Physical therapy can help strengthen core muscles that support the spine, but an interesting study from UCLA a few years ago showed that walking three hours a week was more effective than three hours of physical therapy a week. Epidural steroid injections can be given for low back pain associated with sciatica, but a recent NIH study showed that in patients with spinal stenosis who received epidural injections had worse long term outcomes than those who did not receive them. Surgery may be considered in serious injury situations or if there is progressive neurological deterioration. While there appears to be short term benefit in patients who have undergone surgery, long term benefits going out four years and ten years appear to show no clear advantage compared to those who have not had surgery. Although I am not fond of many of the medications advertised for low back pain, sometimes they serve a purpose in helping someone to become more active and exercise once again.

Prevention
Regular exercise is the best way to keep one’s back healthy. My wife has found walking at least 60 minutes a day helps to lessen recurrences of low back pain. She also stretches regularly, and does not wear high heeled shoes. When she is sitting in the car or a chair, she uses a lumbar support called a Sacro-Ease or an inflatable travel pillow. She avoids any significant lifting, but if she does lift something she lifts with bent knees, carries the object close to her, and does not twist. For me, running, biking, and doing yoga at the PJCC keeps my back in shape, but everyone has to find a regimen that works best for them.

Conclusion
While back pain can be disabling, it can also be managed with regular activity and awareness to prevent further damage. Three months ago my wife injured her back again when she missed a step getting out of an elevator while holding one of our granddaughters who impeded her vision. To avoid trauma to our granddaughter, she sacrificed herself by intentionally twisting her spine as she fell. I am happy to say that granddaughter and “Nana” are back in each other’s arms once again.

For further information about low back pain, visit the NIH site.

Jerry Saliman, MD is a volunteer internist at Samaritan House Medical Clinic in San Mateo. He retired from Kaiser South San Francisco after working there more than 30 years. While at Kaiser SSF, Dr. Saliman was also Chief of Patient Education. He received the 2012 “Lifetime Achievement Award” given by the Kaiser SSF Medical Staff.

Editing acknowledgement: Ellen Saliman

Neither the PJCC or our guest columnists provide medical advice, diagnosis, or treatment. Please make your health care decisions in partnership with your health care provider

 

 

Music As Therapy

by on June 9, 2015

music-therapy-625

My Patient
Irene (not her real name) was my patient for many years, and during a routine visit she showed me a lump on her abdomen which turned out to be metastatic pancreatic cancer. I went to visit her one afternoon in hopes of offering her some comfort. The day I visited her was sunny and cloudless, but when I entered the mobile home, I was ushered in by her daughter into a low-lit room with all the shades drawn. Irene was lying in bed surrounded by Continue reading

Beware Of Ants In Your Toilet!

by on May 5, 2015

daibetes-ants-625

A patient left a message for me which caught my attention. He wanted a blood sugar test for diabetes because there were ants in his toilet. When I spoke to him, he denied having some of the more typical signs of diabetes. His only concern was that there were ants in his toilet. I decided to order the test.

According to the CDC, 29 million people in the U.S. have diabetes, and at least one-quarter of them don’t know it. An additional 86 million people (1 in 3 adults) have pre-diabetes. Without change in lifestyle, 15-30% of pre-diabetics will develop type 2 diabetes in five years.

Diabetes Basics
There are three main types of diabetes. Type 1 diabetes is when your body does not produce enough insulin. Type 2 diabetes is the most common type (90-95% of diabetics), and this is when your body does not use insulin properly. Gestational diabetes occurs in 4% of pregnancies, and these women are at increased risk of developing type 2 diabetes after pregnancy.

Symptoms
The typical symptoms of diabetes include feeling thirsty, frequent urination, fatigue, blurry vision, cuts or bruises that heal slowly, and tingling or numbness in the hands and feet. Many people with diabetes have no symptoms or mild ones that go unnoticed. The American Diabetes Association (ADA) does not list ants in the toilet as a warning sign.

Complications of Diabetes
The biggest risks of having diabetes are strokes and heart attacks, which with proper medication can be prevented. Uncontrolled diabetes leads to damage of many organs in the body, particularly the eyes, nerves, and kidneys. Last year I saw a young man for a check-up because his dentist noticed a severe gum problem which was going to require extraction of most of his teeth. I ordered a blood test which revealed he had diabetes. He had not realized that diabetes was the root cause of his dental woes.

Diabetes is associated with an increased risk of certain cancers, specifically cancer of liver, pancreas, endometrium, colon, breast, and bladder. The explanation for this is unclear. It could be due to shared risk factors such as obesity, diet, and inactivity, or because of something intrinsic about diabetes such as elevated insulin or blood sugar levels.

Diabetes and pre-diabetes are risk factors for Alzheimer’s dementia and other types of dementia.

The Numbers
The normal fasting glucose is less than 100 mg/dL. Pre-diabetes is defined by fasting sugar between 100-125 mg/dL. Diabetes is defined by fasting sugars of 126 mg/dL measured on two different days. Another way of diagnosing diabetes is the A1C test which measures the average glucose in your body over the past 2-3 months. A1C of 6.5% or higher indicates diabetes. Normal A1C is usually less than 5.7%, and 5.7 – 6.4 is considered pre-diabetes depending on the lab reference range.

Treatment
The mainstays of most type 2 diabetics are diet and exercise, but because it is so hard to change one’s habits, pharmaceutical companies are reaping enormous profits from a multitude of diabetic drugs. There are medicines which work on the pancreas, liver, gut hormones, and kidneys to lower sugar, and there is even inhaled insulin now. It takes more effort for people to make personal changes, but an Asian diabetic patient of mine was especially determined to rid herself of diabetes. Her blood sugar was so high when she was diagnosed that she needed to take insulin at least twice a day to keep her diabetes controlled. She decided to give up her routine of eating rice at every meal, the main staple of her diet. She went from minimal exercise to exercising three hours a day. When I saw her back in clinic two months later, she had been successfully able to discontinue her insulin entirely. (Warning: don’t attempt to stop your diabetic meds on your own without doctor’s supervision.) Most people cannot make these dramatic life style changes, but she serves as an example of what healthy lifestyle change can achieve.

Screening for Diabetes
The ADA recommends adults get screened for diabetes every three years. You should get tested more often if you are overweight and have other risks such as family history of diabetes, sedentary lifestyle, history of gestational diabetes, polycystic ovary syndrome, or a racial background of African-American, Hispanic-American, Native-American, Asian-American, or Pacific Islander ancestry.

Conclusion
My patient who I mentioned in the beginning did not have any particular risk factor for diabetes, but I tested him anyway because normally there should not be any urinary sugar in the toilet to attract ants. The bad news was that his blood test did reveal he had diabetes. The good news was that he did not have to hire an exterminator since once his diabetes was controlled the ants had to find a different location to host their picnic. Hopefully early detection will prevent him from having any future complications or further ant invasions.

For further information about diabetes, visit the American Diabetes Association.

Jerry Saliman, MD is a volunteer internist at Samaritan House Medical Clinic in San Mateo. He retired from Kaiser South San Francisco after working there more than 30 years. While at Kaiser SSF, Dr. Saliman was also Chief of Patient Education. He received the 2012 “Lifetime Achievement Award” given by the Kaiser SSF Medical Staff.

Editing acknowledgement: Ellen Saliman

Neither the PJCC or our guest columnists provide medical advice, diagnosis, or treatment. Please make your health care decisions in partnership with your health care provider.

Improving Your Memory

by on March 23, 2015

memory

“Memory is the mother of all wisdom.”
― AESCHYLUS

With advancing age, many adults worry not only about their health, but also about their memory. First, let us examine why we value our memory, and then look at some of the latest research in how to improve memory.

With the externalization of memory by cell phones, computers, digital photographs, books, and pencil and paper, one can wonder why we need our brains to remember anything at all. However, thousands of years ago the major way we passed along information was orally, which required focused attention and memory. Dating back 2500 years, the Iliad and the sequel, the Odyssey, were transmitted orally by the rhythm of the words. It is said that the Torah, or Five Continue reading

Optimism & Your Health

by on February 5, 2015

Optimism-women

During medical training at UCLA, I had the good fortune to learn from Norman Cousins, a Jewish writer, editor, and adjunct professor of medical humanities. Despite being misdiagnosed with tuberculosis at age 11, he set out as a boy to “discover exuberance.” He believed that positive emotions were the key to fighting illness, which he exemplified in the telling of his own battle with a severe form of arthritis. In the book Anatomy of An Illness, he describes his victory over a potentially life-threatening condition by taking mega doses of vitamin C, and watching Marx Brothers movies and TV sitcoms. He relates, “Laughter is a form of internal jogging. It moves your internal organs around. It enhances respiration. It is an ignitor of great expectations.” His Continue reading

Norovirus – The Winter Bug

by on January 16, 2015

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Thanksgiving weekend 2014 was a time to forget for our family. My wife and I planned for the arrival of our children, their spouses, and four grandchildren for months. One of my granddaughters would Facetime daily to see what toys she would play with when she would eventually visit. The night before Thanksgiving, one son-in-law became acutely ill with a GI bug, and he wasn’t able to go to Thanksgiving dinner. The day after Thanksgiving, two of my daughters became acutely ill. By Thanksgiving weekend, the illness had ravaged through our entire family except for my wife and one granddaughter who was protected through the magic Continue reading

Depression — The Lowdown

by on December 2, 2014

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News of Robin Williams’ suicide was a shock. How could a man devoted to making others laugh take his own life? His death brought the disorder of clinical depression to the forefront.

Depression is a common mental illness that is manifested by prolonged sense of sadness, and other symptoms such as loss of desire to do pleasurable activities, irritability, insomnia or oversleeping, change in appetite, loss of energy, fatigue, difficulty concentrating, and sometimes thoughts of death or suicide. Depression affects 1 in 11 adults, and nearly twice as many women as men. Sadness and depression are different. Many people feel sad after losing a loved one, or losing a job, or ending a relationship. People who are depressed, however, can usually differentiate normal grief from the disabling continued weight of clinical depression. Although there is excellent treatment for depression, many people do not seek help because they mistakenly construe it as a personal weakness rather than a legitimate illness. Many celebrities have publically acknowledged their own battles with depression in hopes that others Continue reading

In Search Of Sleep

by on November 4, 2014

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But I have promises to keep, and miles to go before I sleep, and miles to go before I sleep.”  Robert Frost

A relative of mine, Stewart, (not his real name) was driving home from LA, and fell asleep at the wheel. Stewart was 18 years old at the time, and on winter break from college. He drove to LA in the morning, and then, after spending the day there, drove home that night. Although he knew he was drowsy, he made the decision to drive home. The last thing he remembered was listening to a 49er Monday night football game before he dozed off without warning. His new 1996 Toyota Corolla was totaled when the car crashed into a barrier on the side of the highway Continue reading

Hepatitis C – A Stealth Killer

by on October 14, 2014

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I recall my Great Uncle Sidney.  He loved to devour a delicious steak for dinner.   Eventually he had to undergo coronary bypass surgery for cholesterol-clogged arteries of his heart.   Within a decade he died!  His heart did not kill him.  He died of cirrhosis of the liver because of a blood transfusion contaminated with hepatitis C virus which he received during his bypass surgery.

Hepatitis C (HCV) is one of those conditions one hardly hears about because most people who have it don’t know they do.  Of the 3.2 million Americans who have hepatitis C, only 5-6% of them have been successfully treated.   It is 3 times more common than HIV in this country, and it is the leading cause of liver transplantation and liver cancer.  The mortality from HCV has Continue reading

The Meaning of Life – As Seen through The Eyes Of My Patients

by on September 3, 2014

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As we approach the High Holidays of Rosh Hashanah and Yom Kippur this month, I find myself becoming more reflective, particularly about what’s important in my life. Twenty years ago I was asked to complete a biographical survey for a physician newsletter about my personal interests, which included questions such as the latest book I read, my favorite movie, etc. There was one question that stood out, “What is the meaning of life?” My response, “God knows.” It occurred to me a few years later that I could delve into a better understanding of this existential question by probing my patients for their stories about what has been meaningful in their lives. You may wonder how during a 15-20 minute visit with patients I could have time for such a discussion. One cannot come out and say, “Tell me the meaning of your life,” but I felt I could approach the Continue reading

High Blood Pressure – The Hidden Killer

by on August 5, 2014

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On April 12, 1945, President Franklin D. Roosevelt was sitting in his living room having his portrait painted by artist Elizabeth Shoumatoff, who later became most renowned for “Unfinished Portrait” of FDR. Also present was Lucy Mercer, Eleanor’s social secretary, but most notorious because of her affair with the president. His dog, Fala, and two cousins were in the room as well according to biographer Doris Kearns Goodwin. At 1:00 pm, FDR complained of “traffic pain at the back of my head,” and collapsed, unconscious. His cardiologist quickly arrived and recognized the signs of a cerebral hemorrhage, a type of stroke. One could argue that one of FDR’s visitors that day triggered his stroke, but it is much more likely that years of untreated high blood pressure led to FDR’s demise at the age of 63.

High blood pressure or hypertension still remains a hidden killer at large. It is estimated that high blood pressure kills approximately 1000 Americans each day due to its effects on Continue reading

Monkey See, Monkey Do — How Behavioral Modeling Influences Health

by on July 1, 2014

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My 2-year-old granddaughter seemed to welcome her newborn baby sister with bland indifference. I observed her as she played with her blocks and other toys and did not appear to be perturbed by the presence of a new member in her family. After she had dinner, I was surprised when she set out deliberately for the couch, wrapped her mother’s pillow around her lap, lifted her shirt, and clutched her bear to her chest. It was dinner time for her bear! While it was fun to watch her precise imitation of breast feeding, it made me stop and wonder how we as adults subconsciously follow patterns of behavior that may not reach our cognitive awareness. Continue reading

HIV Awareness: HIV Testing Day is June 27

by on June 3, 2014

HIV-625My twin daughters were born in August of 1981, just two months after a publication from the CDC reported the first cases of a rare lung infection that eventually led to what became known as the AIDS epidemic. Because they were very premature, my newborn daughters required numerous blood transfusions from Irwin Memorial Blood Bank in San Francisco. One daughter received over 40 different transfusions. In 1985, the FDA approved the first blood test to detect HIV antibodies in the blood, and blood banks began their first screening of their blood supply. It was shortly thereafter that my wife and I received a letter from the Continue reading

Gesundhiet!

by on April 1, 2014

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“Ahh choo, bless you, ahh choo, gesundheit “ are the expressions one hears this time of year from allergy sufferers and their companions.   People who have migrated to California from other parts of the country are surprised to experience allergy symptoms they never had previously.  Allergy victims march into doctor offices and pharmacies every spring because of the combination of the long growing season here, habitat for many species of plants in California, and windy days. The “bless- yous” and “gesundheits” exclaimed by empathetic bystanders are exclamations based on an ancient superstition to forestall evil spirits from entering the body after one sneezes, but now it seems impolite not to offer consolation.   Sneezing usually heralds the onset of a cold, but can also be triggered by exposure to sunlight or strong odors.  This time of year, sneezing portends hay fever or seasonal allergic rhinitis. You may be one of the estimated 20% of Americans who have this condition and if so, keep reading.

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Your Heart Loves You. Love It Back!

by on February 4, 2014

 

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February is American Heart month. It represents an opportunity to think of hearts other than in the context of Valentine’s Day.

During the course of my career as an internist, I have cared for hundreds of patients with heart disease. Believe me, it is better to make some simple interventions in your life now than to wait until you have severe problems. Let me give you one example of a patient of mine I cared for about 20 years ago. Roger (not his real name) was in his late 50’s when he sustained his second heart attack. He was an ex-smoker, worked hard every day in his stressful job to support his family, and had little time to exercise or to take the time to eat healthy. After his second heart attack, he could not walk even half a block before he developed chest discomfort. I sent him for various cardiac tests with the hope that the obstructions in his coronary arteries could be
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