Tag Archives: Dr. Jerry Saliman

Back Pain – the Bane of Being Human

by on July 7, 2015

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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

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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

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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

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“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

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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