MAYO CLINIC HEALTH LETTER
Transcription
MAYO CLINIC HEALTH LETTER
MAYO CLINIC HEALTH LETTER Reliable Information for a Healthier Life VOLUME 30 NUMBER 10 OCTOBER 2012 Inside this issue HEALTH TIPS . . . . . . . . . . . . . . . . . 3 Sickness and grandchild visits. NEWS AND OUR VIEWS . . . . . . 4 Heart benefit of ‘good’ cholesterol depends on how it occurs. Closing in on a melanoma skin cancer vaccine. DIABETES COMPLICATIONS . . . . . . . . . . . . . 4 Proactive care a must. VAGINAL ATROPHY . . . . . . . . . . 6 Managing vaginal dryness and irritation. FRACTURED RIB . . . . . . . . . . . . . . . 7 Guarding against complications. Gallstones Symptoms usually mean surgery Years ago — after you had a test for something else — your doctor told you that you had gallstones in your gallbladder. The doctor also said not to worry about them unless they started to cause significant pain. Recently, you’ve had a couple of unusual attacks of pain in your upper right abdomen that went away after an hour or two. It’s time to see your doctor. And if you experience another attack in which the pain is more constant and long lasting — or includes other symptoms such as nausea or spreading of pain to your chest or back — a visit to the emergency department is warranted. Gallstones are common and occur in about 10 to 15 percent of people in the United States. About 75 percent of people with gallstones experience no symptoms and require no treatment, because the risk of a surgical procedure is greater than the risk of doing nothing. However, when pain or other symptoms occur, there’s about a 70 percent chance that they’ll occur again within two years — and in some cases these attacks can lead to life-threatening complications. That’s why, when symptoms occur, surgery to remove the gallbladder is typically performed. In fact, gallbladder removal is one of the most common surgical procedures performed in the United States. ➧ SECOND OPINION . . . . . . . . . . . 8 Coming in November MENISCUS TEARS Knee pain isn’t a given. COSMETIC SURGERY Common options for older adults. DENTURE CARE A daily task. OSTEOPOROSIS DRUGS Current and future options. When your gallbladder contracts to expel bile, some of the stones may be carried along with the fluid and migrate to the outlet of the gallbladder leading to the bile duct. There, they can block the outlet of the gallbladder, causing a gallbladder attack. Digestive organ Your gallbladder is a small, pearshaped sac tucked under your liver on the right side of your upper abdomen. It’s part of the biliary system, which creates, stores and transports bile — a digestive fluid that helps break down fats and also helps pass waste and cholesterol from the body. Bile is produced in your liver and drains through bile ducts to your gallbladder. The gallbladder serves as a reservoir for bile. When you consume foods containing fat or protein, the gallbladder contracts and empties the bile it contains through bile ducts that lead to the small intestine. Preventing gallstones Some risk factors for gallstone development — such as being female or having a family history of stones — can’t be controlled. However, you may be able to reduce your risk of developing gallstones with: ■ Regular exercise and physical activity. In one study involving women, this was associated with about a 40 percent reduced risk of gallstone development. ■ Maintaining a healthy weight, because obesity is a key risk factor for gallstone development. ■ Avoiding extreme diets that involve low intake of calories and rapid weight loss. Occasionally, your doctor may prescribe a medication, such as ursodiol, to offset the increased risk associated with rapid weight loss, such as may occur if you have undergone weight-loss surgery. ■ Long-term use of cholesterollowering drugs called statins. These aren’t recommended s olely for gallstone prevention, but gallstone prevention may be an additional benefit of taking them for another reason. 2 www.HealthLetter.MayoClinic.com When bile becomes chemically imbalanced, it forms into hardened particles. These can grow into stones as small as a grain of sand or as large as a golf ball. Some people may develop just one stone, while others may develop several stones or even hundreds or thousands of tiny stones that are sometimes referred to as sludge. Stone types Many factors may contribute to gallstone formation, some of which aren’t well understood. One is too much cholesterol in the bile. Normally, your bile contains enough chemicals to dissolve the cholesterol excreted by your liver. However, if bile contains more cholesterol than can be dissolved, the extra cholesterol can form into stones. Also, when the gallbladder isn’t contracting and emptying as it should, bile stays in the gallbladder and becomes too concentrated. This concentrated bile can then become sludgy and form stones. Either cause can lead to the formation of cholesterol stones, which account for about 80 percent of gallstones diagnosed in the United States. Factors that increase risk of cholesterol gallstones because of too much cholesterol in the bile or improper gallbladder emptying — or both — i nclude: ■ Being female, because estrogen — whether it’s natural estrogen or estrogen-containing medications — causes more cholesterol to be excreted in bile ■ Being overweight or obese ■ Older age ■ Consuming a diet high in fat and cholesterol and low in fiber ■Pregnancy ■ Rapid weight loss such as with crash diets ■ A family history of gallstones ■ Being an American Indian or Mexican-American ■ Having diabetes A second, less common type of gallstone (pigment stone) forms when bile contains too much of a waste product called bilirubin (bil-ih-ROO-bin). People October 2012 with blood disorders and severe liver diseases are most likely to get this type of stone. Gallstone attack Gallstones usually settle at the bottom of your gallbladder. Most of the time they don’t cause problems. Many people don’t even know they have them, and they don’t require any treatment. However, when your gallbladder contracts to expel bile, some of the stones may be carried along with the fluid and migrate to the outlet of the gallbladder. There, they can block the outlet of the gallbladder. The blockage causes the symptoms of a gallbladder attack, such as sudden moderate to severe pain in the upper right abdomen, between the shoulder blades or under the right shoulder. MAYO CLINIC HEALTH LETTER Managing Editor Aleta Capelle Medical Editor Robert Sheeler, M.D. Associate Editors Carol Gunderson Joey Keillor Associate Medical Editor Amindra Arora, M.B., B.Chir. Medical Illustration Michael King Editorial Research Deirdre Herman Customer Service Manager Ann Allen Proofreading Miranda Attlesey Donna Hanson Julie Maas Administrative Assistant Beverly Steele EDITORIAL BOARD Shreyasee Amin, M.D., Rheumatology; Amindra Arora, M.B., B.Chir., Gastroenterology and Hepatology; Brent Bauer, M.D., Internal Medicine; Julie Bjoraker, M.D., Internal Medicine; Lisa Buss Preszler, Pharm.D., Pharmacy; Bart Clarke, M.D., Endocrinology and Metabolism; William Cliby, M.D., Gynecologic Surgery; Clayton Cowl, M.D., Pulmonary and Critical Care; Mark Davis, M.D., Dermatology; Michael Halasy, P.A.-C., Emergency Medicine; Timothy Moynihan, M.D., Oncology; Suzanne Norby, M.D., Nephrology; Norman Rasmussen, Ed.D., Psychology; Daniel Roberts, M.D., Hospital Internal Medicine; Robert Sheeler, M.D., Family Medicine; Phillip Sheridan, D.D.S., Periodontics; Peter Southorn, M.D., Anesthesiology; Ronald Swee, M.D., Radiology; Farris Timimi, M.D., Cardiology; Matthew Tollefson, M.D., Urology; Debra Zillmer, M.D., Orthopedics; Aleta Capelle, Health Information. Ex officio: Carol Gunderson, Joey Keillor. Mayo Clinic Health Letter (ISSN 0741-6245) is published monthly by Mayo Foundation for Medical Education and Research, a subsidiary of Mayo Foundation, 200 First St. SW, Rochester, MN 55905. Subscription price is $29.55 a year, which includes a cumulative index published in December. Periodicals postage paid at Rochester, Minn., and at additional mailing offices. POSTMASTER: Send address changes to Mayo Clinic Health Letter, Subscription Services, P.O. Box 9302, Big Sandy, TX 75755-9302. Stones that block the gallbladder outlet usually drop back down into the gallbladder, typically ending the gallbladder attack. However, a gallstone may become lodged farther down the bile duct and not dislodge. This may block not only the gallbladder, but also the bile ducts leading from the liver and the pancreas. When the blockage lasts for several hours, the gallbladder or pancreas may become inflamed and bile flow from the liver may be blocked. Signs and symptoms may worsen and include: ■ High fever and chills ■ Yellowing of your skin and the whites of your eyes (jaundice) and itching ■ Dark-colored urine ■ Pale-colored stools These signs and symptoms warrant immediate medical attention. Finding stones In a nonemergency setting, ultrasound imaging is the most common way to diagnose gallstones. However, it’s usually not as effective at determining if a stone has passed into a bile duct. If a stone is suspected, additional testing may include blood tests to detect infection, jaundice or inflammation of the pancreas. An X-ray dye may be injected directly into the bile duct from an endoscope tube that’s passed down the throat, through the stomach and to the bile duct opening in the small Gallbladder removal surgery is often performed through several small incisions in your abdomen through which a tiny camera and surgical instruments are passed. intestine. An X-ray image can reveal if a stone is blocking the bile duct. If a stone is found, it can usually be removed using tools attached to the endoscope. Treatment options If you’ve had one or more gallbladder attacks, your doctor will probably recommend surgery to remove your gallbladder. Your gallbladder isn’t an essential organ, and new stones usually form if just the stones are removed or dissolved away with medication. Gallbladder removal surgery is often performed laparoscopically. This means that it’s performed through several small incisions in your abdomen through which a tiny camera and surgical instruments are passed to remove the organ. Laparoscopic surgery may require a brief stay in the hospital. You’ll likely be able to return to normal activities within a few days. Open surgery to remove the gallbladder requires larger incisions — including cutting through abdominal muscles. This procedure generally requires several days in the hospital and several weeks of recovery. Open surgery is only occasionally used, but it may be the best choice for cases in which the gallbladder is severely inflamed or infected, or if there’s scarring from previous surgery. Complications are possible with both laparoscopic and open surgeries. Recovery is usually quicker after laparoscopic surgery. Certain complications — though rare — are more common after laparoscopic surgery. Life without a gallbladder After gallbladder removal, your liver still produces enough bile to digest food from a normal diet. Instead of being stored in your gallbladder, bile flows out of the liver and empties directly into the small intestine. With bile flowing more frequently into your small intestine, you may experience a greater number of bowel movements and stools may be softer. Often, these changes are temporary. ❒ October 2012 Health tips Sickness and grandchild visits Visits with your grandkids are great, but it’s not so great when you catch an illness from them. Minimize your risk of getting sick: ■ Postpone a visit — Avoid visiting when a child has a contagious or severe illness, such as the flu or pneumonia, or if the child is vomiting. If the child has a fever or has just started coughing, the illness is likely contagious. ■ Practice hand hygiene — Frequently wash your hands with warm soap and water, or use an alcohol-based hand sanitizer. ■ Avoid kisses and face-to-face hugs — Save your love and affection — or rough-and-tumble play — for a visit when the child is feeling better. ■ Try not to touch your eyes, nose and mouth — Avoid touching your face unless you’ve just washed or sanitized your hands. Avoid having your grandchildren touch these areas, as well. ■ Remind your grandchildren about good hygiene — This may include reminding them to cough or sneeze into a tissue or crook of the elbow, or how to properly wash hands. ■ Don’t share — Don’t drink from the same glass or soda can as your grandchildren, and don’t share eating utensils. ■ Be healthy — Try to arrive well rested and stay well rested. ■ Keep vaccines up to date — Make sure that you and your grandchildren are up to date with vaccines, particularly vaccines for pertussis, seasonal influenza and pneumonia. ❒ www.HealthLetter.MayoClinic.com 3 News and our views Heart benefit of ‘good’ cholesterol depends on how it occurs There’s a reason why high-density lipoprotein (HDL) cholesterol is called “good.” It’s long appeared that higher HDL levels corresponded to cardiovascular health and reduced risk of heart attack. However, new research shows that raising HDL without making HDLincreasing lifestyle changes may have no cardiovascular benefit. A large study, published in the journal The Lancet, looked at genetic variables of participants in numerous studies, measuring incidence of heart attack. Researchers were able to identify several thousand study participants who had a gene variant that increases HDL cholesterol levels — without affecting other risk factors for heart attack. But within this group with e levated HDL, they found no reduction in heart attack risk. Another large study examined the effect on heart attack risk of prescription-strength niacin — a B vitamin that can help raise HDL cholesterol. Participants were at high risk of heart attack and had their low-density lipoprotein (LDL), or “bad,” cholesterol levels controlled by a statin drug. This study looked at whether raising HDL with niacin further reduced heart attack risk. It didn’t, and the study was stopped early. With reductions in LDL cholesterol, no matter how it’s achieved, there’s a reduction in heart attack risk. HDL cholesterol doesn’t appear to work the same way. Lifestyle factors that increase HDL cholesterol do indeed reduce the risk of heart attack and cardiovascular disease. Raising HDL cholesterol by other means has yet to be proved to reduce heart attack risk. Mayo experts say that recent research further emphasizes that in addition to controlling your LDL cholesterol level, changes in lifestyle — such as increased exercise, eating a healthier diet and maintaining a healthy weight — are among the most powerful steps that you can take to improve cardiovascular health and reduce your risk of heart attack. ❒ Closing in on a melanoma skin cancer vaccine Mayo Clinic researchers are leading a novel approach to develop a skin cancer vaccine that capitalizes on the body’s natural defender, the immune system. The experimental vaccine uses an ancient cousin of the rabies virus — called vesicular stomatitis virus (VSV). The virus has been genetically engineered to deliver a broad spectrum of human DNA obtained from melanoma skin c ancer cells directly to the lymph nodes, where immune cells congregate. It’s a strategy called cancer immunotherapy, and early studies have produced encouraging results. The latest study involving this experimental vaccine appeared in the April 2012 issue of the journal Nature Biotechnology. Tumor cells tend to mutate over time, making it difficult for the immune system to identify them as enemies and fight them off. However, the immune system is fine-tuned to identify and target viral invaders such as VSV. Combining VSV with the whole array of a melanoma cancer cell’s DNA appears to make melanoma much more visible and vulnerable to the immune system. Mayo Clinic doctors say that recent results show that boosting the immune system of people with melanoma appears beneficial. While this new vaccine therapy is exciting, it will be many years before this is ready for human clinical trials. ❒ 4 www.HealthLetter.MayoClinic.com October 2012 Diabetes complications Proactive care a must If you’re one of the millions of Americans living with diabetes, you already know that it takes regular attention on your part to keep your blood sugar (glucose) levels under control. Diabetes means that your blood glucose levels are too high — and without proper management, prolonged episodes of elevated glucose levels can cause widespread organ damage and serious complications. Those complications are directly related to the changes that occur in the body’s larger and smaller blood vessels after exposure to high glucose concentrations. That’s why it’s imperative to approach diabetes care proactively. Glucose monitoring — including periodic hemoglobin A1C blood tests that reflect your average glucose level during an approximately three-month period — is a vital component in diabetes management. (See “Second opinion,” Page 8). Because diabetes multiplies the risks of complications, it’s equally important to control your blood pressure and cholesterol levels together with your blood glucose to lower your risk of heart attack, stroke and related complications. Risk factors for these complications are commonly treated more aggressively than would be the case if you didn’t have diabetes. Complicating factors Complications related to diabetes can be insidious, occurring even before you know you have diabetes. Among the complicating factors you may need to address with your doctor’s guidance and help are: ■ Heart and blood vessel disease — Heart attack and stroke are the leading causes of death for people who have diabetes. If you smoke, stopping smoking is one of the most important steps you can take for your vascular health and long-term survival. Discuss with your doctor the ways in which you can pursue smoking cessation. High blood pressure also can damage blood vessels. That’s why keeping your blood pressure under control is so important. Lifestyle changes may help, including loss of excess weight, increased physical activity and a hearthealthy diet that reduces sodium. If drug therapy is necessary, it’s generally recommended that either an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) be included. Each also offers potential protection for diabetesrelated kidney complications. The benefit of low-dose aspirin is less certain and best discussed with your doctor. Elevated blood fats also can damage blood vessels. The combination of high levels of low-density lipoprotein (LDL), or “bad,” cholesterol, low levels of high-density lipoprotein (HDL), or “good,” cholesterol and high triglycerides accelerates fatty plaque buildup in arteries (atherosclerosis). These changes can contribute to heart attack and stroke risk and poor circulation in the legs and feet (peripheral artery disease). Lifestyle changes previously mentioned along with lipid-lowering statin drug therapy are generally recommended. For most people, the target goal for LDL is below 100 milligrams per deciliter (mg/dL), although that target may be lower for some. ■ Kidney disease (nephropathy) — Diabetes is the most common cause of kidney failure. While the progression to kidney disease can be slow, careful management of blood glucose levels and high blood pressure can give your kidneys a better chance of remaining functional longer. ACE inhibitors and ARBs used to treat high blood pressure are known to delay worsening of nephropathy. ■ Eye damage (diabetic retinopathy) — The back part of your eye — called the retina — is nourished by many tiny blood vessels. These are among the first blood vessels damaged by high blood glucose. High blood pressure also contributes to this damage, which happens slowly over years. The potential risk with diabetic retinopathy is loss of sight or even blindness if the retina becomes d etached and isn’t treated promptly. Reducing the risk or slowing progression of diabetic retinopathy is best done with careful blood glucose control and blood pressure control. ■ Nerve damage (diabetic neuropathy) — This complication is associated with unmanaged high blood glucose. Damage generally occurs slowly and over a number of years. Usually, the sensory nerves are affected, typically in the legs, beginning at the tips of the toes. Sensory nerves detect sensations such as pain, warmth, coolness and texture. Damage may produce sensations that are often mild and may include tingling, numbness, burning and stabbing pain. For some, the sensations are painful and d isabling. Nonprescription pain relievers may help, or for more severe pain your doctor may prescribe medications that reduce nerve pain. (See our October 2011 article, “Peripheral neuropathy.”) ■ Foot wounds — Over time, nerve damage can cause loss of sensation in your feet, putting you at greater risk of unnoticed foot injuries, such as a simple blister or cut. In addition, wounds tend to heal more slowly due to changes in blood flow to the feet. As a result, a small injury can develop into an open sore (ulcer) that’s difficult to treat. Carefully looking over your feet each day may prevent bigger problems. Your doctor may refer you to a diabetic foot care expert, such as a podiatrist, nurse or diabetes foot clinic. Clinical evidence indicates people with diabetes have an increased susceptibility to infections. The greater frequency of infections is tied to the effects of high blood sugar on the immune system’s ability to function properly. October 2012 Age and hypoglycemia Age itself can be a complicating factor. While careful control of blood glucose levels is important, adults older than 65 may need to work closely with their doctors to moderate blood glucose (glycemic) targets in order to avoid episodes of blood glucose becoming too low (hypoglycemia). For some older adults, h ypoglycemia can be a tipping point. Hypoglycemia may set off a dangerous irregular heart rhythm in someone who already has known heart concerns. Dizziness and lightheadedness associated with hypoglycemia may lead to falls and possibly bone fractures. More importantly, hypoglycemia can lead to stroke, impaired cognitive function and even death. For this reason — especially in older adults and those who live alone — the risk of high blood sugar over time has to be balanced with these life-threatening risks from low blood sugar. Sometimes, for these people, diabetes can be less tightly controlled in order to avoid the risks of these potentially devastating complications. Diabetes treatment choices are highly individualized. That’s why it’s important to work closely with your doctor to determine glycemic targets and treatment goals and to develop a plan to prevent complications. In older adults, the focus is generally on drug safety, particularly when it comes to protecting against hypoglycemia, heart failure, kidney failure, bone fractures and possible interactions when taking multiple medications. Proactive management of diabetes complications is in large part dependent on self-care. Self-care, in turn, is related to your mood and your motivational level. Remaining motivated and in a positive mindset can be helped by having an occasional and brief session with a behavioral health counselor. Most primary care clinics usually have behavioral health counselors available on their health care teams. ❒ www.HealthLetter.MayoClinic.com 5 Vaginal atrophy Managing vaginal dryness and irritation Like most women, you probably expected menopause to cause some changes in your body. You might not have been prepared, however, for vaginal itching, urinary incontinence or discomfort during intercourse — all symptoms of vaginal atrophy. Vaginal atrophy (atrophic vaginitis) is the thinning and inflammation of the vaginal walls and lower urinary tract due to a lack of estrogen. The condition typically occurs in menopausal women. By some estimates, about half of postmenopausal women experience vaginal atrophy. Though few women seek help, there are a number of treatment options for vaginal atrophy that can offer relief. Understanding estrogen If you have vaginal atrophy, lower levels of estrogen make your vaginal tissues thinner, drier, less elastic and more fragile. The condition can develop anytime your estrogen production declines, including the years leading up to and after menopause, after childbirth, during breast-feeding, after the surgical removal of both ovaries, after pelvic radiation or chemotherapy for cancer, or as a side effect of breast cancer hormonal treatment. The symptoms of vaginal atrophy can vary from moderate to severe. Vaginal symptoms might include dryness, burning, discomfort during intercourse and light bleeding after intercourse. Burning with urination, urgency with urination, urinary incontinence and more-frequent urinary tract infections also might occur. The thinning of the vaginal walls and changes in the acidity of the vagina caused by vaginal atrophy also can increase your risk of vaginal infections. 6 www.HealthLetter.MayoClinic.com Symptoms of vaginal atrophy might be more intense if you smoke, if you’ve stopped having intercourse for a prolonged time and resume it again, if you’ve had vaginal surgery, or if you’ve never given birth vaginally. Is it vaginal atrophy? Diagnosis of vaginal atrophy generally includes: ■ Pelvic exam — Your doctor will examine your pelvic organs and external genitalia, vagina, and cervix. Your doctor may collect a sample of cervical cells for microscopic examination. He or she may also take a sample of your vaginal secretions for analysis or place a paper indicator strip in your vagina to test its acidity. ■ Urinalysis — If you have urinary symptoms, you’ll need to provide a urine sample for analysis to rule out any other possible conditions, such as a urinary tract infection. Treatment choices If you’re experiencing mild vaginal dryness or irritation, regularly applying a nonprescription vaginal moisturizer (Me Again, Replens, Silk-E, others) can restore some moisture to your vaginal area. A nonprescription water-based lubricant (Astroglide, K-Y, others) also can reduce friction and discomfort during intercourse. Try different products to find a treatment that suits your needs. If you use condoms or a diaphragm, avoid oil-based products, which can damage these types of contraceptives. Sexual activity — either with or without a partner — also can ease the symptoms associated with vaginal atrophy. This is likely a result of enhanced blood flow to your vagina, which helps keep vaginal tissues healthy. If vaginal intercourse is painful, give yourself plenty of time to feel aroused. For moderate or severe symptoms, topical (vaginal) or systemic (oral, transdermal or higher dose vaginal application) estrogen can relieve vaginal dryness and itchiness and improve vaginal elasticity. However, your docOctober 2012 tor might caution against use of systemic estrogen if you have a history of breast cancer or other hormonally sensitive cancers. If estrogen therapy is an option for you, expect noticeable improvements after a few weeks of use. Severe symptoms might take months to improve. Side effects of estrogen therapy, while uncommon, might include vaginal bleeding or spotting or breast tenderness. Hormone therapy can also cause nausea, bloating, headaches, dizziness and mood changes. Ask your doctor what to expect. Estrogen options Topical estrogen is more effective than systemic estrogen at treating vaginal atrophy and limiting your overall exposure to estrogen. Estrogen applied to the vagina can still result in estrogen reaching your bloodstream, but the amount is significantly lower than with systemic estrogen treatment. Vaginal estrogen therapy comes in several forms, including: ■ Vaginal estrogen cream — This type of cream (Estrace, Premarin) is inserted directly into the vagina with an applicator — typically daily for the first two weeks and then twice a week thereafter. ■ Vaginal estrogen ring — You or your doctor will insert a soft, flexible ring (Estring) into the upper part of your vagina. The ring releases a consistent low dose of estrogen. It will need to be replaced every three months. ■ Vaginal estrogen tablet — You’ll use a disposable applicator to place a vaginal estrogen tablet (Vagifem) in your vagina — typically daily for the first two weeks and then twice a week thereafter. Talk to your doctor If you experience vaginal dryness along with other symptoms of menopause — such as moderate or severe hot flashes — your doctor might suggest estrogen pills, patches or gel, or a vaginal estrogen ring. Talk to your doctor to decide if hormone treatment is an option and, if so, which type is best for your circumstances. ❒ Fractured rib Guarding against complications It was that slip on the stairs that caused you to bump your ribs on the railing. That led to a painful injury on your rib cage that your doctor confirmed is a rib fracture. Your doctor said that unlike other types of fractures, there isn’t anything that can be done to treat the rib. Still, your doctor ordered numerous tests to rule out other underlying injuries. Your doctor was right. Usually, nothing that can be done for a fractured rib that isn’t moved out of normal position and alignment (displaced). Treatment is usually limited to providing adequate pain control, avoiding strenuous activities and letting it heal. Use of an incentive spirometer also may be recommended to enhance lung function and help prevent pneumonia. Complications of rib fractures can be serious. One study of older adults found that about 19 percent of those who sustained a fracture of three to four ribs ended up dying from complications. Major trauma Rib fractures are one of the most common types of fracture in older adults. In one study that looked at causes of rib fracture in older adults, about 25 percent of fractures were caused by major trauma such as a car accident. These account for the mostsevere injuries, where multiple ribs are fractured, and when fractured bone ends are displaced. Displaced bones can cause many serious, life-threatening complications, including punctures of the lungs, lung bruising and swelling, bleeding into or around the lungs, and damage to critical blood vessels or organs such as the liver, kidney or spleen. Emergency care is appropriate in most cases of major trauma and for anyone with three or more fractured or displaced ribs. More-common causes The study on rib fracture causes also found that about one-third of the rib fracture causes were due to moderate trauma such as falling from a standing height. For about 40 percent of the fractures in the study, there was no identifiable trauma that caused the fracture, which means that nontraumatic events such as the repeated stress of a coughing spell or swinging a golf club may have caused it. This may be more likely to occur in someone with weakened bones due to osteoporosis. A tiny percentage of fractures had a direct pathological cause, such as a cancer that had spread to rib bones. Rib fractures that are the result of mild to moderate trauma or repeated stress on the bone are usually less severe initially, but can be very painful. Pain often occurs when you take a deep breath. It’s often possible to isolate a spot on the bone that hurts to the touch or that hurts when you bend or twist. Serious complications requiring prompt medical intervention — such as lung bruising and swelling, bleeding into or around the lungs, or a collapsed lung — can occur after rib fracture due to minor to moderate trauma. Such complications may require insertion of a chest tube or other surgery, blood transfusion, and artificial ventilation. Emergency care may be indicated if you have: ■Lightheadedness ■ Shortness of breath ■ Significant chest pain, particularly if it’s worsening Even if a suspected fractured rib doesn’t require emergency care, it’s still important to see your family doctor for diagnosis and possible treatment. occurring in roughly 30 to 35 percent of adults age 65 and older. Pain control may include nonprescription drugs such as acetaminophen (Tylenol, others), ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve). If these aren’t enough, your doctor may prescribe stronger medications. For severe fractures, regional anesthesia may be considered. Most nondisplaced rib fractures heal within six weeks. Although pain will gradually subside over this time, you’re likely to experience some bouts of pain because it’s hard to totally avoid jostling the healing rib. You can often return to your daily activities in less than six weeks. However, for stresstype rib fractures, it may be best to avoid for a longer time the activity that led to the stress fracture. ❒ Pain control is critical Controlling pain of a rib fracture is critical so that you can breathe deeply and cough. When pain prevents you from doing this, the risk of developing pneumonia rises. In fact, pneumonia is the most prevalent and serious complication of rib fractures in older adults, October 2012 www.HealthLetter.MayoClinic.com 7 Second opinion Q I was recently diagnosed with type 2 diabetes and am getting used to doing daily blood sugar tests and logging my results. Why does my doctor want to do a blood sugar test called A1C every few months, too? A Monitoring blood sugar (glucose) levels in your bloodstream is a critical part of keeping your diabetes under control — but on its own, daily glucose testing isn’t enough. It can only capture your glucose level at one particular instant. The A1C blood test reflects your average glucose level for the past three months. After a diabetes diagnosis, A1C provides a gauge of how well your diabetes treatment plan is working over a span of time. The higher your A1C level, the poorer your glucose control. The A1C test measures what percentage of hemoglobin — which is a protein in red blood cells responsible for carrying oxygen — is coated with sugar. When diabetes is uncontrolled, there’s too much glucose in your blood. That extra glucose links up with hemoglobin and continues to c irculate for the life of a red blood cell, which is typically about 120 days. An A1C level of 6.5 percent or higher on two separate tests indicates the presence of diabetes. For most people diagnosed with diabetes, an A1C level of 7 percent or lower is a common treatment target, but the target may be somewhat higher for some. Careful management of blood glucose levels is necessary to minimize diabetes complications, such as damage to kidneys, eyes, nerves and the cardiovascular system. The combination of home glucose monitoring and A1C testing allows you to work with your doctor on targeted goals and, when needed, to make adjustments to your treatment plan to control your diabetes — whether that’s changes in lifestyle or medications. ❒ Q I was diagnosed with heart failure earlier in the year. I’ve taken steps to manage the problem. The disease is stable and I feel good. Still, I’m wondering if I should skip our annual ski vacation to Colorado due to the high elevation? A Your concern is justified, and it’s best to make a final decision after talking with your doctor. Traveling to the thinner air of high elevations — and exercising — puts extra stress on the heart and cardiovascular system that wouldn’t be experienced at lower elevations. Cold w eather can add even more stress. This can cause problems for anyone — and can be especially concerning for people with heart failure or other problems, such as a history of heart attack, angina, bypass surgery or high blood pressure. Up to about 6,500 feet (2,000 meters), people with stable heart conditions are unlikely to experience altitude-related problems if they’re performing activities of similar intensity and duration as performed at lower altitudes. Between 6,500 feet and about 9,800 feet (3,000 meters), health concerns begin to mount. Activity at these elevations can be generally tolerated in those with stable heart conditions. However, it’s wise to take precautions, including: ■ Ascending slowly — such as by spending a day or two at around 6,000 to 7,000 feet — to allow the body to acclimatize. ■ Restricting activity on the first day or two after arrival at your destination to allow for further acclimatization. ■ Generally exercising at an easier effort than you would at lower elevations. Symptoms that come on with exercise, such as those of chest pain (angina) or heart failure, may come on earlier at higher elevations than they would at lower elevations. ■ Staying hydrated and avoiding alcohol. Travel or activity above 9,800 feet isn’t necessarily forbidden for those with stable heart conditions, but should be done only with approval from a doctor after a thorough evaluation. ❒ Have a question or comment? We appreciate every letter sent to Second Opinion but cannot publish an answer to each question or respond to requests for consultation on individual medical conditions. 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