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Febraury 2003

Toenail Problems

Your toenails reveal a lot about your overall health and can provide the first sign of a systemic disease. For instance, nails that are rounded inward like spoons rather than outward, may indicate a severe iron deficiency. Nails that are pitted and thick are a sign of psoriasis. If you notice any abnormality in your toenails, ask a foot care specialist about it.

Ingrown Toenails

An ingrown toenail is one of the most common sources of foot pain. It can be a serious problem for anyone with diabetes or circulatory difficulties.

An ingrown toenail develops when the side of the nail digs into the skin. This can lead to pain, irritation, swelling, and redness. The big toe is most often affected, although no toe is immune. The problem usually develops because the nails have not been trimmed properly. Overly tight shoes may also be a factor. Some people also have an inherited tendency for the problem.

The easiest way to prevent an ingrown toenail is to cut your nails straight across, rather than rounding off the corners. Use a toenail clipper (which is wider and larger than a fingernail clipper) or, if you use scissors, cut the nail in several short movements. Also, clean under your nails regularly with an orange stick. Wear shoes that provide enough room at the toes, and wear stockings or socks that allow your toes to move freely.

Treating Ingrown Toenails

You can treat this problem at home, unless you have diabetes. If you are a diabetic and have an ingrown toenail, you should see your doctor or foot care specialist immediately. Otherwise, if the problem is minor (the toe is irritated and red, but not overwhelmingly painful), soak your feet in warm water to soften the nail; then cut the part of the nail that is pressing against the skin. Trim gently, or you may hurt yourself.

Once that part of the nail is removed, apply a topical antibiotic, which you can purchase at any pharmacy. Wear open-toed sandals or roomy shoes to reduce pressure on the toe. If your toe isn’t better in three to five days, see a foot care specialist. Your toe may be infected, and you may need to start antibiotics and have the ingrown portion of the nail removed.

Toenail Fungus

Fungal nails are fairly common, but can go undetected for years. The problem develops when a fungus infects the area under the surface of a toenail. There are many types of fungal infections, which together account for half of all nail problems.

The moist, dark environment inside your shoes provides a perfect habitat for fungi. Infections are normally spread in damp areas where many people congregate — such as swimming pools and gyms, or even the shower or tub in your own home, if someone who uses it has the problem.

If a toenail becomes infected with a fungus, you may not realize it at first. The early signs are subtle. A scattering of white spots may appear across the nail. This should not be confused with the occasional white lines and crescents that can develop in healthy nails. With time, the toenail becomes thicker and a yellow-brown stain clouds the nail. White, green, and black flecks may also appear. The toes may smell. Untreated, the infection can spread to other toes, and may result in numbness, tingling, pain, and nails so thick that they are difficult to cut. The end of the nail may separate from the bed underneath, and the condition may become so painful that you have trouble walking.

To prevent fungal infection, avoid walking barefoot in heavily trafficked public areas, like the gym. (Wear sandals or “shower shoes.”) Wash your feet daily with soap and water and dry them thoroughly, especially between the toes. Put on a pair of clean socks every day, and change them more often if you sweat a lot or get your feet wet.

Treating Nail Fungus

If you have a mild infection (white spots or a small, defined stain), apply topical over-the-counter antifungal agents to suppress the infection. Be aware, however, that these topical medications do not always penetrate the nail to reach the underlying infection (which is the reason oral medications have long been the mainstay of treatment for fungal nails). If the stain does not disappear, seek medical attention.

Recent advances have greatly improved treatment of fungal nails. In 1999 the Food and Drug Administration approved a liquid form of ciclopirox (Penlac Nail Lacquer) as the first topical medication specifically intended for fungal nails. This prescription medication is applied daily, much like a nail polish, and takes 48 weeks to work.

Your doctor may prescribe a medication such as fluconazole (Diflucan), itraconazole (Sporanox), and terbinafine (Lamisil) that kills the fungus in about three months.

Be aware that the FDA recently issued a public health advisory warning that both Sporanox and Lamisil tablets can cause serious liver damage, resulting in liver failure and death. Sporanox has also been associated with a small risk of developing congestive heart failure. Although the FDA is still investigating, your doctor will likely do a baseline liver function test before prescribing either of these medications. If you do receive these pills, you will probably repeat the liver function tests six weeks after initiating therapy.

February 2003 Update

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Vitamin E supplements

If you’ve been taking vitamin E supplements, you’re not alone. The positive results of early studies on the antioxidant led many to take it in hopes of preventing or slowing everything from respiratory infections to macular degeneration. But what proves hopeful in early, preliminary studies doesn’t always pan out in larger research settings, and vitamin E is a case in point.

Age- Related Macular Degeneration

Age- Related Macular Degeneration (AMD) is the breakdown of cells of the macula, the small part of the eye that allows us to see things sharply and in color. Little is known about what causes AMD, which is the leading source of vision loss in people older than 55.

Early observational studies showed vitamin E might help prevent macular degeneration. To test this theory, researchers recruited close to 1,200 participants between the ages of 55 and 80 to receive either a daily vitamin E supplement or a placebo for four years. Participants underwent annual eye exams to detect signs of development or progression of AMD and changes in visual function.

The results of this study showed the incidence of AMD was similar among participants in the two groups. In the vitamin E group 8.6% developed AMD, whereas 8.1% in the placebo group did. Though this study clearly indicates that vitamin E does not help prevent or slow the progression of AMD, the study period was short, so it doesn’t prove that vitamin E doesn’t help in the long run.

(British Journal of Medicine, July 6, 2002)

Respiratory Infections

Early studies showed that vitamins and minerals, particularly vitamin E, may boost immune response in healthy elderly people. With this in mind, Dutch researchers set out to investigate whether either of the supplements lessens the rate and severity of respiratory infections in the elderly.

The researchers enlisted 652 participants over the age of 60 and broke them randomly into four groups. Each day, they either took a multivitamin with minerals and a placebo, a vitamin E pill and a placebo, both a multivitamin with minerals and vitamin E pill, or two placebos. After fifteen months of follow-up, the researchers found that the rate of respiratory infections did not differ among the groups. However, those who took vitamin E supplements actually had respiratory infections that were more severe — they were longer, caused more symptoms, and restricted more of the sufferer’s activities.

(Journal of the American Medical Association, August 14, 2002)

February 2003 Update

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Movement Disorders in Sleep

Sleepers typically shift position every 15–30 minutes, and it’s normal for muscles to jerk at the onset of sleep. For some people, however, uncontrollable movements make it impossible to obtain a restful night’s sleep.

Restless Leg Syndrome (RLS)

An estimated 1%–5% of adults have restless legs syndrome (RLS), a neurological disorder characterized by strange aching, crawling, or painful sensations in the lower legs that can be temporarily relieved by moving the legs.

Sleep deprivation is a major problem for people with RLS, as the symptoms are most prominent at night. People develop a variety of coping strategies, such as pacing, doing knee bends, rocking, or stretching the leg muscles. Symptoms are worse when sitting still, and the irresistible urge to move can make it difficult for people with RLS to take car or plane trips, enjoy a movie, or even hold a desk job. At night, RLS symptoms may compel the person to get in and out of bed many times.

Daytime symptoms sometimes abate for a few hours, days, or even years. Some people get temporary relief by rubbing or squeezing their leg muscles, wrapping their legs in bandages, or applying cold or warm compresses.

Because the symptoms sound bizarre or vague, and the need to be constantly mobile seems like nervousness, people with RLS are frequently thought to have psychiatric problems. In the past, they were often misdiagnosed as having hypochondria, manic-depressive illness, or a stress-related disorder. Children who have RLS are often diagnosed as having attention-deficit disorder. In adolescents, RLS may be mistaken for growing pains or back trouble. RLS usually worsens with age. Women may find that symptoms flare up during menstruation, pregnancy, or menopause. At least 1 in 4 pregnant women experiences restless legs.

As many as half of people with RLS note that other members of their family have similar symptoms. In at least a third of cases, genetic studies indicate that the disorder results from a single aberrant gene, with each child of an affected person having a 50% chance of inheriting the condition.

Restless legs can be a complication of alcoholism, iron deficiency anemia, diabetes, heart failure, or kidney failure. In some people, caffeine, stress, nicotine, fatigue, or prolonged exposure to a cold or very warm environment can worsen the symptoms. Certain medications — including antihistamines, antidepressants, or lithium — can exacerbate RLS.

Periodic Limb Movement Disorder (PLMD)

This neurological condition is similar to RLS, except that it occurs during sleep. During the night, the leg muscles involuntarily contract every 15–45 seconds, which causes jerking movements that at least partially rouse the person from sleep. The same movement (involving the hip, knee, or ankle) may be repeated hundreds of times a night. Unless a bed partner complains, the affected person will likely remain oblivious to the movements and baffled at feeling tired after what he or she believes was a full night’s rest. Up to 50% of the elderly may experience such leg movements during sleep. Nearly everyone with RLS will also have PLMD.

Treatments for Movement Disorders

Drugs that ease the tremors of Parkinson’s disease also reduce the number of leg movements and thus improve quality of life for people with RLS and PLMD. Levodopa-carbidopa (Sinemet), pergolide (Permax), and pramipexole (Mirapex) are first-line treatments for these disorders.

People with mild movement disorders may be prescribed diazepam (Valium), clonazepam (Klonopin), or temazepam (Restoril), which may improve sleep by reducing the number of awakenings due to leg movements. Most people who take these medications for insomnia develop a tolerance to them after a few weeks, but this doesn’t seem to happen when such drugs are taken for RLS.

Because of the potential for addiction, most physicians are reluctant to treat sleep disturbances with opiates (opium-containing drugs) such as propoxyphene and oxycodone. However, these drugs often help people with severe RLS symptoms that resist other treatments. The opiates decrease the discomfort of RLS and, for some patients, dramatically reduce leg movements at night. When properly used, they may provide long-term benefit with little risk of addiction.

February 2003 Update

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News on blood pressure drugs

Behind the scenes at your doctor’s office debate continues about which drug should be the first line of treatment for high blood pressure. Diuretics (also known as water pills) have been around for decades, but the makers of newer, more specialized — and more costly — drugs have been wooing physicians and their patients. The question isn’t whether these drugs work effectively to lower blood pressure; they do. But evidence indicating which is best at reducing heart disease and other cardiovascular events has been missing — until now.

The ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) study was designed to compare a diuretic to three other commonly prescribed classes of antihypertensive drugs — calcium channel blockers (CCBs), alpha-adrenergic blockers, and angiotensin-converting enzyme (ACE) inhibitors. The study involved 42,000 patients over the age of 55 with hypertension and one other risk factor for heart disease, such as previous heart attack or stroke. Each of the patients was randomly assigned to receive one of the study drugs for four to eight years. Researchers monitored the patients’ blood pressures and recorded evidence of heart disease and cardiovascular events.

Part of the study was halted early when evidence showed patients taking the alpha-adrenergic blocker had higher rates of cardiovascular disease and heart failure than patients taking the diuretic.

The primary results of the comparison of the ACE inhibitor lisinopril and the CCB amlodipine to the diuretic chlorthalidone were striking. The occurrence of death from heart disease was the same across each of the groups, and the rate of nonfatal heart attack was also similar. However, a slightly higher percentage of patients taking the diuretic chlorthalidone achieved better blood pressure control. Chlorthalidone was also better at preventing heart failure than amlodipine, the CCB. Patients taking the ACE inhibitor lisinopril had a higher risk of stroke, angina, and heart failure. In particular, black participants who took lisinopril had a 40% higher risk of stroke than black participants who took the diuretic.

The findings of the ALLHAT study indicate that when it comes to drugs for high blood pressure, newer and more costly does not mean better. In fact, diuretics should be the first line of treatment for many people with high blood pressure. Not only are they better at controlling high blood pressure while preventing major cardiovascular events, diuretics also cost less than the other drugs. A one-year supply of Chlorthalidone costs about $96, while the CCB amlodipine would set you back $480. Lisinopril costs $384 a year for the brand name drug (either Zestril or Prinovil), and $240 for the generic.

What should you do with these study results? If you’re just starting drug treatment for high blood pressure, you might want to try a diuretic first. If you, like most people, need a combination of drugs to keep your blood pressure in check, one should probably be a diuretic. If you’re already taking a different kind of medicine and it is working well for you, there’s no need to switch. However, if you want to cut down your drug bills, you might want to talk to your doctor about a diuretic.

(Journal of the American Medical Association, December 18, 2002)

February 2003 Update

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