All posts in Dr. Smith’s Articles

Swollen Glands

I’ve got this gland in my neck that’s all swollen.  I just noticed it shaving a few days ago and I don’t have any idea how long it’s been there.  What the heck do you think it is?”  Danny, a man in his 30’s had that deer-in-the-headlights look in his eyes.  He was obviously thinking the worst, having Googled the possibilities.

Commonly referred to as “swollen glands,” enlarged lymph nodes can show up as small lumps (from BB sized to a couple inches across) at many locations, including all around the neck, under the arms, at the elbows, in the groin, as well as inside the abdomen and chest.

Lymph nodes are a normal part of our anatomy consisting of groupings of cells that help filter the lymph and produce immune cells to fight infection.  Of course not all lumps are swollen lymph nodes.  Some turn out to be salivary glands, lipomas (benign fatty growths), cysts and a number of other common entities.  So when a new lump is noticed, the first distinction to be made is whether it is a lymph node or one of these other entities.

If the lump is indeed a lymph node, the question is then whether this is a normal reactive lymph node or something more serious.  Reactive lymph nodes are simply lymph nodes that have enlarged due to fighting some infection or inflammation.  For example a child with an ear infection will often have enlarged lymph nodes around that ear, someone with Strep throat will have enlarged nodes under the angle of the jaw, and a person with eczema or similar scalp condition may have enlarged nodes at the base of the skull.  Likewise if someone has an infected finger they may get enlarged lymph nodes in the elbow and axilla (underarm) on that side.  Other conditions such as mononucleosis can enlarge lymph nodes in many locations at once.

But the reason enlarged lymph nodes get the attention they do is that a very small percentage of them can be a red flag alerting us to something much more serious.  Lymphomas, leukemias and other cancers can produce enlarged lymph nodes as well.

So what are the clues that a swollen lymph node is one of these bad guys vs. just a reactive lymph node doing its job?  No one feature is full proof.  But certain locations, such as a swollen node just above your collar bone, are more worrisome than, for example, one in the groin.

The growth trend of the lymph node also matters.  A reactive node tends to enlarge fairly quickly and then starts to shrink after the inciting infection goes away.  On the other hand, a cancerous lymph node almost never shrinks without treatment of the cancer.  So even if a swollen node doesn’t totally go away, if it shrinks considerably that’s a reassuring sign.

As to what they feel like, reactive nodes tend to be smooth, mobile, and sometimes tender whereas a cancerous node is more likely to be very hard, stuck to the underlying tissues and not sore or tender to push on.

Other red flags would be the presence of other symptoms when the enlarged lymph nodes show up.  Symptoms like night sweats, unexplained weight loss, or localized pain near the lymph nodes can be concerning.

So what do you do if you find a lump?  You could reasonably watch it for a while if you don’t have any of the red flag symptoms and feel like it fits with being a reactive lymph node.  But if it persists or continues to grow it would be best to have it checked out.  A physical exam, blood work and sometimes a trial of antibiotics followed by rechecking the node a couple weeks later can be adequate follow up if the node is shrinking.  If not, imaging such as x-ray, ultrasound, MRI or CT scan, and possibly biopsy of the lymph node may be needed.

But keep in mind the odds are very much in your favor if you get a swollen lymph node.  We see hundreds and hundreds, if not thousands of normal reactive lymph nodes for every one bad guy cancerous node we see.  At the same time we don’t want to miss that one bad guy.  So if you’ve got a suspicious lump, get it checked out.

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Cholesterol Meds – Awesome or Awful?

Statins – those frequently-prescribed cholesterol-lowering medicines that include Zocor (simvastatin), Lipitor (atorvastatin), Crestor (rosuvastatin), Livalo (pitavastatin), Mevacor (lovastatin), Lescol (fluvastatin), and Pravachol (pravastatin) – are they awful toxins or awesome remedies?  You can certainly read both opinions if you follow the news or scan the web.  The New York Times once touted them as “the underused wonder drugs” while other articles and blogs claim they are dangerous and no one should use them.  Meanwhile they are the most prescribed drugs in the world and over 20 million Americans take them.

So where is the truth when it comes to statins?  No one can credibly claim that they don’t effectively lower cholesterol.  We routinely see up to and beyond 100 point drops three weeks into treatment with a statin.  What’s more, they act as anti-inflammatants inside the blood vessels and inflammation promotes plaque formation (the stuff that damages and blocks arteries leading to heart attacks and strokes).  But does lowering cholesterol and inflammation translate into reduced heart attacks, strokes, and overall mortality?  For high-risk individuals who have already had a coronary event (a heart attack or stent or bypass surgery) the answer is clearly, yes.  Statins reduce the chance of a second heart attack by about a third.

However, in what’s called primary prevention – preventing bad outcomes in individuals who are at lower risk and have never had a coronary event – the numbers are still there, but not quite as compelling.  An analysis of 14 randomized trials involving almost 35 thousand patients showed the following:

  • 17% reduction in all-cause mortality
  • 28% reduction in heart attacks
  • 22% reduction in strokes
  • No significant additional adverse events in those treated vs. placebo groups nor negative effect on quality of life

That sounds fairly impressive, but put another way, when the numbers are worked out, 1000 people would have to be treated for one year to prevent one death.  So there is a real, but modest benefit in treating lower risk individuals with statins.

On the side-effect side of the equation, we already noted that substantial side effects seem to be statistically insignificant in the studies.  But that’s not the whole story.  Liver effects are actually rather uncommon, with a significant rise in liver enzymes occurring in roughly 1 in 100 patients.  If they occur, the statin is simply stopped and the enzymes return to normal.  Actual liver failure rates in those on statins are almost the same as those in the untreated population.

Muscle pains occur in some 10% (estimates vary) of those on statins and, again, generally resolve promptly when the statin is stopped.  More serious muscle damage can occur, though rarely (in over 25 years of prescribing I’ve not had my first yet).  Other recent findings note a slight rise in blood sugar with statins and a fairly uncommon incidence of mental fuzziness and memory issues. If the latter occurs, the statin can be stopped and the problem clears.  All in all, my experience has been that some 8 out of 10 persons put on statins have no problem.

So, in the real world, if you have high cholesterol, how do you decide whether to be on a statin?  Sit down with your physician and go over your cholesterol numbers in detail.  Then look at all your other risk factors for heart disease and stroke (smoking, hypertension, diabetes, family history, sedentary life style, etc.).  For many I also recommend a coronary calcium score (a rapid, non-invasive CT of the coronary arteries looking for calcified plaque), a cardiovascular inflammation panel (I use Cleveland Heart Lab), and sometimes a CIMT (carotid intima media thickness, an evaluation of the state of plaque formation and inflammation in the blood vessels).  These tools give us a much better handle on who really is showing blood vessel damage and risk and who isn’t.  This allows us to target our preventive efforts, including statin use, on those who will most benefit from it.  Of course in all of this, don’t forget lifestyle changes such as the one highlighted in another New York Times article: “Underused Therapy for the Heart: the Gym.”

So statins are neither simply awesome nor awful; they’re one treatment that may or may not be right for you, when added to your steady efforts to minimize all those other risk factors.

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Upper Respiratory Infections

Now that Christmas is over, tis the season for coughin’ and sneezin’.  This is the time of year when legions of folks dealing with some kind of upper respiratory symptoms try to decide whether or not to make the trek into their doctor’s office.  Let’s see if we can help sift through some of the factors involved and maybe save a few trips.

Upper respiratory infections (URI’s) include the common viral illnesses (where antibiotics are useless and just add cost, side effects and resistance) such as colds, flu, viral sore throats, bronchitis, laryngitis, croup, mono, and viral sinusitis.  As well, there are the much less common bacterial URI’s (where antibiotics may be appropriate):

  • Bacterial sinusitis – about 2% of viral URI’s progress on to this
  • Bacterial bronchitis – again, far less common than its viral cousin
  • Whooping cough – still very common and deadly in poorly immunized countries and raising its ugly head in pockets of this country having poorer immunization rates
  • Strep throat – comprising less than 10% of sore throats and rarely occurring in children less than 2-3 years old.

Overall, URI’s are the most common acute illness seen in medical offices.  In the U.S. we have about a billion URI’s per year. Children have about 3-8 viral URI’s per year, adolescents and adults have approximately 2-4 annually, while people older than 60 have fewer than 1 cold per year.  With the average URI lasting a few days to nearly two weeks start to finish, that’s a lot of days with symptoms.  The flu affects 5-20% of the US population during each flu season.

So which symptoms are worth a trip to a doctor, and which ones are just viruses that need to run their course?  Your typical cold, viral bronchitis or sinusitis rarely benefits from a trip to the doctor.  This would include your typical runny nose, cough, sore throat, headache type of illness and it is the vast majority of URI’s.  As stated above, antibiotics are worse than useless for these.  Drink lots of water, take acetaminophen or ibuprofen for higher fevers (101 and up as a rule of thumb) and general pain, and consider something like Mucinex DM if you want to further thin out the mucous and quiet a cough.  Take a long shower in the morning and blow and cough out everything you can from the night before.  Of course try not to pass it on to your family, friends and co-workers.

So when should you come see the doctor with URI symptoms?:

  • If the symptoms worsen after initially improving for a time
  • If the symptoms are more severe (shortness of breath, wheezing, dehydration)
  • If the symptoms are not gone or nearly gone within 10-14 days
  • Go in as soon as possible if moderate or severe flu symptoms hit (cough, congestion, fever, body aches) during flu season (fall to spring) as prescription flu medications only help if started within the first 48-72 hours of illness.
  • If you have a bad sore throat, possibly with headache and nausea but without runny nose or congestion as this kind of symptom combination is more often strep throat (or mono if you are in your teens or 20’s).  An antibiotic is then appropriate if a strep test confirms strep throat.
  • If you or the person with symptoms is frail and in poor overall health, including the very young and the very old.
  • If URI symptoms have led to severe ear pain.
  • As far as sinusitis, the recommendations say “Uncomplicated sinus infections typically clear up without antibiotics. Antibiotics should be prescribed only if there are persistent symptoms for more than 10 days, or if a patient develops severe symptoms or a high fever, has nasal discharge or facial pain for at least three days in a row, or ‘worsening symptoms following a typical viral illness that lasted five days, which was initially improving.’”

One final thought: I cringe at the idea of telephone or internet medical care where a person pays to call a doctor, have a phone diagnosis, and get a prescription called in.  The likelihood of overprescribing antibiotics for viruses will be even higher as well as missing more serious infections such as early pneumonias.

I hope that helps give some idea of when it’s more worth coming in and when it may not be.  Certainly, when in doubt, check it out.

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Hypertension

“I was late rushing over here.” “Traffic was terrible.” “I just had a cup of coffee.” “Work’s been really stressful.” “My blood pressure’s only high when I’m here in the office. I can feel when it’s high and it’s never high at home.”

For some reason, when I mention that someone’s blood pressure (BP) is high (also called hypertension when it’s consistently high) more often than not some reason is given to explain it away. And there can be some truth to some of these reasons. For example, “white coat hypertension,” where someone’s BP seems to mostly be high from tensing up in the doctor’s office, is a real thing. However, even here, those who have it have been found to have increased risk compared to those who don’t.

The bottom line is that high BP is:
• extremely common, with about one in three adults, as well as many children (19% of boys and 13% of girls and rising) having it
• usually without symptoms (until it causes a catastrophe such as stroke, heart attack, heart failure, an aneurysm, kidney failure or loss of vision)
• crippling and/or deadly, as seen from the list of severe consequences noted above

So high BP is common and deadly but silent for years and so often ignored. In fact only about half of those with high BP have it under control. Although lots of folks think they can feel it when their BP is high, it turns out that when this is tested, almost no one can reliably tell whether there BP is high unless it is extreme (like 220/120). And we don’t want our first clue that we’ve had untreated high BP to be that we wake up with the squeezing chest pain of a heart attack, or that we suddenly can’t speak right, or our left side isn’t moving because we’re having a stroke. So the bottom line is you need to measure BP, preferably at various times of the day under varying levels of stress to get a sense of where your range is.

What’s recommended as a healthy BP? Well that number may have recently gotten a bit lower. In a recently published study, those treated to a BP under 120/80 did so much better compared to those only treated to the less aggressive goal of under 140/90 that the study was stopped early. It was considered unethical to not treat all of the patients to the lower goal. The top number (systolic) proved to be particularly important to control aggressively. Specifically, the group taken down to the lower (120/80 or below) goal had a 27% lower incidence of events such as heart attack and stroke. This study was comprised of folks who were over 50 years old and had at least one other risk factor for heart disease or stroke.

So, we can reasonably say that for the over 50 crowd with at least one other risk factor (such as smoking, diabetes, high cholesterol, family history of heart disease), shooting for the 120/80 goal is ideal if it can be done without a lot of side effects. Only about 5% of folks treated to the lower (120/80) goal had substantial side effects such as light-headedness with standing. And the percentages weren’t that different in the 140/90 treatment group.

Okay, then how do we treat high BP?
• If you smoke, you really need to quit
• Slowly shave off those extra pounds
• Regular aerobic exercise if your doctor clears you for it (such as a 3-4 MPH walk for 30 minutes at least every other day)
• Choose low salt foods (60% of people with high BP are made worse by high salt intake)
• No more than 1 (for women) or 2 (for men) alcoholic drinks per day
• Avoid decongestants and anti-inflammitants — they raise BP
• Manage stress (always easier said than done)

If in spite of your efforts the numbers just aren’t getting where they should be, it’s time to talk with your doctor about medicine options. It may not excite you to take a medicine, but it beats a stroke, heart attack or any of the other problems on the list. And there are enough medicine choices where you can almost always find one (or a combination) that doesn’t hassle you with side effects.

If I can be appropriately dramatic, untreated high BP is kind of like an axe murderer who we let hang around our home because he is quiet and polite and mostly stays out of our way… until one day he strikes, devastatingly. Likewise, when we treat high BP we won’t necessarily feel any better. But we will have tied up the murderer in a corner so that he can’t harm us.

So see if high BP is lurking quietly around your house. And if you find him, don’t explain him away; take him seriously, tie him up and then check on him often enough to be sure he stays put.

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