MAYO CLINIC HEALTH LETTER Reliable Information for a Healthier Life VOLUME 31

NUMBER 6

JUNE 2013

Inside this issue NEWS AND OUR VIEWS . . . . . . 4 Vegetarians reduce risk of heart disease by a third. Diabetes drug may improve ovarian cancer survival. NUTS . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Small packages, big nutrition. PSEUDOGOUT . . . . . . . . . . . . . . . . 6 Crystals and joint pain. PAGET’S DISEASE . . . . . . . . . . . . . . 7 Common cause of bone weakening. SECOND OPINION . . . . . . . . . . . 8

Hearing aid technology Less seen, more heard You always enjoy dining with friends at lively restaurants with conversation, music and lots of laughter. Lately, you‘ve found it increasingly difficult to keep up with the conversation, and you hate to ask people to repeat themselves. Hearing loss can be frustrating. For many, the thought of using hearing aids seems almost as bad as the hearing loss itself. It’s estimated that less than half

of older adults who could benefit from hearing aids wear them. There are several reasons for this. Cost is important, as hearing aids aren’t covered by Medicare and may not be covered by a private medical plan. Perhaps equally important is the stigmatization people believe will occur if they wear hearing aids, and a belief that hearing aids won’t help much. Many older adults don’t appreciate how advanced hearing aid technology has become, with near-constant improvements being made. They’re better at amplifying sounds that you want to hear — and reducing unwanted sounds and feedback. ➧

Coming in July ENLARGED PROSTATE Know your treatment options. TUBERCULOSIS AND RELATED BACTERIA Tackling tough bugs. DEALING WITH GRIEF Sometimes, help is needed. PERSISTENT ITCHING Relief is usually possible.

The banana-shaped “area of speech” represents all of the sounds that make up normal, conversational speech. Mild and moderate hearing loss results in an inability to hear certain sounds. Severe and profound hearing loss means that conversational speech sounds are unable to be heard without amplification.

Contrary to being a stigma, hearing aids can greatly enhance your social interactions and help you maintain your independence and enjoyment of life. How they work The fundamental purpose of all hearing aids is to make sounds louder, and thus more audible. They start by collecting sounds from the environment through small microphones. Next, a computer chip converts the incoming sound into digital code. Hearing aids analyze and adjust the sound based on your hearing loss, listening needs and the level of the sounds around you. The signals are then converted back into sound waves and delivered to your ears through speakers. Hearing aids won’t restore your hearing to what it used to be, but they should help you understand conversation better — especially if someone is speaking in a soft voice. They can help you hear electronic devices better, such as a television or a beeping kitchen timer, stay more alert to your surroundings, and help in situations such as a theater performance or worship service where the speaker is far away. Additional features can offer even more hearing enhancement, including: ■ Directional microphones — These are aligned on hearing aids to provide for improved pickup of sounds coming from in front of you with some reduction of sounds coming from behind or beside you. They can improve your ability to hear when you’re in an environment with a lot of background noise. Some new aids can be configured to focus on sound from your right, left or behind you. ■ Telephone adapters or telecoils — The telecoil picks up the sounds from a telecoil-compatible telephone, which are then broadcast through your hearing aids. Some hearing aids switch automatically when the phone is held up to the hearing aid. ■ Wireless technology — Some new hearing aids can wirelessly pick up signals from various devices via an inter-

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face, transmitting sounds through the hearing aids. These devices include cell phones, telephones, televisions or tiny remote microphones that can be placed in close proximity to a sound source that you want to hear. ■ Direct audio input — Some hearing aids have a direct plugin so you can connect to audio from a television, computer or music device. ■ Variable programming — Some hearing aids can store several preprogrammed settings for various listening environments, such as a quiet or noisy situation. As your listening environment changes, you can switch programs for better sound quality, although most hearing aids make some automatic changes dependent on the environment. ■ Remote controls — Some hearing aids come with a remote control so you can make changes such as adjusting the volume, activating the directional microphone or increasing the noise reduction without touching the hearing aids. Some hearing aids can be controlled by a conventional phone, and others have a remote control app that can be downloaded to a cellphone or tablet.

not have heard for a while — and sounds that are different with amplification. To get maximum benefit from your hearing aids, it helps a great deal to have a positive attitude — and be willing to learn how the device works and how to insert it properly. Take advantage of follow-up visits with your hearing aid provider for any necessary adjustments and to ensure your new hearing aids are working for you as well as they can. It may take several weeks or months before you’re used to the hearing aids. But the more you use them — including using them in different sound environments — the more quickly you’ll adjust to amplified sounds.

Buying tips Before considering hearing aids, see your doctor or an ear, nose and throat specialist to determine if you might benefit from hearing aids. Some causes of hearing loss are medically correctable. Ask for a referral to a reputable audiologist who will work with you to find the hearing aids that fit your needs — and potential future needs if your hearing loss gets worse — and your budget. The cost of a hearing aid varies widely, from around a thousand dollars to several thousand. It’s important to request a trial period so that you have time to adapt to a new hearing aid and see if it is right for you. A warranty that covers parts and labor for a specified period also is important. Getting used to hearing aids takes patience and practice. Your brain takes time to adjust to sounds that you may

EDITORIAL BOARD

June  2013

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

Operations Manager Christie Herman

Copy Editing Miranda Attlesey Donna Hanson Julie Maas

Administrative Assistant Beverly Steele

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; 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.

Hearing aid types Completely in the canal (CIC) or mini CIC These are molded to fit inside your ear canal and can improve mild to moderate hearing loss.

Pros: The smallest and least visible hearing aids. These may help reduce problems with wind noise. Easiest to use with a telephone. Cons: The least powerful without much capacity for features. Short battery life of two to four days. Susceptible to earwax clogging the hearing aid. Small size makes them difficult to handle.

In the canal (ITC) These are custom molded and fit partly in the ear canal. This hearing aid can improve mild to moderate hearing loss.

Pros: Hardly visible. Similar to the completely-inthe-ear model, but more powerful with greater capacity for features and longer battery life. Easier to use with the telephone than are some styles. Cons: Susceptible to earwax clogging. Small size makes them difficult to handle.

In the ear (ITE) These come in a full-shell mold that completely fills the ear canal, and a half-shell mold that fills the lower portion of the bowl-shaped area of your outer ear. Both are good for mild to moderately severe hearing loss, with the full-shell also being good for severe hearing loss.

Pros: Easier to handle than smaller aids, with longer lasting batteries. Can include more features such as a directional microphone, telecoil and volume control. Cons: More visible and may pick up more wind noise than smaller aids. Susceptible to earwax clogging the hearing aids.

Behind the ear (BTE) with custom ear mold These hook over the top of your ear and sit behind the ear with an ear mold that fits inside your ear canal. A tube connects the aid to the ear mold. They’re good for almost all types of hearing loss.

Pros: The most powerful type with the most fitting flexibility. Easiest to maintain and usually require the fewest repairs. Cons: They’re usually more visible and may pick up more wind noise.

Receiver in canal (RIC) or Receiver in the ear (RITE) with custom ear molds The piece on top of and behind the ear houses the microphone and circuit, while the speaker sits in the ear canal. The parts are connected with a tiny wire. They’re good for almost all types of hearing loss.

Pros: Can fit a wide range of hearing loss by using a speaker that’s more or less strong as needed. Can be very small because the hearing aid case doesn’t have to house the speaker. Cons: The speaker may have to be replaced due to earwax clogging the end of it. They may pick up wind noise.

Open fit BTE, RIC or RITE These leave the ear canal partially open. The thin tube on the BTE or the speaker of the open fit RIC and RITE models is coupled with a dome. Works well for those with adequate lowfrequency hearing and mild to moderate hearing loss at higher frequencies.

Pros: Less visible. Because they don’t plug the ear canal, low-frequency sounds enter the ear canal normally, which can make your own speech sound better. Cons: Small parts can make these more difficult to handle. Limited volume due to feedback and frequency range makes them less effective for more severe hearing loss.

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News and our views Vegetarians reduce risk of heart disease by a third According to new research published in The American Journal of Clinical Nutrition, following a vegetarian diet can reduce your risk of a heart attack by more than 30 percent. The research involved about 45,000 adults living in England. About 15,000 of the study participants were classified as vegetarians — meaning they didn’t eat any meat or fish, although some consumed eggs or dairy (lacto-ovo vegetarians). About 11 years after the study began, researchers looked at records to determine how many participants had been admitted to a hospital for heart attack or similar heart problems, or had died from a heart attack. They found the vegetarians in the study had a 32 percent lower risk of heart attack than did nonvegetarians, even after statistically adjusting for factors such as smoking and activity level. Researchers also found the vegetarians had lower blood pressure and better cholesterol levels than did nonvegetarians. Mayo Clinic doctors say the results of the study build on previous research. By not eating meat, you’re avoiding one of the primary sources of cholesterol and saturated fat in a typical American diet that can contribute to plaque buildup and blockage in the arteries of the heart. Further, you’re likely eating more — and a wider variety of — disease-preventing phytochemicals such as antioxidant vitamins and other nutrients found in minimally processed plant-based foods. They note that study participants who had been vegetarians less than five years still had a reduced risk of heart trouble compared with nonvegetarians, which is evidence that it’s never too late to start. Whether you’re a vegetarian or not, you can get the most health benefits by eating a wide variety of healthy plant foods and minimizing intake of cholesterol and saturated fat. ❒

Diabetes drug may improve ovarian cancer survival The diabetes drug metformin (Glucophage) may play a role in longer survival for women with ovarian cancer. A recent Mayo Clinic study reports that women with ovarian cancer who were taking metformin to manage their diabetes had a better survival rate than did women with ovarian cancer who weren’t taking metformin. The study appeared in the Feb. 1, 2013, issue of Cancer. Metformin is commonly prescribed to treat diabetes. In recent years, other studies have suggested the drug may have anti-cancer effects on a number of cancers, including prostate, colon, pancreas and brain cancers. This latest retrospective study drew from a data pool of women with ovarian cancer. From this group, researchers found that 67 percent of the women who took metformin for diabetes survived after five years compared with 47 percent survival for those who weren’t taking metformin. Once other aspects — such as cancer severity and the type of chemotherapy — were factored in, those who took metformin were nearly three times more likely to survive. Mayo Clinic researchers say their findings pave the way for further exploration into the use of metformin in the overall treatment of ovarian cancer. They suggest using metformin in large-scale, randomized clinical trials involving women with ovarian cancer. The latest study illustrates how very meaningful progress can occur in medical treatment when new roles for currently available drugs are discovered. ❒

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Nuts Small packages, big nutrition Some notions die hard, like the one that says you shouldn’t eat nuts because they’re high in calories. For their size, nuts are calorie dense — but they’re also packed with heart-healthy nutrients. Understanding the nutritional value of nuts is key to judiciously working them into your diet as a protein substitute or as a replacement for other, less healthy snacks. The guts of nuts Most nuts are seeds, or the dried fruit from trees. Although peanuts are legumes — like beans and peas — they have a similar nutrition profile to tree nuts and are commonly thought of as nuts right along with walnuts, almonds, cashews and the rest. Almost all nuts are high in fat, which explains why such small nuggets of food can be so high in calories. However, the majority of fat in nuts is “good” fat — meaning the fat is monounsaturated and polyunsaturated. These fats are likely key players in the positive cardiovascular effects. Of note, walnuts top all other nuts — as well as all edible plants — when it comes to alpha-linolenic acid (ALA) content. ALA is a heart-healthy omega-3 fatty acid. Walnuts rank high on the American Heart Association’s list of foods to eat for heart health. Nuts also provide dietary fiber. ­Diets high in fiber can help lower cholesterol. Fiber in nuts — along with fat content — may also help provide a sensation of feeling full, so including a small serving of nuts may help you feel fuller longer. Nuts are an excellent source of protein. As part of the protein package, nuts often are high in a particular amino acid — L-arginine — that promotes nitric oxide production. Nitric oxide is essential for proper blood vessel function.

Among other nutrients, nuts offer a good dose of folate, which is a B vitamin that can help curtail the accumulation of homocysteine. High levels of homocysteine may increase risk of coronary artery disease. Some nuts also contain plant sterols. These natural substances are known to help lower cholesterol and are added to some margarine-like spreads and orange juice for their health benefits. Health nut tally A review of recent study data provides a quick snapshot of the influence nuts appear to have on various health aspects, particularly cardiovascular health. Several studies provide consistent evidence that eating nuts is associated with a: ■ Decrease in cholesterol — Multiple studies have shown a relationship between regularly eating nuts and a cholesterol-lowering effect, usually without harming the level of HDL cholesterol — the “good” cholesterol. ■ Decrease in risk of coronary artery disease (CAD) and death due to CAD — One pooled analysis of data from four studies found that those who ate nuts more than four times a week had a 37 percent reduced risk of death due to CAD when compared with those who never or rarely ate nuts. Largescale epidemiologic studies suggest

there’s benefit in eating nuts and other foods high in omega-3 fatty acids for those at risk of coronary artery disease. ■ Decrease or no change in body weight — Although it may seem counterintuitive, multiple studies have demonstrated a neutral or even inverse relationship between nut consumption and weight. Some say the main reason weight gain doesn’t occur is because nuts are a satisfying fatty food with considerable fiber. As such, eating nuts appears to dampen the need to eat. In addition, nuts are a healthier alternative to other high-fat, high-salt or high-sugar foods. There’s also limited evidence that nut consumption may increase healthy blood vessel elasticity and decrease: ■ Sudden cardiac death — A large, multiyear study found that men who ate nuts two or more times a week had a 47 percent reduced risk of sudden cardiac death compared with men who never or rarely ate nuts. ■ Inflammatory markers in blood — Inflammation is linked to blood vessel damage that can lead to heart disease. There’s increasing evidence associating frequent nut eating with lower levels of some inflammatory elements in blood. However, more study is needed to determine if nuts are responsible for the anti-inflammatory effect. ■ Blood pressure — There’s limited

circumstantial evidence that eating nuts may offer some protective effect against developing high blood pressure. In addition, two large studies found that those who ate nuts more frequently had between a 25 and 30 percent reduced risk of gallstone disease. Choose unsalted, dry-roasted nuts The American Heart Association recommends eating four servings of unsalted, dry-roasted nuts a week. Because nuts are high in calories, enjoy them judiciously by substituting them in for other foods, rather than adding them to your diet. A typical serving size is about 1.5 ounces of whole nuts. That’s the equivalent of a small handful of nuts or 2 tablespoons of a nut butter. Most people who enjoy nuts have a favorite or two. But, if you want a wider variety of nutrients, try mixed nuts. When eating mixed nuts you receive the benefit of a wider array of nutrients because each nut has a slightly different nutrient profile. Enjoy nuts as a late afternoon snack to tide you over to dinner. Try adding some cashews to a stir-fry. Add some pecans, walnuts or almonds to a green salad. Toss nuts into your morning cereal or stir them into yogurt. Pine nuts or pistachios can be a nice topping to pasta dishes. A small amount of nuts can provide a lot of flavor. ❒

Nut

Number of nuts

Calories

Total fat grams

Unsaturated fat grams

Protein grams

Fiber grams

Almonds

33

253

22

19

9

5

Brazil nuts

9

279

28

19

6

3

Cashews

27

244

20

15

7

1

Hazelnuts

31

275

27

23

6

4

Macadamia nuts

15-18

305

32

26

3

3

Peanuts

42-43

249

21

17

10

3

Pecans

29 halves

302

32

27

4

4

Pine nuts

250

286

29

22

6

2

Pistachios

74

241

19

16

9

4

Walnuts, English

21 halves

278

28

24

6

3

June 2013

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Pseudogout Crystals and joint pain Your knee has been unusually achy the last day or so. But why would it go from achy to downright painful and swollen just overnight? It even hurts to walk. Your doctor says the knee pain may be a form of arthritis commonly referred to as pseudogout (SOO-doegout) and that a couple of tests should help determine if that’s the cause. Pseudogout is an inflammatory form of arthritis that comes on suddenly. Once identified, it generally responds well to treatment. What’s in a joint? What causes pseudogout isn’t completely understood. It’s one of several joint disorders collectively called calcium pyrophosphate deposition disease (CPPD). The term “pseudogout” came about because of the condition’s similarity to another inflammatory arthritis called gout. The two can cause similar symptoms, flaring up out of nowhere and usually affecting a single joint. Although both disorders involve crystal formation in the affected joint, the crystal deposits are different. Gout is caused by crystals of uric acid and often occurs in the joint at the base of the big toe. Pseudogout crystals are composed of a calcium salt called calcium pyrophosphate dihydrate. These crystals become more numerous with age. They first show up in the cushioned covering (cartilage) on the ends of joint bones. Eventually, the crystals are found in the joint’s protective lining (synovium) or the joint’s synovial fluid where they can cause inflammation — but not always. While an attack of pseudogout is linked to the presence of calcium crystals in the joint, most people who have these crystal deposits never develop the disorder. Any joint may be affected by pseudogout, but most often it flares up in

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large joints, such as the knee or wrist. It more commonly affects a single joint. Signs and symptoms may include: ■ Swelling ■ Redness and warmth ■ Pain that becomes severe over a matter of hours or days A low-grade fever — usually below 100 F — also may be present. Who’s at risk? The frequency of pseudogout varies with age. Typically, it occurs in people older than 55, and in most cases, there’s no clear reason that explains its sudden onset. In addition to age, other factors may increase the risk of developing pseudogout, including: ■ Previous joint trauma — A serious joint injury or surgery on a joint increases the risk of crystal deposits in that joint. ■ Genetic tendency — In some families, people inherit a predisposition for these crystal deposits in joints and are more likely to develop pseudogout, possibly at a younger age. ■ Mineral imbalances — Having excessive stores of iron (hemochromatosis), too much calcium in the blood or too little magnesium put you at greater risk of pseudogout. ■ Certain medical conditions affecting metabolism — An underactive thyroid (hypothyroidism) or overactive parathyroid glands may contribute to risk of pseudogout. Sorting it out Typically, lab tests and X-rays of the affected joint are done to confirm a diagnosis of pseudogout. Blood tests can help sort out if there are other underlying disorders affecting the thyroid or parathyroid glands or if mineral imbalances are present. A sample of synovial fluid may be withdrawn from the joint using a needle. The fluid can then be tested for the presence of crystals. There’s no cure for pseudogout, but once it’s identified, treatment can help relieve pain and improve the joint’s June  2013

function. To help relieve pressure and pain, your doctor may insert a needle into the affected joint to remove the excess fluid. Then, a numbing medication and corticosteroid are injected to reduce inflammation. Medication options may include: ■ Nonsteroidal anti-inflammatory drugs (NSAIDs) — Depending on your overall health, your doctor may recommend taking a prescription-strength NSAID for several days until the flare subsides. Typically a medication such as naproxen (Naprosyn, others) or indomethacin (Indocin) is prescribed. However, these drugs may not be an option if you have decreased kidney function, you take warfarin (Coumadin), or you have a history of congestive heart failure, heart attack or stomach ulcers. ■ Colchicine (Colcrys) — This drug is used to treat gout, but it’s also effective at low doses for pseudogout. Colchicine may not be an option if you have kidney or liver problems. ■ Corticosteroids — If you can’t take other medications, your doctor may recommend an oral corticosteroid, such as prednisone. During a joint flare-up, it helps to rest the joint for a couple of days. Cold packs also can help reduce inflammation. Down the road Although treatment of pseudogout generally provides significant relief of joint pain and swelling within a matter of days, it doesn’t completely remove or prevent the formation of calcium pyrophosphate dihydrate crystals. How soon symptoms resolve is variable. The time frame depends on the form of treatment and the attack’s severity. An attack can last from days to weeks. Most people diagnosed with the disorder have few attacks. These occasional flare-ups tend to be spread out over a long period of time. However, if joint pain attacks are more frequent than several times a year, your doctor may recommend either a daily low dose colchicine or NSAID as a preventive measure. ❒

Paget’s disease Common cause of bone weakening After you injured your leg in a car accident, the X-rays didn’t show any fractures. However, they did show an abnormal appearing bone in your leg caused by a condition that you had never heard of — Paget’s disease. Paget’s disease is common in older adults of European descent. It may affect up to 5 percent of women and 8 percent of men at age 80. It often goes undetected and typically progresses gradually over decades. For many who have Paget’s, it never causes problems. Bone pain is the most common symptom, and it usually responds to treatment. Unfortunately, serious complications of Paget’s can occur — and preventing or treating these problems isn’t as simple. Remodeling gone awry Bone is living tissue in a continuous process of renewal called remodeling. During remodeling, old bone is removed (resorbed) and replaced by new bone. This process is disrupted in bone affected by Paget’s disease. In Paget’s, old bone is ­removed up to 10 times faster than normal. New bone formation increases to keep pace with resorption. Bone that’s more rapidly formed is disorganized, and over time, the bone becomes enlarged, deformed and more fragile. Paget’s disease may occur in one or two bones, or it can involve multiple bones. Commonly affected areas ­include the pelvis, legs, spine and skull. Bone pain with Paget’s disease is typically mild to moderate in severity and may persist throughout the day and night. The pain can worsen when you’re on your feet, especially if Paget’s affects your pelvis or legs. Sometimes, skin over an affected bone may feel warm. Complications of Paget’s disease can occur depending on where the dis-

ease is located and can be challenging to manage. These include: ■ Nerve compression — Enlargement of bone near a nerve, especially in the skull and spine, may press on nerves, causing pain and loss of function of the nerve. This can also damage a nerve traveling through the skull, which can cause double vision or paralysis of facial muscles. It can also put pressure on the spinal cord or the nerves as they branch off the spinal cord. This can cause pain, weakness and loss of sensation in the legs. ■ Bone deformity — Weakened bones in the limbs gradually become bowed. ■ Fractures — Fractures can occur in bone weakened by Paget’s. These fractures are most common in the legs. They can also lead to stress fractures or fissure fractures on the outer surfaces of extremities that are bowed. Stress fractures can progress to complete fractures. ■ Arthritis — This develops in arms and legs that are bowed because of excessive wearing of the joint due to misalignment of the extremity. Joints also wear out more rapidly if Paget’s disease affects the bone adjacent to the joint. This can result in a need for hip or knee replacement. ■ Rare problems — Bone cancer (osteosarcoma) is a rare complication of Paget’s disease. This complication is suspected if you have Paget’s disease and experience new symptoms. Treatment dilemma Paget’s disease is most often discovered during an examination for another reason. Diagnosis of Paget’s is usually made on the basis of an X-ray. Additional tests may be done to confirm a diagnosis or rule out other problems. Bone pain caused by Paget’s disease responds rapidly to treatment with drugs called bisphosphonates, which can be taken orally or given by injection. These drugs are often used to treat bone-thinning osteoporosis. They work so well that bone pain caused by Paget’s often goes away within days or weeks, at which point bisphosphonate June 2013

therapy can be discontinued. Bisphosphonates can be used again if bone pain returns. Recently, the intravenous bisphosphonate zoledronate was shown in a single infusion to provide a higher response rate and more durable benefit — more than five years — when compared with oral bisphosphonates. Work with your doctor to decide whether bisphosphonates are appropriate for you. Bisphosphonates can cause side effects — such as fever and chills, aches and pains, and gastrointestinal symptoms. Rare complications include ulcers in the mouth that are associated with necrosis of the jawbone or stress fractures of the bone in the thigh. It’s important to weigh the risks against benefits in treating Paget’s complications. If you have a family history of Paget’s disease or disease activity in areas where complications are more likely to develop — such as weight-bearing bones, the spine or the skull — the risk of bisphosphonate therapy may be an acceptable trade-off. ❒

A complication of Paget’s disease is weakened bones in the limbs that can gradually become bowed. www.HealthLetter.MayoClinic.com

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Second opinion

Q

What a shock I had when I looked in a mirror this morning and saw that part of the white in my left eye was blood red. How did this happen? My vision is fine and it doesn’t hurt, but I’m wondering if I should see my doctor about this.

A

You probably had a subconjunctival hemorrhage. On its own, a subconjunctival hemorrhage is usually a harmless development that occurs when a tiny blood vessel leaks under the thin membrane (conjunctiva) that covers the white of your eye. As long as you’re not experiencing bleeding elsewhere — which might suggest a bleeding disorder — there’s generally no need to see your doctor. However, if you have eye pain, light sensitivity or a change in vision, the problem may be something more serious and requires urgent medical evaluation. With subconjunctival hemorrhage, it isn’t always apparent what causes the vessel to leak. Forceful coughing, sneezing, straining or vomiting may lead to a blood vessel rupture. Sometimes the cause is minor trauma to the eye, such

Subconjunctival hemorrhage occurs when a tiny blood vessel leaks under the membrane that covers the white of the eye.

as rubbing the eye. Commonly, the rupture occurs for no appearent reason. Whatever the cause, it usually clears up within a couple of weeks as the blood is slowly reabsorbed. If you end up having repeated episodes of subconjunctival hemorrhage, check with your doctor. An exam may be appropriate to check the conjunctiva for abnormal vessels or to check for an underlying blood disorder. It may also be worthwhile to review any medications you’re taking — such as blood thinners — that could be a factor. ❒

Q A

What is coconut water? Is it good for you?

Coconut water is the clear liquid found inside immature coconuts, not to be confused with coconut milk. Coconut milk is an emulsion of fresh grated coconut meat from a mature coconut. However, many canned coconut milk products include other ingredients, so check the label carefully. Coconut water — in its pure form — is a type of juice. But, unlike other juices, unflavored coconut water is low in sugar and calories. Ounce for ounce, typical fruit juices have twice as many calories as unflavored coconut water. Coconut water is popularly used as a healthy drink for rehydration after physical activity or an illness, such as diarrhea. It’s true that coconut water has natural electrolytes — such as potassium, sodium and manganese — but amounts can vary due to changes that occur in coconut water as the coconut matures. So, while there’s some evidence suggesting it may be comparable

to having a sports drink, there’s also evidence that coconut water may be no more effective than drinking plain water. Coconut water can be a significant source of potassium. For someone with diminished kidney function, drinking a lot of coconut water might increase the risk of elevated potassium levels (hyperkalemia). There’s also some preliminary research suggesting that drinking coconut water might lower blood pressure in people who have high blood pressure. In theory, it might lower blood pressure too much if you’re already taking medications for high blood pressure. As a casual beverage, coconut water is generally considered safe. Remember, coconut water in its natural unflavored form does have some calories. If you’re watching calorie intake, be sure to check the label of your coconut water product. ❒

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. Editorial comments can be directed to: Managing Editor, Mayo Clinic Health Letter, 200 First St. SW, Rochester, MN 55905, or send email to [email protected] For information about Mayo Clinic services, you may telephone any of our three facilities: Rochester, Minn., 507-284-2511; Jacksonville, Fla., 904-953-2000; Scottsdale, Ariz., 480-301-8000 or visit www.MayoClinic.org

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