Monday, April 27, 2020

Medications for Back Pain

by Zinovy Meyler, D.O.


Different medications used to control back pain fall into different categories. Now, the broad spectrum of the categories can be broken down initially into the way we take the medication itself. So, oral medications, those that can be used as topical medications, and those that need to be injected.

So, to talk about the oral medications, which are more commonly used as an initial treatment. Over-the-counter medications that control the pain, such as Tylenol, can be used to control the pain itself. Now if we are to actually employ the use of the anti-inflammatory and pain control, we can seek the aid of non-steroidal anti-inflammatory medications/drugs (NSAIDs). The most common ones are ibuprofen, naproxen, and the common brand names are Aleve, Motrin, Advil.

The other medications that can be used are steroids. If there is a lot of inflammation that causes the back pain, oral steroids can be employed. Now, generally, we don’t like to use oral steroids for a variety of reasons – they don’t tend to help pain that is axial, or in other words pain that is limited to the actual back without radiating into the extremities. So, we are actually using the steroids very sparingly because it has systemic effects - although minimal, but it does - and as with any treatment, we try to minimize the systemic effect or any side effect by achieving the highest yield in terms of relieving pain. So, steroids can be used, but are not commonly used.

Another type of medication is narcotic medication. Now, narcotic medications are opioids and they are used to dissociate the patient from the pain. They are usually used for severe, acute pain. They are meant to be used for a short period of time, such as the initial injury, or initial trauma, or initial onset of the most acute pain or they can be used in post-operative pain control. Another group of medications are muscle relaxants. Now, muscle relaxants are used to decrease the tone of the muscles and the reason to use them is because in many cases of back pain, muscle spasm is what usually accompanies it.

Another oral medication that can be used to control back pain is antidepressants and a variety of antidepressants can be used. An example of those would be tricyclic antidepressants or antidepressants like Cymbalta.

So, there are certain medications that can be used by just putting it directly on the skin over the area that is affected and that can be helpful. The benefit of these medications is that it is directly applied to where the pain is and where the injury is. The medications are either anti-inflammatory or pure painkillers. So the pure painkillers are things like lidoderm patch, which is lidocaine that is slowly released through a patch through the skin and that can be applied to used to just numb up the area and reduce the localized pain. Another type is the use of diclofenac, which is one of the older non-steroidal anti-inflammatory medications and that can be used in the form of a patch as Inflector patch or in the form of a cream, such as Voltaren or other formulations. The benefit of this is that it is localized and systemic absorption is quite limited. That limitation is the fact that it only penetrates a certain depth and so really the use is, to an extent, limited.
Another group of the medications are the medications that are injected and there are really two of the main ones that are used for back pain. One is non-steroidal anti-inflammatory medication that can be injected, such as Toradol, and that’s injected into the muscle and the effect is systemic - or in other words it affects the whole body - in reducing the pain and its anti-inflammatory action. Another one is anesthetic, which is anesthetic like lidocaine, bupivacaine, or any other form of an anesthetic that is used to numb up the area. That can be used either to break up a muscle spasm or to numb up an area so that other manipulations can be performed in order to relieve the pain.

Another medication that can be used as an injectable is a steroid. A corticosteroid, as opposed to an oral corticosteroid, goes directly to where the problem is. So, it doesn't have to be systemically absorbed - it bypasses the systemic effect - even though it is systemically absorbed to a small degree, but it bypasses the major systemic side effects and its concentration doesn't have to be diluted by all the processes that have to happen in our body in order to get that medication to the source of the pain.

So, that really is a general overview of the medications we can use in controlling, and relieving, and in treating back pain.
_________________________________




Sunday, April 19, 2020

Texas will not take the mark of the beast

'Anti-Something' Protesters At Texas State Capital, April 18, 2020

No, COVID-19 isn't like the Flu

Anti-Quarantine Protest in Olympia, Washington
“When enough insane people scream in harmony that they really are healthy, they can actually start to believe themselves. Or put even more simply: people with overlapping delusions get along wonderfully.” (Daniel Mackler, Toward Truth, 2010)

From my friend Everett Daniel Maroon, who writes this for anyone who needs to hear it:
  1. People dying from the flu over a 7-month period vs. the same number of people dying from COVID-19 over a 6-week period is an important difference.
  2. People dying from cancer in hospice or at home vs. people dying in an ICU bed is a big difference in terms of hospital resources.
  3. People dying from accidents, gun shot trauma, homicides vs. people dying from a communicable disease is a huge difference in risk to the community.
  4. People dying from a communicable disease that we HAVE treatments and cures for vs. people dying from a communicable disease that has no vaccine or curative treatment is a catastrophic difference.
  5. People dying from a disease we know about (smallpox, rabies) vs. people dying from a disease we don't yet fully understand is WHY WE TELL PEOPLE TO STAY AT HOME.
  6. Acting like these differences don't matter is exactly why governmental leaders around the globe have ordered us to stay home.
  7. This is not a Jay Inslee issue. It is not ultimately a Donald Trump issue. Please stop acting like there is nothing different about this novel coronavirus.

Wednesday, April 15, 2020

First Do No Harm!

PURPOSE

The purpose of this post is to describe the similarities and differences between the symptoms and diagnostics that might be used to distinguish between COVID-19 and pericarditis. I'm interested in this because, as I've described in some detail in a prior post, I've experienced acute pericarditis and still suffer from its effects.

In addition, fatalities associated with COVID-19 are overwhelmingly associated with the elderly and people with existing chronic or temporary medical conditions, such as heart disease, lung disease, asthma, the flu, or other preexisting conditions. Of course, COVID-19 will also target people who may have compromised immune systems, including those compromised by medications they may be taking to treat a preexisting condition, such as patients suffering an acute attack of pericarditis being treated with prednisone, a corticosteroids which, like others, suppresses the immune system.

COVID-19

In 2019, a new coronavirus was identified as the cause of a disease outbreak that originated in China.
The virus is now known as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease it causes is called coronavirus disease 2019 (COVID-19).

The signs and symptoms of COVID-19 compiled by WebMD based on information gathered from researchers in China, included:
  • Fever 83%-99%
  • Cough 59%-82%
  • Fatigue 44%-70%
  • Lack of appetite 40%-84%
  • Shortness of breath 31%-40%
  • Mucus/phlegm 28%-33%
  • Body aches 11%-35%
 Symptoms usually begin 2 to 14 days after one comes into contact with the virus.

Other symptoms may include:
  • Sore throat
  • Headache
  • Chills
  • Stuffy nose
  • Nausea or vomiting
  • Diarrhea
Some people have experienced the loss of smell or taste.

PERICARDITIS

The Mayo Clinic describes pericarditis is swelling and irritation of the pericardium, the thin sac-like membrane surrounding the heart. Pericarditis often causes chest pain and sometimes other symptoms. The sharp chest pain associated with pericarditis occurs when the irritated layers of the pericardium rub against each other.

Depending on the type pf pericarditis, its signs and symptoms may include some or all of the following:
  • Sharp, piercing chest pain over the center or left side of the chest, which is generally more intense when breathing in
  • Shortness of breath, especially when reclining
  • Heart palpitations
  • Low-grade fever
  • An overall sense of weakness, fatigue or feeling unwell
  • Cough
  • Abdominal or leg/feet swelling
Many of the symptoms of pericarditis are similar to those of other heart and lung conditions, including COVID-19.

COVID-19 or PERICARDITIS?

I am day 11 into COVID-19. I'm in the emergency room with severe chest pain and breathing problems. ER nurse said my heart and lungs may be inflamed. My ECG is "abnormal." My pulse is strong. I can’t get to my regular doctor because of the lock-down here. In the last 2 days since my visit to ER I have felt dizzy and nauseous. I have pain in middle of my chest and a panicky fluttery feeling. Now I have a really sore throat. Is this now pericarditis?

Answering the question of this patient on the basis of this information isn't straight-forward. As the symptoms described in the previous sections show, COVID-19 and acute pericarditis symptoms mirror each other closely. This is further illustrated in Table 1, below.


Research indicates that the most common cause of idiopathic pericarditis "in developed countries" is a virus of unknown specificity, thus the diagnosis "non-specific idiopathic pericarditis." Deriving from the severe acute respiratory syndrome coronavirus 2, COVID-19 may well trigger pericarditis, or in a patient with the pre-existing condition, a pericarditis flare up. On the other hand, patients with pre-existing cardiac conditions, like pericarditis, may be more susceptible to COVID-19 because of a disease-induced depressed immune systems, or because a treatment protocol for their pericarditis depresses their immune system, e.g., prednisone (see Figure 1).

Fig. 1. Complementary relationship between COVID-19 and Pericarditis

One of the key ways humans encode and then retrieve information is by labeling and compartmentalizing it, e.g., this disease manifesting these symptoms is COVID-19. This disease manifesting these symptoms is the flu. This disease manifesting these symptoms is pericarditis.

The lay person gets the sniffles concludes they have a cold, the sniffles evolves to a cough, fever, and achy body and they lament having contracted the flu. But in the midst of a SARS-CoV-2 pandemic, they might fear they've come down with COVID-19.

In diagnosing any given patient with the objective of learning and then treating the source of their misery it's imperative that physicians understand (and most do) that the patient is a living history of all that ails them. A patient that presents with flu-like symptoms, is experiencing shortness of breath, and has sharp chest pain, must give a full health history, be examined, and be given a complete laboratory workup to sort out the source of their misery, realizing that it may be generated by a combination of linked factors, i.e., COVID-19 and pericarditis. The course of treatment depends on doing this. Otherwise it might do more harm than good.

Sunday, March 8, 2020

You don’t have to be a socialist to want to improve America

Not Tom Hanks and Meg Ryan Sleepless in Seattle
Frank Watson tells us in his Thursday, March 5th commentary in the Cheney Free Press, that, “…patriotism really is a good thing.” Read on and discover that what Frank means is that if you agree with him, you’re patriotic and if you don’t, you’re not. But Frank is not so much commenting on patriotism as he is on socialism — a favorite axe Frank enjoys grinding.

Frank is taking Bernie Sanders to task for advocating accessible and affordable health care for all Americans (Medicare4A), and vastly improved education, including tuition-free undergraduate degrees at public colleges and universities. Not one for nuanced argument, Frank paints all the Democratic candidates (even Mike Bloomberg, for cryin’ out loud) with the same broad brush — dipped in red to reflect their socialist (and by extension,“communist”) leanings.

I responded to an earlier lament that Frank wrote about the evils of socialism (CFP, 10/17/19) by pointing out that Frank, as a member of the military, spent much of his working life living under a model socialist system, and now in his retirement enjoys continuing socialist programs (Medicare, Tri-Care for Life, military pension, and other VA benefits, including burial). Nevertheless, Frank believes he isn’t a socialist, and that’s because Frank doesn’t want other Americans to enjoy the same benefits.

The bottom line on Frank’s arguments extolling the virtues of America’s hospitals and universities is that he’s right — they are excellent. They just aren’t affordable for the vast majority of Americans. You don’t have to be a socialist to want to change that.

“When we stop and look into the face of poverty,
we recognize that “the poor” are not strangers.
They are our sisters and brothers, members of our human family.”
A Pastoral Letter from the Catholic Bishops of the State of Washington

Sunday, February 9, 2020

Newt Gingrich Tears Into Nancy Pelosi for Tearing Donald Trump's 2020 SOTU Speech


By way of full disclosure, Newt Gingrich is not one of my favorite people. Nevertheless, out of respect for those of you who may be members of his "Inner Circle," I read his essay on Nancy Pelosi and the "petty, nasty Democrats." First, as a “thought piece” on the coming 2020 Election, it lacks any original, let alone objective insight. Here’s a much more insightful analysis of what’s happening in American political discourse by McKay Coppins in the Atlantic.

Second, Gingrich criticizing Pelosi for ignoring tradition and protocol in how she behaved during Trump’s SOTU speech once again demonstrates how little Republicans seem to know or care about irony. In 1978 Gingrich lectured a group of young student Republicans, “One of the great problems we have in the Republican Party is that we don’t encourage you to be nasty.” McKay Coppins credits, if that's the right word, Gingrich with turning politics into a blood sport.

Trump has broken every rule in the book when it comes to how one behaves in the highest office in the land. Two days ago in a publicly televised rambling diatribe in the East Room of the White House he used profanity to yet again denounce the Russia probe, and to claim that he did nothing wrong in his call with Ukraine President Zelensky.

At the National Prayer Breakfast last Thursday, Trump told Arthur C. Brooks, who spoke on the theme of his book, “Love Your Enemies,” that he didn’t agree with him, and proceeded to turn the communion into a pejorative-laced rant against his enemies, real and those yet to come. Trump has undermined faith in the Intelligence Community, the FBI, the DOJ, the Media, and now in faith itself.

 If you watched the SOTU speech, which I did, you saw Speaker Pelosi read through the speech as Trump gave it — easy to do, since Republicans made sure to applaud Trump’s pronouncements as often as possible without looking totally absurd. Pelosi was clearly angered by the blatant lies and exaggerations layered throughout the speech, but she kept her cool and waited until Trump had accepted his accolades from his assembled sycophants before she gave the speech its due, and tore it to shreds. Here’s what David Frum of the Atlantic (2/5/2020) said of the speech:

“The president crammed his speech with blatant and aggressive lies. The Trump administration is not committed to protecting patients with pre-existing conditions; it has repeatedly sought to end this protection and is in court right now trying again. The U.S.’s position as the world leader in oil and gas production is not thanks to any action of Trump’s; the country moved into first place in 2012. Trump has not presided over any kind of “comeback” of the economy, which grew faster in the three years before he took office than in the three years since. Manufacturing employment has not recovered under Trump; because of his trade wars, manufacturing employment has crashed on his watch. Trump’s untruthfulness is notorious, but it’s still a departure to lie and mislead so often and so brazenly before all the assembled Congress.”

For myself, I find it Orwellian that Gingrich and other Republican blowhards pretend outrage over Pelosi tearing up Trump’s SOTU speech while at the same time pretending that it’s okay to withhold military aid appropriated by Congress in order to coerce Ukraine to announce an investigation into a political rival.

I have to wonder if Gingrich or these other Republican snowflakes will feel the same outrage as Trump exacts his vengeance against those who obeyed Congressional subpoenas and testified during the House impeachment hearings, such as LTC Alexander Vindman, along with his brother LTC Yevgeny Vindman, both of whom were escorted from the White House, and U.S. Ambassador to the E.U. Gordon Sondland. Fiona Hill, who spoke at the hearings in defense of Vindman, is gone, Jennifer Williams, a Pence advisor, is gone, of course Marie Yovanovitch is gone, and William B. Taylor Jr., who served in the Vietnam War and earned a Bronze Star and an Air Medal with a V device for valor, is gone.

So, in my view, the damage that Nancy Pelosi may have done to the solemn honor and privilege of the Chamber and the Chief Executive is nothing compared to the damage Donald John Trump and his minions, including Newt Gingrich, are doing to truth and decency, to the Constitution, and to the country.

Sunday, January 5, 2020

The Assassination of Qassim Suleimani

Demonstration in Tehran Over U.S. Assassination of Qassim Suleimani
On Friday, an American drone fired missiles into a convoy leaving the Baghdad airport and killed Maj. Gen. Qassim Suleimani, who for decades has led Iran’s Quds Force of the Islamic Revolutionary Guards Corps. Several officials from Iraqi militias were also killed.


President Donald Trump, speaking from his Mar-a-Lago resort, said,”Suleimani was plotting imminent and sinister attacks…” He did not provide any details or evidence of such. Given the President’s propensity for lying, the credence of Trump’s rationale can certainly be questioned.

Suleimani was definitely an enemy of America, but George W Bush and Barack Obama both had opportunities to take him out and chose not to because the benefit was largely symbolic and the cost was largely unknowable. Of course, neither Bush nor Obama were facing an impeachment trial in the U.S. Senate.

What the general public is missing in all the “Sturm and Drang” over impeachment is the detrimental impact Trump’s global actions — self-serving, ill-considered, or simply impetuous — have on American interests and on American lives. This is particularly true of this latest precipitous act.

The assassination of a revered Iranian leader undermines Iranian elements seeking regime change. It encourages Iran’s accelerated development of a nuclear arsenal. Because it was carried out on Iraqi soil, it forces Iraqi’s leaders to demand the removal of U.S. forces, opening the divided country to further Iranian and Russian influence. And it effectively neuters our NATO allies. Also, although unlikely to be discussed by authoritative sources, it very likely compromised significant elements of U.S. national technical means, if not HUMINT against Iran.

People have asked whether this action will lead to an American war in Middle East. My answer is, “Where the hell have you been for the last six decades!”*

_____________________________
 *The July 1958 Marine landing in Beirut, Lebanon began the modern era of America’s wars in the region.