MAYO CLINIC HEALTH LETTER
VOLUME 27 NUMBER 3
is only one of the many situations thatmay increase your risk of DVT.
Inside this issue
People who develop DVT are
often predisposed to quicker clotting.
HEALTH TIPS . . . . . . . 3
That's often coupled with some cir-
Luggage without pain.
Preventing blood clots
cumstance — more likely hospital-ization or surgery than a long airline
NEWS AND OUR VIEWS . . . 4
in the legs
flight — that triggers clot formation.
Pneumococcal vaccine may re-
If you have an elevated risk of
duce heart attack risk. Forget about
You know the drill: Anytime you fly
blood clot development, taking pre-
ginkgo supplements to aid mem-
on an airplane for more than a cou-
cautions to prevent DVT is important.
ple of hours, you're supposed to stay
Once a clot develops, it may take
hydrated, avoid alcohol and period-
months to go away, even with treat-
TREATING ANXIETY . . . . 4
ically move your legs to prevent
ment. However, treatment greatly
Take back your life.
blood clots forming in your veins
reduces the risk that the clot will
SMALL INTESTINAL BACTERIAL
(deep vein thrombosis, or DVT).
become bigger, or that some or all of
OVERGROWTH . . . . . . 6
This is generally good advice. But
it will break away and block a lung
Cause of digestive trouble.
while public perception closely links
artery. This commonly fatal condition
cramped airline seats with DVT, this
is called a pulmonary embolism. ➧
SURGERY . . . . . . . . 7
Age limits are changing.
SECOND OPINION . . . . 8
Coming in April
Making the impossible possible.
THE B VITAMINS
Simplifying the complex.
Getting your gait back.
Recognizing what connects you.
If fragments of a deep vein thrombosis break loose, they can be carried to the lungs, block-
ing blood flow. This is called a pulmonary embolism, and it can be fatal.
Visit us on the Internet at the address listed to the left, where you'll find more
health information, great offers and more!
■ A past incident of DVT or pul-
Deep vein thrombosis is much
If you're found to have a DVT,
more common than most people
■ Use of hormone replacement
the immediate focus of treatment is
realize. It's estimated that each year
therapy or birth control pills
preventing the clot from getting big-
around 350,000 Americans are
■ Pregnancy and especially re-
ger and reducing the risk of pul-
affected by DVT or pulmonary em-
monary embolism. The mainstays of
bolism, its primary complication.
■ A family history of blood
therapy are drugs to prevent blood
DVT develops in the larger
clots, which may indicate an inher-
clotting (anticoagulants). These won't
"deep" veins that are the final con-
ited blood-clotting disorder
dissolve the blood clot, but they
duits funneling blood back to the
■ Lifestyle factors such as obe-
help prevent blood clots from break-
heart. It mostly occurs in the largest
ing off of your DVT, and prevent fur-
veins of the legs and pelvis, although
In addition, any one of several
ther blood clot growth.
DVT may occasionally develop in
situations may be a triggering event
Initial anticoagulant therapy
the arms. Many factors can make
leading to DVT. Even after the trig-
involves injections of a fast-acting
you more prone to DVT, including:
gering event is over, risk of DVT may
drug such as heparin. The oral anti-
■ Certain cancers, especially
be heightened for up to three months.
coagulant warfarin (Coumadin) may
pancreatic, brain, lymph node and
Triggering events include:
be started along with heparin. War-
lung cancers, or chemotherapy
■ Hospitalization for a sudden
farin takes a few days before it's fully
■ Advanced age or medical cir-
medical problem — Trauma to the
effective. As the warfarin takes effect,
cumstances that require you to be
leg area or pelvis or a fracture of a
you will likely be instructed to stop
in a nursing home
leg or pelvis bone puts you at espe-
cially high risk.
Most people with DVT can
■ Major surgery — This espe-
expect to take an anticoagulant drug
Beware of pulmonary
cially includes hip or knee replace-
for a minimum of three months.
ment or surgery in the pelvic area.
■ Long periods of sitting —
MAYO CLINIC HEALTH LETTER
From the deep veins of the
Airplane flights that are around six
legs and pelvis it's a straight
or more hours are the main culprits,
Robert Sheeler, M.D.
shot to the heart, and only a
but long car or train rides can be, too.
Associate Medical Editor
Amindra Arora, M.D.
short distance farther to the
lungs. If a fragment — or,
Hard to detect
more commonly, several
Many DVTs can develop and
fragments — of a deep vein
grow quite large before causing any
thrombosis break loose, they
symptoms. Still, almost all cause
can be carried to the lungs,
signs and symptoms eventually.
blocking blood flow. This is
These may include:
called a pulmonary embo-
■ Swelling in the ankle area of
Shreyasee Amin, M.D., Rheumatology; Amindra
lism, and it can be fatal.
the affected leg. Typically, only one
Arora, M.D., Gastroenterology and Hepatology; BrentBauer, M.D., Internal Medicine; Tracy Berg, R.Ph.,
Signs and symptoms of
leg is affected.
Pharmacy; Julie Bjoraker, M.D., Internal Medicine;
pulmonary embolism vary.
Bart Clarke, M.D., Endocrinology and Metabolism;
■ Leg pain that often starts in
William Cliby, M.D., Gynecologic Surgery; Diane
Sometimes, no symptoms
the calf and can feel like a cramp.
Dahm, M.D., Orthopedics; Mark Davis, M.D.,Dermatology; Timothy Hobday, M.D., Oncology; Lois
are evident. However, seek
■ Redness or warmth over the
Krahn, M.D., Psychiatry; Michael Mahr, M.D.,
emergency medical care if
affected area and fever.
Ophthalmology; Lance Mynderse, M.D., Urology;Suzanne Norby, M.D., Nephrology; Robert Sheeler,
If your doctor suspects DVT,
M.D., Family Medicine; Phillip Sheridan, D.D.S.,Periodontics; Peter Southorn, M.D., Anesthesiology;
■ Unexplained shortness
ultrasound imaging is typically the
Ronald Swee, M.D., Radiology; Farris Timimi, M.D.,
of breath, which can come
first test used because it's safe, wide-
Cardiology; Aleta Capelle, Health Information. Ex-officio: Carol Gunderson, Joey Keillor.
on gradually or suddenly
ly available and quite accurate.
Mayo Clinic Health Letter (ISSN 0741-6245) is published
■ Sharp chest pain when
Additional testing, such as more
monthly by Mayo Foundation for Medical Education
you inhale or cough
advanced imaging scans or addi-
and Research, a subsidiary of Mayo Foundation, 200First St. SW, Rochester, MN 55905. Subscription price
■ Feeling lightheaded or
tional blood testing, may be done
is $29.55 a year, which includes a cumulative index
dizzy or even fainting
published in December. Periodicals postage paid at
to aid in diagnosis, identify the root
Rochester, Minn., and at additional mailing offices.
■ Coughing up blood
cause of the problem or to help
POSTMASTER: Send address changes to Mayo ClinicHealth Letter, Subscription Services, P.O. Box 9302,
establish effective therapy.
Big Sandy, TX 75755-9302.
2 www.HealthLetter.MayoClinic.com March 2009
That's often about how long it takes
impair blood flow. Blood that should
for the body to dissolve the blood
be getting pumped up to your heart
clot. However, depending on the
can instead pool in your legs when
causes of your DVT and your risk of
you're upright. The result is leg
developing another, you may need
swelling due to fluid accumulation
Luggage without pain
to continue anticoagulants for as
(edema). Without treatment, addi-
long as your risk remains increased.
tional skin problems and large, dif-
More than 50,000 people
With anticoagulant use, there's in-
ficult-to-heal sores may occur.
sought treatment in 2007 due
creased risk of bleeding, so it's
When swelling occurs as a result
to injuries related to lugging
important to work closely with your
of DVT, it's called post-thrombotic
luggage. These travel safety tips
doctor to monitor your risk.
syndrome. About 30 to 50 percent
are from the American Aca-
If you can't take anticoagulants,
of those who have DVT will devel-
demy of Orthopaedic Surgeons:
a clot-trapping filter may be placed
op post-thrombotic syndrome. The
■ Pack lightly — Most
in the large vein in your abdomen
chances of developing it are high-
people bring much more than
that leads from your legs to your
est within the first one to two years.
needed. Cut back. Avoid mus-
heart. The filters may be able to
But anyone who has had DVT is at
cle strains, pulls and tears by
block a clot from reaching your
risk of developing post-thrombotic
packing items in a few small-
lungs. However, they're not risk-free
syndrome at some point later in life.
er bags instead of one large
and may actually increase the risk
Well-fitted compression stock-
piece of heavy luggage.
of developing clots in the legs. In
ings that are put on the affected leg
■ If possible, use wheeled
addition, evidence showing they
the moment you get out of bed and
luggage — Doing so reduces
can save lives is lacking.
worn all day are the main treatment
the time you're carrying the full
In rare cases, clot-dissolving
of post-thrombotic syndrome. How
weight of your luggage. If
drugs (thrombolytics) may be used
they're worn varies. Some doctors
you're purchasing new lug-
to dissolve DVT. For most, the risk
recommend that everyone with DVT
gage, choose sturdy, light
of potentially deadly bleeding out-
wear them for one to two years.
pieces with four wheels or two
weighs the clot-dissolving benefit.
Others feel they're only needed if
wheels and an extendable
significant swelling is present.
handle. When pulling wheeled
Once post-thrombotic syndrome
baggage or carrying bags,
A deep vein blood clot is like-
develops, you'll probably need to
avoid fully straightening (ex-
ly to cause vein damage or result in
wear a compression stocking on the
tending) your arm. Instead,
residual vein blockage. This may
affected leg for life. ❒
keep that arm bent and closerin to your body. If you mustuse stairs, carry your rolling
luggage as you climb or de-
For most healthy adults, DVT is extremely rare and not worth
scend the stairs.
worrying about. If you're at elevated risk of DVT or are working to
■ Use smart lifting and
prevent a second episode, help keep your legs clot-free by:
carrying techniques — Lift lug-
■ Taking precautions when traveling — Stay hydrated, avoid
gage with your leg muscles,
alcohol and take hourly breaks from sitting to walk around. The
not your back and waist. Stand
extra legroom of an aisle or business-class seat may help. For those
alongside your suitcase, bend
at especially high risk, a below-the-knee compression stocking or
at your knees, then grasp the
an injection of heparin prior to travel may be needed.
handle and straighten up.
■ Making lifestyle changes — Losing weight if you're obese may
Avoid twisting or rotating your
help reduce your risk of DVT.
spine, and don't rush. Carry
■ Following instructions from your doctor or surgeon — There
luggage as close to your body
are well-established guidelines for preventing DVT in many med-
as possible. If using a shoulder
ical situations, particularly with surgery. Anticoagulants feature
bag, be sure the strap is pad-
prominently in almost every DVT prevention plan. It's important to
ded and switch sides often.
take anticoagulants for the length of time recommended by your
■ Don't overdo — Check
doctor or surgeon — which may be for several weeks or longer —
heavier items when traveling.
and to carefully follow any additional instructions.
If you need help, ask for it. ❒
News and our views
Pneumococcal vaccine may reduce heart attack risk
For adults 65 and older, the pneumococcal vaccine offers protec-
Take back your life
tion from a common and sometimes deadly strain of bacteria that cancause serious infections of the lungs (pneumonia), the lining of the
It would be great to wake up and
brain (meningitis) or blood (bacteremia). But that may not be the only
look forward to the day. But it's been
way the vaccine prevents illness and death.
months since that happened. In-
A study published in the Oct. 7, 2008, issue of the Canadian
stead, your first thoughts are shroud-
Medical Association Journal showed that among recipients of the pneu-
ed by inescapable worries: "I hope
mococcal vaccine, the risk of a heart attack in hospitalized patients
I don't feel sick again today. What if
who were at risk of heart attack was halved.
I get another migraine? I can't face
Researchers studied about 5,000 Canadians with an average age
meeting with my book club tonight.
of about 60 and at least one risk factor for heart attack. A fifth of these
I feel so trapped, and I can't focus.
had been admitted to the hospital for heart attack. Pneumococcal vac-
I wish I didn't have to leave the
cination rates in this group were compared with those of the remain-
house and deal with anyone."
ing 4,000 participants who hadn't had a heart attack.
You weren't always like this. And
Among those who had received a pneumococcal vaccine at least
chances are pretty good that you
two years prior, heart attack rates were about 50 percent lower than
don't have to stay like this if you get
in those who received the vaccine within the past year or who had-
n't received it at all.
Anxiety disorders affect about
Mayo Clinic specialists agree with study authors that more research
40 million American adults. The
is needed to confirm results. There are a number of potential biases
good news is that there are effective
that the study didn't take into account. For example, participants in
treatments for anxiety disorders that
the group that had more heart attacks also had more of the diseases
can help you take back your life.
that increase heart attack risk. In addition, it may be that people
Recognizing the problem
who get the pneumococcal vaccine had better health care overall. ❒
Generalized anxiety disorder
Forget about ginkgo supplements to aid memory
(GAD) is one of the most common
Does the popular medicinal herb ginkgo (Ginkgo biloba) prevent
anxiety disorders. Often, it has its
dementia? Apparently not, according to results from the Ginkgo
beginnings somewhere between
Evaluation of Memory (GEM) study published in the Nov. 19, 2008,
childhood and middle age, although
issue of the Journal of the American Medical Association.
it can become evident at any age.
Participants were randomly assigned to two groups. One group
Among older adults, GAD can coin-
took 120 milligrams (mg) of ginkgo extract twice daily, and the other
cide with depression. Close to 7 mil-
group took identical-looking tablets with no active ingredients.
lion adult Americans have GAD,
Although ginkgo supplements are commonly promoted as use-
with about twice as many women
ful for enhancing and preserving memory, the GEM findings indi-
as men having the disorder.
cated otherwise. The rates of dementia or Alzheimer's disease were
Signs and symptoms of GAD
the same in both groups. And, there was no evidence that taking gink-
may appear gradually over time. In
go supplements reduced progression of dementia among those who
fact, those who have the disorder
had mild cognitive impairment at the start of the study.
may not recall the last time that they
Mayo Clinic doctors say that the GEM study findings are quite
felt at ease. If you have GAD, you
clear-cut. Although smaller studies in the past have suggested mem-
typically can't seem to shed your
ory benefits from ginkgo use, the GEM study along with other recent
worries, even though you probably
studies delivers a hard blow to the concept of ginkgo supplements
realize they're out of proportion to
preventing dementia. Instead of spending your money on supple-
any given situation. In addition to
ments, it might make more sense to spend it on a good book and a
excessive worrying, you may startle
good pair of athletic shoes, since being mentally active and physi-
easily, have trouble falling or stay-
cally fit has known benefits for the brain. ❒
ing asleep, and find it difficult toconcentrate when you're awake.
4 www.HealthLetter.MayoClinic.com March 2009
Other signs and symptoms of GADmay include fatigue, muscle tension
A thoughtful course of action to cope with anxiety
or aches, restlessness, feeling out ofbreath, nausea, diarrhea, headaches,
Cognitive behavioral therapy (CBT) can be a powerful treatment
and excessive irritability.
tool for anxiety disorders. This therapy addresses the thought
General anxiety disorder is just
patterns that support your fear or anxiety and helps you change the
one of several types of anxiety dis-
way you behave or react in situations that trigger anxiety.
orders. Others include phobia, panic
CBT is typically done with the help of a therapist who meets
disorder, obsessive-compulsive dis-
with you regularly, generally at least an hour each week over the
order, post-traumatic stress disorder
course of several months. The therapy is directed at your specific
and social anxiety disorder.
form of anxiety and is tailored to your needs. For instance, if youdeal with panic disorder, you'll learn about the physical mecha-
Deciding on treatment
nisms that produce the uncomfortable symptoms experiencedduring a panic attack — and, despite how it may feel, that you're
If anxiety interferes with your
not dying. If you're gripped with anxiety at the thought of being in
daily activities, it's time to see your
a large gathering of people, you'll learn to overcome the belief that
doctor. Anxiety disorders can occur
you're being judged and watched by others.
on their own, independent of any
The second prong of CBT therapy occurs when you and your
other health concerns. However, a
therapist decide you're ready to confront your fear. Exposure-based
whole host of disorders that may be
behavior therapy — where you encounter the object or situation
encountered with age — such as
that triggers your anxiety — may be gradually introduced, some-
heart disease, lung disease, thyroid
times using pictures or sound recordings. When you are ready to
problems and even dietary problems
face the feared situation, it's not uncommon for your therapist to
— can have anxiety as a symptom.
accompany you to provide support and guidance.
If there's an underlying condition,
Research shows that CBT is among the most powerful treat-
treating and managing it can help
ments for anxiety disorders. It may not cure your anxiety, but it can
reduce or eliminate anxiety.
give you the power to cope with your situation in a more healthy
When the primary concern is
way and to feel better about yourself and your life.
anxiety on its own, the main treat-ments include:
■ Psychotherapy — This involves
■ Medications — Generally, two
For treatment of acute anxiety
working with a therapist to under-
types of drugs — antidepressants
and over the short term, your doc-
stand how feelings and behaviors
and anti-anxiety drugs — are used
tor might recommend a benzodi-
can result from how you think about
to treat anxiety disorders. Among
azepine, which generally eases anx-
yourself and your experiences. This
antidepressants that have anti-anx-
iety within 30 to 90 minutes. These
may be done through cognitive
iety properties, the first choice often
include alprazolam (Xanax), chlor-
behavioral therapy, which involves
is a selective serotonin reuptake
diazepoxide (Librium), clonazepam
learning to identify unhealthy, neg-
inhibitor (SSRI), such as fluoxetine
(Klonopin), diazepam (Valium) and
ative beliefs and behaviors that con-
(Prozac), paroxetine (Paxil), sertra-
lorazepam (Ativan). There are con-
tribute to anxiety and how to replace
line (Zoloft) and citalopram (Celexa).
cerns over long-term use of benzo-
them with healthy, positive beliefs.
Other antidepressants that may be
diazepines, because they are habit-
These types of therapies can be
considered include duloxetine (Cym-
forming. In addition, they may cause
particularly helpful at improving
balta) and venlafaxine (Effexor).
unsteadiness, drowsiness, reduced
anxiety symptoms. With the help of
These drugs can be highly effec-
muscle coordination and balance
your therapist, you can learn to bet-
tive, but it may take several weeks
problems. Memory problems are
ter understand your anxiety triggers,
to months before the full effects are
possible and the risk increases with
develop coping skills and learn
noticed. In addition, it may be nec-
higher doses and long-term use.
relaxation skills. These treatments,
essary to try several before you find
Buspirone (BuSpar) is another
although generally short-term, can
one that works best for you.
drug used for anxiety. It's not in the
help you acquire the "tools" you'll
How long medication may be
benzodiazepine class and doesn't
need to identify, manage and turn
needed varies and is best decided
pose a risk of dependence. It takes
around the otherwise faulty think-
with the help of your doctor, who
several weeks to relieve anxiety and
ing patterns that can contribute to
can help tailor treatment to your
must be taken regularly, rather than
on an as-needed basis. ❒
your small intestine. There, fluid isextracted to be tested for bacteria
count. Tissue samples (biopsy) of thewall of the intestine also may be
taken to look for evidence of abnor-mal tissues or inflammation.
That's a fairly involved process
Cause of digestive trouble
that may not be appropriate for justanyone with digestive issues. How-
Persistent bloating, gut discomfort,
ever, additional clues may suggest
gas and diarrhea are signs and
bacterial overgrowth and can help
symptoms common to many types
you and your doctor determine how
of digestive problems. One that's
far you want to go in pursuing a
Small intestinal bacterial overgrowth means
been getting more attention recent-
diagnosis. These include:
there is either too much bacteria or the
ly is small intestinal bacterial over-
■ Evidence of poor nutrient
wrong type in the small intestine.
growth. This simply means that you
absorption — Weight loss, foul-
have either too much bacteria or the
in a section of small intestine with-
smelling, greasy stools — or a pos-
wrong type in your small intestine.
out normal intestinal movement
itive stool-fat test — anemia and
Interest has grown because anti-
(blind loop). These create a hide-
deficiencies of vitamin B-12 may all
biotics are sometimes effective at
away for bacteria to thrive.
suggest poor absorption or malnu-
eliminating symptoms, although
■ Scleroderma and Crohn's dis-
trition. In addition, since bacteria
they may be needed on an ongoing
ease, which can cause hardening
produce folate, and to a lesser extent
basis. This can be a ray of hope for
and scarring of intestinal tissues,
vitamin K, excesses of either nutri-
those with digestive troubles, be-
compromising movement within the
ent also may be a clue.
cause many struggle to find relief.
■ Hydrogen breath test — The
However, bacterial overgrowth
A number of disorders may con-
digestion of certain sugars by bac-
probably isn't that common. Among
tribute to bacterial overgrowth. Chief
teria in the colon produces hydro-
those with intestinal digestive prob-
among them is diabetes, which can
gen, which is absorbed into the
lems, such as irritable bowel syn-
lead to diminished immune and
bloodstream and exhaled through
drome (IBS), the ability to relieve
small intestine mechanical function.
the lungs, where it can be measured.
symptoms with an antibiotic remains
Excessive bacteria in the small
As these sugars — such as lactulose
the exception rather than the rule.
intestine, or bacteria in the small
— pass through your small intestine,
Still, bacterial overgrowth may
intestine that is normally found in
they should remain undigested. If
be a reasonable avenue to explore
the colon, can result in excessive
you have bacterial overgrowth, a
if you have persistent digestive prob-
gas production in the small intes-
hydrogen spike may appear in your
lems — especially if there's evidence
tine. This can cause bloating, grum-
breath as the sugar passes through
of malnutrition or poor nutrient
bling gut, abdominal discomfort,
the small intestine. Unfortunately,
absorption, such as weight loss.
excess flatulence and diarrhea.
this test may be accurate only about
Bacterial overgrowth may lead
60 percent of the time.
to malnutrition and weight loss. It
Bacteria in the small intestine
can cause inflammation and dam-
Keeping it in check
are naturally kept under control pri-
age the lining of your small intes-
The underlying cause of most
marily through your immune sys-
tine, limiting your body's ability to
bacterial overgrowth is usually an
tem and the coordinated actions of
absorb nutrients. Bacteria also com-
anatomical problem involving the
the intestinal muscles that propel
pete with your body for nutrients,
small bowel. Therefore, antibiotics
food and bacteria toward the colon.
particularly vitamin B-12.
are the main way to manage it.
When one or more aspects of
Unfortunately, the root cause
this system become compromised,
Adding it up
remains and overgrowth often re-
bacterial overgrowth may occur.
The gold standard test — though
turns within a year. For many, an on-
Potential causes may include:
not perfect — for diagnosing bac-
and-off cycle of antibiotic use, or
■ Outpouchings (diverticula) in
terial overgrowth involves inserting
continuous intermittent use of rotat-
the wall of the small intestine or cer-
a thin, flexible tube (endoscope) into
ing antibiotic types, is necessary to
tain surgical procedures that result
your mouth and to the upper part of
keep the bacteria under control. ❒
6 www.HealthLetter.MayoClinic.com March 2009
■ Nonsurgical rehabilitation —
A treatment path of physical thera-
py and modified activity is depen-dent upon several factors. Theseinclude whether the knee is stable
Age limits are changing
during typical daily activity, theextent of associated damage to your
It was a sickening sound — the loud
knee and whether you plan to forgo
"pop" emitted from your knee as
participation in high-risk activities
you attempted to return a well-
— such as jumping, pivoting, sud-
placed tennis volley. The severe pain
den stops or starts — that challenge
that followed put an end to your
the knee joint.
weekly tennis match in favor of an
Rehabilitation often focuses on
ice pack and a call to your doctor.
strengthening muscles that support
It turns out you tore your knee's
the thigh, hip and ankle and on
anterior cruciate ligament (ACL), one
regaining balance and your sense
of the key ligaments that stabilize
of position. Physical therapy can be
and support the knee joint. And now
time-consuming in the first few
it's time to decide how to treat it.
months, but normal daily activities
Until recently, ACL tears occur-
usually can be resumed within a
ring after age 50 — and even after
month. Typically, lifelong strength
age 40 — were typically managed
and stability exercises for your legs
A torn ACL is reconstructed with a piece
with nonsurgical care in the form of
of tendon from your leg (autograft) or with
are recommended for optimal knee
modified activity levels and physi-
a tendon from a donor cadaver (allograft).
stability. If you opt for nonsurgical
cal therapy, which led to recovery
treatment, a knee brace often is rec-
but not the same level of stability as
mal range of motion and is a par-
ommended for activities that involve
surgical repair. But that's changing.
ticularly important stabilizer of the
twisting and pivoting. Use of the
More and more people 50 and
knee during twisting, pivoting or
brace may reduce, but not eliminate
older are leading considerably active
the risk of your knee giving way.
lives, which generally makes them
An ACL tear — whether partial
Although many do well with
good candidates for surgical recon-
or complete — is typically the result
nonsurgical treatment, any future
struction of the ACL. The procedure
of a hard twist on the joint, a sud-
injuries — in particular recurrent
is proving to be an option for older
den stop while running, a jump
instability, or episodes of the knee
adults who want to remain as active
landing or a direct blow to the knee
giving way — may put the knee at
as they were before their ACL injury.
— although most are noncontact
risk of additional damage.
injuries. At the time of an ACL injury,
■ Surgery — This form of treat-
you may feel or hear a pop in the
ment may be considered if the knee
Your ACL is one of many liga-
knee and sometimes experience
is unstable and gives way during
ments in your body. These strong
severe pain. Knee swelling usually
daily activities, if you're unable to
bands of tissue attach one bone to
occurs within four to 12 hours. In
participate in activities important to
another. In the case of the ACL, it's
addition, the knee may give way and
you due to instability or the inabil-
one of two ligaments that cross in
feel unstable when you try to stand
ity to trust your knee, or if joint car-
the middle of the knee to help sta-
or put weight on it.
tilage or other knee ligaments also
bilize the joint.
The ACL connects your thigh-
Age used to be a concern with
bone (femur) to your shinbone (tibia)
Initially, treatment for an acute
this surgery. But that's changing as
and controls movement of your
ACL injury is aimed at reducing pain
more and more people remain ac-
lower leg bone in several ways. It
and swelling in the knee, in addi-
tive as they get older.
limits rotation of your lower leg and
tion to regaining normal joint move-
A torn ACL can't be sewn back
prevents the tibia from moving too
ment and strengthening muscles
together. The ligament is recon-
far forward in relation to the femur.
around the knee.
structed with a piece of tendon from
Your ACL also helps keep the
Consider with your doctor what
your leg (autograft) or with a tendon
knee from extending beyond its nor-
treatment best suits your needs:
from a donor cadaver (allograft). ❒
Questions and our answers
February 2009 Special Report,
depend on how many teeth are
"Lifelong exercise"). This is usually
filled or capped, as these will not
Q: I'm an 82-year-old man, and in
enough to net noticeable gains in
change color appreciably. Also, the
the last couple of years I seem to
strength within just a few weeks.
amount of enamel on your teeth is
have lost all the muscle in my thighs
Conversely, continued muscle loss
a strong indication of how well your
and upper arms. I walk a lot for my
may result in falls or frailty that may
teeth will lighten in color. For exam-
part-time job and at home. None
affect your independence. ❒
ple, teeth that are severely worn or
of this seems to help. Is this just the
have root system exposure don't
result of getting older?
Q: Is it possible to whiten teeth too
whiten as easily. Finally, if teeth are
much? I've seen some people who
relatively white to begin with, it may
A: Age-related muscle loss (sarco-
have almost freakishly white teeth.
not be reasonable to expect them to
penia) is largely due to reduced
whiten several shades.
physical activity. Lacking adequate
A: There's no documentation that
As for how white is too white,
exercise, muscle mass typically
whitening of teeth causes a detri-
that's a matter of personal choice.
decreases about 1 percent a year
mental change in tooth composi-
From the standpoint of someone
after age 30. However, sarcopenia
tion. However, there's evidence to
who desires teeth to be whiter than
can be significantly slowed with
support the fact that whitening of
natural, there may not be such a
weight training and exercise.
teeth can create sensitivity or pain
thing as too white. Without a doubt,
In your case, you've had sub-
upon eating foods that are cold or
teeth can be whitened more than
stantial muscle loss in a fairly short
hot or even sweet foods. Often,
what's found in the natural makeup
period, despite the reasonable level
these changes are seen within a few
of teeth — magazine cover photos
of exercise you get by walking.
days of starting the whitening pro-
demonstrate this on a daily basis.
Given these facts, it's probably
cess and usually subside after whit-
As everyone's case is unique, it
best to talk to your doctor about
ening is discontinued. Certain whit-
may be wise to seek the advice of
what may be causing your muscle
ening products list specific treatment
your dental professional. ❒
loss. Potential causes among many
durations, and if carefully control-
may include testosterone deficien-
led, don't typically lead to these
cy, thyroid overactivity, inadequate
problems. Still, caution is advised.
Have a question or comment?
function of your adrenal gland, undi-
When it comes to cosmetic den-
We appreciate every letter sent to Second
agnosed diabetes or other under-
tistry — which includes procedures
Opinion but cannot publish an answer to each
lying factors such as a tumor.
to whiten teeth — it's recommend-
question or respond to requests for consultation
Whether your muscle loss is
ed that you first get a clean bill of
on individual medical conditions. Editorialcomments can be directed to:
caused by aging or some abnor-
oral health from your dentist.
Managing Editor, Mayo Clinic Health Letter,
mality that can be managed, the
Your dentist can determine if
200 First St. SW, Rochester, MN 55905, or
good news is that it's never too late
your mouth is free of cavities and
send e-mail to [email protected]
to rebuild lost muscle through resis-
gum disease — or address any prob-
For information about Mayo Clinic services,you may telephone any of our three facilities:
tance or strength training.
lems that are found — before dis-
Rochester, Minn., 507-284-2511;
By using a weight machine, sim-
cussing whether whitening is appro-
Jacksonville, Fla., 904-953-2000;
ple free weights or elastic bands, or
Scottsdale, Ariz., 480-301-8000 or visitwww.MayoClinic.org
your own body weight as resistance,
If you're thinking about pur-
you can challenge various muscle
chasing a nonprescription whiten-
groups for at least 20 to 30 minutes
ing kit, other considerations in
Check out Mayo Clinic Health Solution's
two to three times a week (see our
whitening your teeth should also
Web site, at www.MayoClinic.com
2009 Mayo Foundation for Medical
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8 www.HealthLetter.MayoClinic.com March 2009
Zeitschrift für Kinder- und Jugendmedienforschung 2/14 4. Jahrgang ISSN 2235-1248, www.kids-media.uzh.ch Männlichkeiten – Indianer in der Pampa: Wann ist ein Mann ein Mann? – „Die Zukunft besteht nur aus Alter, Krankheiten und Schmerzen." Der deformierte, männliche Körper im realistischen Jugendroman – Der grosse Leser: Männlichkeit, Macht und Leseschwäche in fantastischen Kinder- und Jugendmedien der Gegenwart – Abschied vom Macho: TKKG-Tim im Wandel –
Optimal clinical management of children receiving the ketogenic diet: Recommendations of the International Ketogenic Diet Study Group ∗Eric H. Kossoff, †Beth A. Zupec-Kania, ‡Per E. Amark, §Karen R. Ballaban-Gil, ¶A. G. Christina Bergqvist, #Robyn Blackford, ∗∗Jeffrey R. Buchhalter,