|| DukeMedNews || Paravertebral Block for Surgery

Background: In cases when patients have significant illnesses, anesthesiologists perform a procedure that blocks pain to a specific region, not systemically as a general anesthetic does. Called a paravertebral block, a series of injections are made to numb the nerves that emerge from the spinal cord to supply the chest area. The block doesn’t affect overall lung or heart functioning and because blood flow is low in the area injected with the paravertebral block, anesthetic is absorbed slowly and pain relief lasts for up to an astonishing 30 hours, during which the body has started to recover.

The procedure was first used at Duke in 1995. To date, more than 200 patients at Duke have had the block, and now 80 percent of women undergoing the surgery choose the new technique. Of these, about one-third choose to go home within hours of their operation. A preliminary report, published in 1995 in the Annals of Surgery that detailed Duke’s initial experience using the block on 15 patients, said that the block provided pain relief for the patients for an average of 23 hours, and 10 of the women elected to go home the same day of the surgery. In all, “the most meaningful aspect of this initial experience with paravertebral blocks has been patient satisfaction,” the doctors concluded. They now are conducting a much larger, 150-patient prospective, randomized clinical trial comparing paravertebral block to general anesthesia.

Word has quietly spread about the success of the block, which is now being practiced in a handful of hospitals, from Georgetown Medical Center to one in Ireland. Anesthesiologists at Duke are training more and more doctors in its use.

Suggested lead: For reasons that doctors don’t fully understand, women who receive general anesthesia for breast cancer surgery suffer severe side-effects. At Duke University Medical Center, doctors are trying a new technique for these patients and are pleased with the results. Melinda Stubbee describes the experience of woman who gone through the procedure both ways.


In Cut 1, Loy says being one of the first women to be injected with the block was a positive experience and one she would recommend to others.

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Loy says the second time she had breast cancer surgery she decided to take the “easy way out” by just “going to sleep” under general anesthesia.. She says it was horrible, and she suffered severe nausea. In Cut 2, she says the block was much better.

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|| DukeMedNews || Nitric Oxide Found to Control Oxygen Delivery to Tissues

Today on the Newsline: Dr. Jonathan Stamler talks about his research, published in the June 27 issue of the journal Science.

Background: Stamler and his colleagues at Duke University Medical Center shook up conventional views of how blood delivers oxygen last year when they discovered hemoglobin also distributes nitric oxide. Now they have put the pieces of the oxygen-delivery puzzle back together by solving three apparent paradoxes that have left scientists perplexed for years.

The researchers report that hemoglobin is an exquisitely tuned biosensor that adjusts blood flow to provide exactly the right amount of oxygen to tissues and organs.

In Cut 1, Stamler says most doctors believe blood flow is regulated by the expansion or contraction of the blood vessels themselves. But they’ve shown that hemoglobin in the blood itself can sense how much oxygen a tissue needs and change blood flow to meet that need.

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Stamler says he thinks the findings may open up a whole new avenue of treatment for diseases such as stroke and heart attacks, in which blocked blood vessels are deprived of oxygen, or tissue injury after balloon angioplasty, in which reopened arteries can get too much oxygen too quickly.

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In addition, the findings have implications for treatment of sickle cell disease, lung injury and development of effective blood substitutes, the researchers say. For example, the current generation of blood substitutes behave as though the tissue is getting too much oxygen, and actually decrease oxygen delivery to tissues to compensate. A thorough understanding of how blood senses oxygen content in tissues could help researchers design more effective substitutes.

|| DukeMedNews || Improving Education for Tuberculosis DIagnosis

This week on Duke MedMinute: Duke University Medical Center tuberculosis specialist Dr. Carol Dukes Hamilton, who has received a Tuberculosis Academic Award from the National Heart, Lung, and Blood Institute, talks about developing strategies to improve education for health care workers in the diagnosis and treatment of TB.

Background: The five-year, $375,000 award by the National Institutes of Health agency is intended to help stem the rising incidence of tuberculosis in the United States. Three such awards have been granted each year for the past four years; the Duke award is one of few dealing with TB in rural settings.

Less than 10 years ago, scientists were predicting the imminent eradication of tuberculosis in the United States. Now, due mainly to the rise of TB in people living with HIV and the increase in immigration from Southeast Asia and Africa, TB once again poses a serious threat to U.S. public health. North Carolina, whose incidence rate ranks in the middle of the 50 states, has a number of counties — concentrated in the eastern portion of the state — with TB incidence rates rivaling the nation’s largest cities. The declining incidence of TB nationwide during the late 1980s and early 1990s was accompanied by a decrease in federal spending on TB research and dwindling attention on the disease from the medical community.

Suggested lead: Less than 10 years ago, scientists were predicting the elimination of tuberculosis in the United States. But now, TB one again poses a serious threat to public health. TB is on the rise in many rural areas, and researchers at Duke are working to reverse that trend. Melinda Stubbee explains.

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In Cut 1, Hamilton says they’re now finding that many health care providers are not adequately equipped to diagnose and manage patients with TB, and the situation is especially true in rural areas, where many providers have had minimal experience with TB.

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What makes the rise in TB so frustrating for physicians, Hamilton says, is that it is usually completely curable with drugs. However, the drugs must be taken every day for at least six to 12 months to eradicate the disease, but many patients, who can start feeling better within six weeks, stop taking the medications too soon.

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|| DukeMedNews || Research on Mothers’ Stress Levels

Suggested lead: Sending the kids back to school might help you feel a little more relaxed, but that stress you’re feeling will probably stay with you. Tom Britt has more.

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It is widely accepted that having a child changes a woman. Studies at Duke University Medical Center show it’s not just psychological. There is a stress-related hormone in a woman’s body that elevates on the birth of the first child and doesn’t drop until long after the kids have grown up and left home. Duke psychiatrist Dr. Redford Williams says it’s called cortisol, and it ‘s elevated in working moms 24 hours a day, seven days a week.

“We think it’s because the stress associated with being a mother and having child care responsibilities — while most active only when you’re with the kids during the evening hours — is still always there, even when you’re at work and apparently even when you’re asleep.”

Dr. Williams also says working moms tend to put in 20 hours a week more than their husbands, something called the second-shift phenomenon. So a helpful husband and father can go a long way toward reducing the stress for the working mother. I’m Tom Britt.

Williams says a lot of working mothers get caught up in what is referred to as the “second-shift phenomenon.”

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“It’s been shown that women who work outside the home work on average 20 hours more a week than their husbands do. If we could get the husbands to take on a fairer share of the workload at home this might also make things better.”

|| DukeMedNews || Staying Healthy throughout Menopause

Suggested lead: Children aren’t the only ones who need to be reminded to eat their vegetables. Tom Britt has more.

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Nutritional needs change as we get older. Marilyn Sparling is a registered dietician with Duke University Medical Center. She says women entering menopause need to start watching for signs of osteoporosis, heart disease, and if weight is a problem, diabetes and hypertension. One way to fight osteoporosis is to increase calcium intake. The obvious source is milk, but some people either don’t like milk, or are allergic to it. For these people, Sparling recommends more vegetables in the diet, primarily greens, like broccoli, spinach, and turnip greens.

“It’s not really that hard to get it in your diet, although some people just don’t like those foods, and then a calcium supplement is appropriate. I also think for a woman over 50 it’s not a bad idea to take a basic multi-vitamin. One that’s formulated for women over 50.”

Sparling stresses that such specially formulated multi-vitamins have more D, B, and E and less iron. Sparling advises to stay away from highly processed foods and anything that has saturated fat, “trans-fat” or hydrogenated oils. I’m Tom Britt.

Sparling says when it comes to calcium, more can sometimes lead to too much.

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“Most menopausal women, from age 50 on, need somewhere between one thousand and 15 hundred milligrams. It’s okay to go a little higher, but no one should go over 2 thousand because there can be some risks.”

|| DukeMedNews || Shoes can cause Foot Pain

Suggested lead: Your waistline isn’t the only thing that tends to get larger as you get older. Tom Britt has more.

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You might be thinking that the reason your feet hurt more these days is just a sign of getting older, and in a way that’s true. Because as you get older, your feet are probably getting bigger. Dr. Larry Wu in the Department of Family Medicine at Duke University Medical Center says it’s a natural part of aging.

“Your shoe size ordinarily gets larger as you get older. For women it is especially a problem after they’ve borne children. So getting your feet re-measured every other year and especially after you’ve had children, is important.”

Dr. Wu also offers some advice for anyone, young or old, looking for shoes. Shop for shoes in the evening, because your foot grows an extra five percent during the day. And above all, avoid shoes with narrow toes. Most people, he says, have feet shaped like a duck’s, and trying to fit them into narrow shoes leads to persistent problems with foot pain. I’m Tom Britt.

Dr. Wu says the normal foot shape is the opposite of the configuration of most shoes.

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“The normal foot has somewhat of a narrow heel and a very wide forefoot. Most feet have toes that splay out like a duck’s foot does.”

|| DukeMedNews || Information about Bee Stings

Suggested lead: The sting from a bee, wasp or yellow jacket is usually seen as an annoyance, but for a small number of people, it can be deadly. Tom Britt has more.

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For most people, bee stings are painful but temporary. But some two percent of those who are stung can actually suffer life-threatening reactions. Dr. Larry Williams of Duke University Medical Center says typical reactions might include some redness and swelling around the sting. But for those who react badly, the symptoms can be much more widespread.

“The allergic reactions that are dangerous are what’s referred to as anaphylaxis. This is an allergic reaction that involves multiple systems of the body.”

Williams says symptoms include breaking out in hives away from the area of the sting, difficulty breathing, and, in some cases, chest pain that could indicate a heart attack. The best defense, he says, is to ask your doctor for injectable epinephrin that can be administered immediately after the sting. Otherwise, he says, simply wear light-colored clothing and avoid wearing perfumes when outdoors. I’m Tom Britt.

Williams says there is now a treatment that can help those few people who are severely allergic to stings, but you have to ask for it.

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“If you have a major allergic reaction to a sting, ask the physician about a referral for insect venom, skin testing and desensitization.”

|| DukeMedNews || Avoiding Cigarettes to Ease Stress

Suggested lead: Is your smoking a habit or an addiction? If you can’t stop, or you’re afraid to try, you can still get help. Tom Britt has more.

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Tobacco use has dropped dramatically in the United States in recent years, as research reveals more and more of the serious, and often deadly side effects of nicotine. Some former smokers say they simply threw their pack away and never looked back, but for others, quitting can be nearly impossible. Research has shown that for these smokers, stopping can be on the same level as breaking a heroin addiction. Dr. Eric Westman is the director of the Nicotine Research Program at Duke University Medical Center. He says many of the patients he sees have convinced themselves their nicotine addiction will not hurt them.

“For many people the addiction is the problem right now. These other effects on the brain, the heart and the lungs take many years to have their toll. So many people think they can get away with smoking and the nicotine effects.”

Dr. Westman says if you cannot stop for even a day, or if you’re afraid to try, there are several new drugs and treatments available that you might not be aware of. Contact your physician, local heart or lung association or health department for a list of stop-smoking programs near you. I’m Tom Britt.

Westman says there is a big difference between a habit and an addiction.

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“It is a habit, but it’s also an addiction. Many habits are easy to break. You can stop doing things for a day. For many people, smoking is so much of an addiction they can’t stop smoking for just one day. And that differentiates a habit from an addiction.”

|| DukeMedNews || Checking the Ingredients of Insect Repellant

Suggested lead: Before you apply that insect repellant and head for the backyard cookout, you might want to check the ingredients. Tom Britt has more.

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Most insect repellants contain the insecticide DEET, a chemical that is generally safe when used in small amounts and by itself. But when combined with other chemicals and medications, DEET can have poisonous effects on the brain and the body. Duke University pharmacologist Mohammed Abou Donia has spent several years researching the effects of DEET. He says it can be safe and useful, with certain precautions.

“In order to avoid problems using DEET, we have to, number one, use as small an amount as possible. Two, we should be careful not to use it in combination with medications.”

Abou Donia says we should never use insect repellants on an infant. Their skin is too thin to provide an adequate barrier against absorption, and their systems cannot metabolize drugs and chemicals as well as an adult’s. He says there is evidence to show that DEET can cause severe brain damage in infants. He says it would be much better to simply keep the baby inside. I’m Tom Britt.

Abou Donia says there has not yet been enough research to show exactly which medications are dangerous when combined with DEET.

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“However, since we don’t know, to be safe, we just should not combine it with other drugs in general, even the simplest drugs for cough or cold.”

|| DukeMedNews || Good Advice for People who Suffer from Migraines

Suggested lead: Millions of people suffer from migraine headaches, but there is hope, and it could be as close as your medicine cabinet. Tom Britt has more.

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The symptoms of a migraine include a moderate to severe often throbbing headache, on one side or on both sides of the head. There is usually extreme sensitivity to light and sound, and often nausea and vomiting. Migraines have been around for thousands of years, but only recently have researchers found medications that seem to alleviate the symptoms. Dr. Joel Morgenlander is a neurologist with Duke University Medical Center. He says the vast majority of migraine sufferers do find relief with over-the-counter medications made especially for those symptoms. But people who continue to self-medicate, without consulting their physician, could complicate their treatment once they do go in to see the doctor.

“One of the problems we have with a lot of migraine patients is if you take too much of that type of medication, you basically get ‘hooked’ on it, so that you get a withdrawal type problem much like if you’re a caffeine coffee drinker every morning.”

Morgenlander says recurring migraine symptoms do warrant a trip to the doctor, since what you assume is a migraine could actually be something else even more serious. I’m Tom Britt.

Morgenlender says what you assume is a migraine could be something even more serious.

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“There’s nothing absolutely specific about the bad, severe, sick throbbing headache of a migraine. It could be from more serious things, but often-times it’s not. That’s something that the physician needs to evaluate.”