Month: December 2022

I recently saw a car vanity plate that read “LBODOC” (as in elbow doc). The driver — probably an orthopedic doctor or arthritis specialist — was clearly a fan of the elbow, an unassuming joint and a surprisingly central player in many daily tasks. I could relate: throughout my medical career, the elbow has been my favorite joint.

Here’s why we should give praise to elbows and do all we can to protect them.

What if we didn’t have elbows?

Let’s face it: the human experience would be quite different without elbows.

Imagine your arm without a joint that bends at the elbow. You’d be unable to easily feed yourself, put on makeup, shave your face, or brush your teeth. It’d be tough to get dressed or throw a ball without elbows. And, importantly, wiping yourself after using the bathroom would be nearly impossible.

Yet, when it comes to joints and joint disease, we hear little about elbows; hips and knees get most of the attention. So, let’s consider for a moment what the lowly elbow does and why it deserves more credit.

How do your elbows work?

Three bones come together at the elbow joint: the humerus, which is in the upper arm, and two long bones called the ulna and radius in the lower arm.

Your elbow has two main motions:

• Flexing and straightening. Flexing your arm allows you to bring your hand toward your body (flexion), which you do when bringing food to your mouth or putting your hands on your hips. Straightening your arm (extension) allows such motions as putting your arm in a shirt sleeve or reaching your toes.
• Turning up and down. You can also flip your palms from facing the ceiling (supination) to facing the floor (pronation). These motions are important for many common movements, such as turning a key or a doorknob.

Bumping your elbow: Why is it called the funny bone?

Probably for two reasons:

• The humerus in the upper arm sounds just like the word humorous, meaning funny.
• Bumping your elbow often puts pressure on the ulnar nerve, since it’s located between the bones of the joint. Pressure on this nerve can cause a funny tingling sensation that runs down your arm.

Elbow trouble: Four well-known problems — and a surprising fifth

Like so many overlooked and underappreciated things, most people think little about their elbows until something goes wrong. Here are some of the most common elbow problems:

• Arthritis. Several types of arthritis can affect the elbow, including rheumatoid arthritis, psoriatic arthritis, and gout. Interestingly, the most common type of arthritis, osteoarthritis, doesn’t usually affect the elbow unless there’s been prior damage to the joint.
• Bursitis. The bursa is a saclike structure that surrounds the tip of the elbow. Bursitis develops when it becomes swollen or inflamed, due to infection, gout, or bleeding.
• Tendonitis. Tendon inflammation (tendonitis) may develop on the inside part of the elbow (called “golfer’s elbow”) or the outside (called “tennis elbow”). Despite these names, you don’t have to play any particular sport to develop elbow tendonitis.
• Trauma. Everyday activities and athletic pursuits put the elbow at risk. A bike accident, falling off a skateboard, or just tripping on a curb and falling onto your arm can cause significant elbow injuries. These include ligament damage, broken bones, or bursitis.

And the surprising fifth problem? Cell phone-induced nerve irritation: holding your elbow bent for a long time can lead to “cell phone elbow” due to pressure on the ulnar nerve. This can cause numbness and pain down the arm. The solution? Put the phone down — or at least go hands-free.

How can you protect your elbows?

Considering all our elbows do for us, we need to do our best to protect them. That means:

• Wear elbow protectors when engaging in activities likely to injure the elbows (like skateboarding or roller blading).
• Learn proper technique for activities that can stress the elbow like racquet sports, baseball, weight training, or repetitive motions in carpentry and other types of work. For example, a trainer or coach can help you improve your tennis stroke to avoid overstressing the elbow joint and its tendons or ligaments.
• Use appropriate equipment. For example, avoid using a tennis racquet that’s too heavy for you.
• Train well. Strengthening forearm muscles and stretching can help avoid golfer’s elbow.

The bottom line

As the junction between hand and shoulder, our elbows play a pivotal role in everyday function. It’s high time we recognized them for what they do for us. Even if the elbow isn’t your favorite joint — as it is for me — perhaps it should be in your top five. After all, think of all the things you couldn’t do without them.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

You may have heard recent news reports about a company that knowingly sold defective lead testing machines that tested tens of thousands of children between 2013 and 2017. Or wondered about lead in tap water after the widely reported problems with lead-contaminated water in Flint, Michigan. Reports like these are reminders that parents need to be aware of lead — and do everything they can to keep their children safe.

How is lead a danger to health?

Lead is poisonous to the brain and nervous system, even in small amounts. There really is no safe level of lead in the blood. We particularly worry about children under the age of 6. Not only are their brains actively developing, but young children commonly touch lots of things — and put their hands in their mouths. Children who are exposed to lead can have problems with learning, understanding, and behavior that may be permanent.

How do children get exposed to lead?

In the US, lead used to be far more ubiquitous than it is now, particularly in paint and gas. Yet children can be exposed to lead in many ways.

• Lead paint. In houses built before 1978, lead paint can sometimes be under other paint, and is most commonly found on windowsills or around doors. If there is peeling paint, children can sometimes ingest it. Dust from old paint can land on the floor or other surfaces that children touch with their hands (and then put their hands in their mouths). If there was ever lead paint on the outside of a house, it can sometimes be in the dirt around a house.
• Leaded gas. While leaded gas was outlawed in 1996, its use is still allowed in aircraft, farm equipment, racing cars, and marine engines.
• Water passing through lead pipes. Lead can be found in the water of older houses that have lead pipes.
• Other sources. Lead can also be found in some imported toys, candles, jewelry, and traditional medicines. Some parents may have exposure at work or through hobbies and bring it home on their hands or clothing. Examples include working in demolition of older houses, making things using lead solder, or having exposure to lead bullets at a firing range.

What can parents do to protect children from lead?

First, know about possible exposures.

• If you have an older home, get it inspected for lead if you haven’t done so already. (If you rent, federal law requires landlords to disclose known lead-based paint hazards when you sign a lease.) Inspection is particularly important if you are planning renovations, which often create dust and debris that increase the risk of exposure. Your local health department can give you information about how to do this testing. If there is lead in your home, don’t try to remove it yourself! It needs to be done carefully, by a qualified professional, to be safe.
• Talk to your local health department about getting the water in your house tested. Even if your house is new, there can sometimes be older pipes in the water system. Using a water filter and taking other steps can reduce or eliminate lead in tap water.
• If you have an older home and live in an urban area, there can be lead in the soil. You may want to have the soil around your house tested for lead. Don’t let your child play in bare soil, and be sure they take off their shoes before coming in the house and wash their hands after being outside.
• Learn about lead in foods, cosmetics, and traditional medications.
• Learn about lead in toys, jewelry, and plastics (yet another reason to limit your child’s exposure to plastic).

Second, talk to your pediatrician about whether your child should have a blood test to check for lead poisoning. The American Academy of Pediatrics recommends:

• Assessing young children for risk of exposure at all checkups between 6 months and 6 years of age, and
• Testing children if a risk is identified, particularly at 12 and 24 months. Living in an old home, or in a community with lots of older homes, counts as a risk. Given that low levels of lead exposure that can lead to lifelong problems do not cause symptoms, it’s always better to be safe than sorry. If there is any chance that your child might have an exposure, get them tested.

How is childhood lead exposure treated?

If your child is found to have lead in their blood, the most important next step is to figure out the exposure — and get rid of it. Once the child is no longer exposed, the lead level will go down, although it does so slowly.

Iron deficiency makes the body more vulnerable to lead poisoning. If your child has an iron deficiency it should be treated, but usually medications aren’t used unless lead levels are very high. In those cases, special medications called chelators are used to help pull the lead out of the blood.

For more information, visit the Centers for Disease Control and Prevention website on lead poisoning prevention.

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

Health guidelines recommend adults get at least 150 minutes per week of moderate-intensity aerobic exercise, or at least 75 minutes of vigorous exercise. Which activities you choose don’t matter as long as they get you moving.

But what if an injury, illness, health condition, disability, or even normal aging makes being active hard for you? In those cases, adaptive sports could lend a much-needed hand.

What are adaptive sports?

Adaptive sports are competitive or recreational sports or activities for people with disabilities or physical limitations. They often run parallel to traditional endeavors, but are modified to support people’s specific physical abilities.

“Eventually, almost everyone will experience some kind of disability that impedes regular exercise, whether it’s mild arthritis, requiring a knee or hip replacement, limited vision, or a more significant physical disability,” says Dr. Cheri Blauwet, an associate professor in physical medicine and rehabilitation at Harvard Medical School, and a former wheelchair racer who is a seven-time Paralympic medalist and two-time winner of both the Boston and New York City Marathons. “But today, because of advanced technology and supportive infrastructure, people can find almost any kind of sport or activity that takes into account their abilities and helps them stay active.”

Why is it important to stay active?

Not getting sufficient regular exercise increases the risk of heart disease, stroke, obesity, diabetes, and cancer. It also affects mood. And people with disabilities are especially vulnerable because of the challenges of staying active, says Dr. Blauwet. “Adaptive sports are a way for us to continue to exercise regularly and support our health and well-being going forward.”

Research backs this up. According to one study, people participating in adaptive sports and activities report better overall health, quality of life, and social life.

How can you learn about options for adaptive activities near you?

You can find state and local adaptive sports programs and accessible activities through the websites of the National Center on Health, Physical Activity and Disability and the Challenged Athletes Foundation. “These programs also can help you find mentors, coaches, and the support system that you need to be successful,” says Dr. Blauwet.

What kind of sport or activity you choose ultimately depends on your interests and level of function, but many options are available.

Build on strengths and consider new activities

Dr. Blauwet shares other strategies that can help you transition to adaptive activities.

Look at your current form of exercise. “Almost any kind of sport or activity can be adjusted to accommodate people with disabilities, so there is a good chance you can continue with a favorite endeavor,” says Dr. Blauwet.

For instance, as part of her ongoing therapy, former Arizona representative Gabby Giffords, an avid cyclist who lives with a brain injury after an assassination attempt, now rides a recumbent bike because of paralysis on her right side and balance issues. (A recumbent bike is a three-wheel bicycle that places the rider in a seated or laid-back reclining position.)

Other sports and activities can be altered similarly. For example, specialized golf carts can help you stand and stabilize your body while swinging the club. Sledge hockey uses sleds to skate across the ice.

Focus on your strengths. Don’t dwell on what you can’t do, but focus on what you can. Running no longer an option? How about power walking using walking poles for support? Can’t use your legs? Focus on upper body activities like swimming or kayaking. Low vision? Guides are available to help you walk, run, and cycle.

Join a team. Many adaptive sports have organized team leagues with adjusted rules and formats, like wheelchair basketball and tennis, and “beep” baseball and kickball for individuals with low vision. “These are a great way to build more awareness about your new endeavor and build a community with other peers with similar disabilities,” says Dr. Blauwet. “Plus, a little competition provides extra motivation.”

Try something new. Use your new functional status as an opportunity to attempt a different sport or activity. “Test the waters and try something that has always interested you,” says Dr. Blauwet. “Now might be the ideal time to explore waterskiing, windsurfing, horseback riding, or rock wall climbing.”

It may be mentally and emotionally tough to embrace adaptive sports and activities, as it can feel like your disability has become magnified. But don’t let that dissuade you, adds Dr. Blauwet. “Staying committed to being active and investing in your health can help reduce and eliminate any negative stigma you feel. Participation in adaptive sports is not a lesser way of living, but a way to live better.”

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

For people with obesity, weight-loss surgery can reverse or greatly improve many serious health issues, such as diabetes, high blood pressure, and pain. But these procedures also change how the body metabolizes alcohol, leaving people more likely to develop an alcohol use disorder. A new study finds that one type of surgery, gastric bypass, may increase the dangers of drinking much more than other weight-loss strategies.

“Alcohol-related problems after weight-loss surgery are a known risk. That’s one reason we require people to abstain from alcohol for at least six months — and preferably a full year — before any weight-loss surgery,” says Dr. Chika Anekwe, an obesity medicine specialist at the Harvard-affiliated Massachusetts General Hospital Weight Center. The new findings are interesting and make sense from a biological perspective, given the differences in the surgeries, she adds.

How does weight loss surgery affect alcohol absorption?

Weight-loss surgeries dramatically reduce the size of the stomach.

• For a sleeve gastrectomy, the most common procedure, the surgeon removes about 80% of the stomach, leaving a banana-shaped tube.
• For a gastric bypass, a surgeon converts the upper stomach into an egg-sized pouch. This procedure is called a bypass because most of the stomach, the valve that separates the stomach from the small intestine (the pylorus), and the first part of the small intestine are bypassed.

The lining of the stomach contains alcohol dehydrogenase, an enzyme that breaks down alcohol. After weight-loss surgery, people have less of this enzyme available. So drinking wine, beer, or liquor will expose them to a higher dose of unmetabolized alcohol. Some alcohol is absorbed directly from the stomach, but most moves into the small intestine before being absorbed into the bloodstream.

After a sleeve gastrectomy, the pyloric valve continues to slow down the passage of alcohol from the downsized stomach to the small intestine. But with a gastric bypass, the surgeon reroutes the small intestine and attaches it to the small stomach pouch, bypassing the pyloric valve entirely. As a result, drinking alcohol after a gastric bypass can lead to extra-high blood alcohol levels. That makes people feel intoxicated more quickly and may put them at a higher risk of alcohol use disorders, says Dr. Anekwe.

Findings from the study on weight loss surgery and alcohol

The study included nearly 7,700 people (mostly men) from 127 Veterans Health Administration centers who were treated for obesity between 2008 and 2021. About half received a sleeve gastrectomy. Nearly a quarter underwent gastric bypass. Another 18% were referred to MOVE!, a program that encourages increased physical activity and healthy eating.

After adjusting for participants’ body mass index and alcohol use, researchers found that participants who had gastric bypass were 98% more likely to be hospitalized for alcohol-related reasons than those who had sleeve gastrectomy, and 70% more likely than those who did the MOVE! program. The rate of alcohol-related hospitalizations did not differ between people who had sleeve gastrectomy and those who did the MOVE! program.

The health harms of alcohol use disorder

Alcohol use disorder can lead to numerous health problems. Some require hospitalization, including alcoholic gastritis, alcohol-related hepatitis, alcohol-induced pancreatitis, and alcoholic cardiomyopathy. As the study authors note, people who had gastric bypass surgery had a higher risk of being hospitalized for an alcohol use disorder, even though they drank the least amount of alcohol compared with the other study participants. This suggests that change in alcohol metabolism resulting from the surgery likely explains the findings.

Advice on alcohol if you’ve had weight-loss surgery or are considering it

“We recommend that people avoid alcohol completely after any type of weight-loss surgery,” says Dr. Anekwe. A year after the surgery, an occasional drink is acceptable, she adds, noting that most patients she sees don’t have a problem with this restriction.

People who undergo weight-loss surgeries have to be careful about everything they consume to ensure they get adequate amounts of important nutrients. Like sugary drinks, alcohol is devoid of nutrients — yet another reason to steer clear of it.

Gastric bypass has become less popular than sleeve gastrectomy over the past decade, mostly because it’s more invasive and slightly riskier. While the new study suggests yet another downside of gastric bypass, Dr. Anekwe says it can still be a viable option for people with severe obesity, as bypass leads to more weight loss and better control of blood sugar than the sleeve procedure.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

Perhaps you’ve seen this ad about a drug for thyroid eye disease. If so, you may be wondering what thyroid eye disease is — and why the woman in the ad is wearing five pairs of sunglasses at once. Read on for answers.

What is thyroid disease and how does it affect the eyes?

The thyroid gland is a small, butterfly-shaped organ at the front of the neck. It releases thyroid hormone, which helps control many functions in the body. If it releases too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), bothersome and sometimes serious symptoms may develop, including changes in muscle strength, bowel function, and heart function.

An overactive thyroid gland can cause thyroid eye disease, prompting swelling and inflammation in tissues surrounding the eyes. The condition causes bulging eyes, a dry, gritty sensation in the eyes, tearing, pressure or pain behind the eyes, and blurring or double vision.

As many as half a million people in the US have thyroid eye disease. It affects up to half of people with Graves’ disease, an autoimmune illness marked by an overactive thyroid.

Thyroid eye disease ad: The pitch and the evidence

The ad opens with a woman wearing large, dark sunglasses, identified as a real patient named Jeanne. “With thyroid eye disease,” she explains, “I was always wearing sunglasses to hide my bulging eyes. I wore them just about everywhere.”

She removes her sunglasses to reveal that she’s wearing another pair underneath. In fact, she’s wearing three pairs of sunglasses and later will be wearing five!

As the music turns upbeat, she continues: “But then my doctor recommended Tepezza, a prescription medicine for thyroid eye disease, and I didn’t have to hide so much.”

A drawing of a bulging eye morphing into a more normal eye accompanies her next words: “In a clinical study, more than eight out of 10 patients taking Tepezza had less eye bulging. And nearly seven out of 10 saw improvements in double vision.”

Warnings about this medicine

You know what comes next: a fast-talking voiceover warning of possible side effects. For Tepezza, these include:

• Infusion reactions. Now we learn that Tepezza is an intravenous (infused) medicine. A course of treatment is eight 90-minute infusions, each separated by three weeks. Infusion reactions may be mild or severe, including allergic reactions (such as itching or hives) and other side effects that occur during or just after the infusion (such as fever or sweats).
• When to call for advice. “Tell your doctor right away if you have symptoms such as high blood pressure, fast heartbeat, shortness of breath, or muscle pain,” the voiceover instructs. Keep in mind that most people with high blood pressure have no symptoms, but if severe it can cause headaches, blurry vision, or chest pain.
• Before starting treatment. If you have diabetes or inflammatory bowel disease, or if you are pregnant or planning to become pregnant, you should tell your doctor before starting treatment. That’s because Tepezza may harm a developing fetus or worsen other diseases.

A big finish: Controlling thyroid eye disease

As the commercial winds down, Jeanne is back, removing her fifth consecutive pair of sunglasses to reveal normal-appearing eyes. “I look more like my old self again. Now I wear sunglasses because I want to.”

“Ask your doctor if Tepezza is right for you,” the narrator advises before suggesting a visit to the website for before and after pictures of Jeanne. I checked; they’re impressive.

What the ad gets right

The ad accurately describes

• thyroid eye disease symptoms
• how the condition alters appearance and can cause embarrassment
• results of a single, small study investigating the risks and benefits of Tepezza.

What else do you need to know about treatments for thyroid eye disease?

• You must treat thyroid disease as well as your eye condition. Medicines or surgery are often good options. Radiation therapy may be effective, but sometimes makes thyroid eye disease worsen.
• Selenium, a mineral supplement, is recommended by some experts.
• Quitting smoking is always recommended, partly because smoking may worsen thyroid eye disease.

If thyroid eye disease is mild, moisturizing eye drops, eye shades or patches, or dark sunglasses may be sufficient.

If thyroid eye disease is moderate to severe, options include:

• medicines that suppress inflammation or an overactive immune response. Examples include glucocorticoids, teprotumumab (Tepezza), mycophenolate mofetil (Cellcept), tocilizumab (Actemra), or rituximab (Rituxan).
• surgery to remove excess tissue around the eyes.

Small studies, like the one cited in the ad, may not detect all side effects, especially rare ones.

Last, but certainly not least: Tepezza is expensive. The price for a year of treatment can be $300,000 or more — and insurance coverage varies.

The bottom line

I still don’t know why the woman in the ad wears multiple pairs of sunglasses at the same time. Maybe it’s to emphasize how serious she is about hiding her eyes. Or maybe it’s just a way to grab our attention. Direct-to-consumer drug marketing strategies can be even more mysterious than the illnesses they hope to treat.

If you’re concerned you may have thyroid disease or thyroid eye disease, talk to your doctor. A costly new drug may be an option for some people, but it pays to learn about all options. Academic medical centers, the NIH, or a medical society are more likely to give you reliable and balanced information than a drug ad.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD