Category: Medicine Hat News

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Nipple Discharge

“The secretion of fluid from the nipple of a newborn baby or any mature woman is not unusual, nor is it a sign of breast pathology,” says a textbook, Breast Diseases.

Nipple discharge is not an uncommon complaint. At one breast clinic, using a special suction device, researchers were able to demonstrate nipple secretion in 83 per cent of the consecutive breasts examined.

Statistically, only five percent of the patients with breast problems present with nipple discharge. But it is the third most common complaint after breast lumps and pain. Breast lumps – with or without pain – account for 70 to 80 per cent of complaints.

What information a physician wants when a patient presents with nipple discharge?

1. Is it spontaneous or elicited? If it is elicited then probably it is benign. To be significant, nipple discharge should be true, spontaneous, persistent and non-lactational.

2. Is it from one nipple or both nipples? If it is from both nipples then the chances of serious pathology is small.

3. Is it from one duct or multiple ducts? Discharge from one duct is of more concern than from multiple ducts.

4. What is the color and consistency of the discharge? If it is milky (galactorrhea), multicolored and sticky, or pus then it is probably benign. Pus needs to be drained and infection taken care of. Galactorrhea should be investigated for a pituitary tumor. A multicolored and sticky secretion is usually due to dilated ducts (duct ectasia) near the nipple.

5. Is the discharge surgically significant? Yes, if it is clear (watery), serous (yellowish), pink (blood stained) or bloody. It may indicate presence of a polyp in a duct, fibrocystic changes, pre-cancerous changes or cancer.

What about investigations?

A smear from the discharge can be sent for microscopic examination to see if there are any cancer cells. But it is not a very reliable test in this type of situation. A mammogram may or may not pick up a lump. Special x-ray of the nipple with dye in the duct (ductogram) can be helpful if it picks up a lump.

So, how do we know if the discharge is due to cancer? Quite often one can never be sure. But certain signs and symptoms may suggest presence of cancer in the breast if:
-the discharge is watery, serous, pink, or bloody
-it is accompanied by a lump
-it is from one nipple
-it is from one duct
-if mammogram is abnormal
-and if a woman is over 50 years of age.

In one series of 249 patients with nipple discharge, only four per cent of the patients had cancer of the breast. Nipple discharge due to cancer is not that common – but one can never know until appropriate investigations, including surgical biopsy, says there is no cancer.

What is the surgical management?

Most surgeons will recommend breast biopsy for all women with persistent spontaneous single duct nipple discharge, whether it is serous or bloody. However there are exceptions, in pregnant women and women on birth control pill usually secretion is not pathological.

Spontaneous multiple duct nipple discharge may occur in several benign conditions. Surgery is usually recommended to relieve profuse discharge.

Although nipple discharge is often due to benign conditions, it should not be ignored. Appropriate consultation and investigation should be undertaken to make sure a serious pathology is not missed.

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Foot Pain

Some time ago I had received a question about feet pain. What are its causes? What exercises to do to prevent painful feet and what sort of foot wear to use to keep feet healthy and pain free.

Like back pain there is no perfect cure for all ailments of the feet. Most of us are on our feet longer than any other part of our body. So our feet receive the biggest brunt of all the damage we inflict on ourselves.

Feet problems present in different ways with pain, deformity and swelling.

About 10 per cent of the general population suffer from feet pain, and in the elderly it is much higher – ranges from 53 to 95 per cent. Proximal plantar fasciitis (inflammation of the fascia – a thick tissue which runs from the heel to the ball of each foot) is the most common cause of painful feet in clinical practice, and is twice as common among women as among men.

Metatarsalgia (pain in the forefoot in the region of the base of the toes) is probably the most common cause of foot pain among middle-aged women. Most women in this age-group have been exposed to high-heeled shoes over many years.

There are many other conditions which cause painful feet. Some of these are: plantar warts, corns, calluses, ingrown toe nails, hammer toes, flat feet, bunions, arthritis, gout, stress fractures and some others.

Treatment for most of these conditions remain the same: elevate and rest your feet as much as you can – but with the busy schedule we keep, not many of us have time to do that. Other management points are: lose weight, use pain killers, hot or cold compresses, arch support, good quality fitting shoes, foam cushions to relieve pressure on painful areas, and keep feet clean and dry.

Gout and other types of arthritis may require anti-inflammatory medications. Ingrown toe nail can be surgically fixed in a doctor’s office. Some conditions require injection of cortisone to relieve inflammation and pain. Physiotherapy can relieve many ailments of the feet.

One may have to try different combinations of therapy to find relief.
Foot is a complex structure and needs to be treated with respect. There are 26 bones in our foot and they are held together by ligaments. In addition to that, there are variable numbers of accessory bones called sesamoids.

Foot is divided into forefoot, midfoot and hindfoot. When one stands normally, the body weight is equally distributed between the heel and the ball of the foot. The weight distribution depends on muscle contraction.

“Studies have shown that relatively small changes in muscle balance and tone can result in significant changes in the load distribution of the foot,” says Dr. William Hamilton in the Surgical Anatomy of the Foot and Ankle. The normal function of the foot depends on the bones, ligaments, and muscles acting in concert.

A lot depends on how you stand, how you walk, how you run, what you wear, how much you weigh, and how much care you take of your feet. Foot pain and deformities are widespread. So, treat your feet with respect. Without them you cannot go too far comfortably!

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Antibiotics

A concerned mother has a question: My pediatrician recently told me that he no longer recommends that patients who are prescribed antibiotics finish their entire dose. He said that recent research shows that finishing the dose may lead to greater antibiotic resistance, not less. He also said that pediatricians are no longer automatically prescribing antibiotics for bacterial ear infections. Could you comment on these two points in one of your columns?

Sure, I can do that. The use of antibiotics and other agents is widespread among humans, animals, in agriculture and other industries. I don’t think there is a person or an animal who has not been prescribed antibiotics. Let us look back in time.

Canadian statistics show that in 1999, about 25 million prescriptions for oral antibiotics were dispensed and that, after cardiovascular and psychiatric drugs, antibiotics were the most commonly prescribed class of agents, says an article in the Canadian Medical Association Journal.

Seventy years ago, sulphonamides (popularly known as sulpha) was the first chemical agent discovered to kill bacteria. Until then molds had been used to fight infection for 2500 years, but its effect was unpredictable and sometimes toxic.

In 1928, a Scottish physician, Alexander Fleming, noticed that a small amount of mold growing on a Staph culture destroyed the bacteria. He named an extract of the mold penicillin. In early 1940s, penicillin was mass-produced by drug companies. Since then many anti-bacterial agents have arrived in the market.

There is no doubt that modern anti-bacterial therapy has considerably decreased illness and deaths from infections, has prevented disease, and has contributed significantly to the development of modern surgery, trauma therapy, and organ transplantation.

“The broad application of antimicrobial agents in modern medicine has not, however, been problem-free. These agents occasionally cause major adverse reactions, interact with other classes of pharmacologic agents, and exert a major selective pressure for widespread antimicrobial resistance among bacteria,” says one textbook of medicine.

So, how long should one take antibiotics for?

Just the right number of days! And there is no magic formula. Short therapy fails to cure the illness. And unnecessarily prolonged therapy leads to undesirable reactions. For most acute infections, it is a good idea to continue therapy for two to three days after the temperature has returned to normal and all signs of infection have gone. If in doubt, then ask your physician.

What about antibiotics for ear infection?

The diagnosis of middle ear infection has the distinction of being the single most common diagnosis reported from pediatric office practices, yet there is no consensus in the literature about optimal methods of diagnosis, prevention, treatment and follow-up, says some medical literature.

Ear infection can be viral or bacterial. Seventy-five percent of children experience at least one episode of middle ear infection by their third birthday. Almost half of these children will have three or more ear infections during their first 3 years.

The majority of uncomplicated cases of ear infection do not require antibiotics as they resolve spontaneously. Since there is so much confusion on how to care for ear infection, a clinician’s experience may be more important than actual scientific knowledge. So, follow your physician’s advice regarding use of antibiotics for this condition.

Finally, here is what Caskie Stinnett said about antibiotics:

“The trouble with being a hypochondriac these days is that antibiotics have cured all the good diseases.”

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Hypertension

“Hypertension is a growing concern in our society. The increase in the prevalence of this condition is in part related to changes in levels of physical activity and diet and increases in obesity and the average age of the Canadian population,” says an article in the Canadian Medical Association Journal (CMAJ).

Why should we worry about hypertension?

Hypertension (high blood pressure) is a silent killer. One may have high blood pressure but have no symptoms. It silently causes damage to our vital organs and eventually results in heart attack, congestive heart failure, stroke, kidney failure and blindness.

It is estimated that 25 percent of the 42 million people with high blood pressure in the United States are unaware that they have high blood pressure and approximately three fourths of those with known hypertension have blood pressure that exceeds the recommended level! This is dangerous!

What is the normal blood pressure?

Normal blood pressure is defined as systolic blood pressure of less than 140 mm Hg (mercury) and diastolic blood pressure of less than 90 mm Hg. It is written as – systolic over diastolic (for example 120/80 mm Hg).

Blood pressure is lowest in the early morning, rises as the day progresses, then dips down during the night and earliest hours of the morning, says another CMAJ article.

Blood pressure also varies from minute to minute, depending on levels of stress and physical activity, as well as other determinants of cardiovascular activity.

“White-coat hypertension” means a person’s blood pressure is up in the doctor’s office but not elsewhere.

Why do people have hypertension?

Hypertension affects 22 percent of Canadians. The incidence of hypertension increases with age. Most elderly Canadians have high blood pressure – probably due to thickening of blood vessels. No cause is identified in 80 to 95 percent of people with hypertension.
This is known as idiopathic or essential hypertension. Others have hypertension due to primary disease of kidneys or due to certain hormonal disorders.

What can we do to prevent and control hypertension?

Hypertension can be prevented and/or treated with lifestyle changes – with or without medication.

Here are some suggestions: eat a healthy diet, lose weight if you are overweight, do not smoke, limit alcohol intake, eat a low salt diet, do regular exercise – three to five times a week, relax and learn to manage stress with laughter and meditation.

An article in the New England Journal of Medicine states that in general there is poor control of hypertension as 50 per cent of the patients with high blood pressure discontinue their antihypertensive medications by the first year. There are many reasons why this happens. But this is not good. It is dangerous.

Now, here is something for your Thursday morning smile – written by an unknown author:

It’s sad for a girl to reach the age
Where men consider her charmless,
But it’s worse for a man to attain the age
Where the girls consider him harmless.

So, let us be careful about our blood pressure before it makes us charmless, harmless and worthless!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!