Therapy and Treatment
At Prime Med of Ozark, the doctors treat a range of disorders and diseases from Primary Care, Acute Pain Management, Psychiatry and Neurology. A proper medical check-up can often be crucial in determining potential individual health problems, prevention options, or even to make early diagnoses.
Prime Med of Ozark's philosophy is firmly focused on the individual and aims to help patients face the second half of life with the most positive attitude possible. Under the supervision of medical professionals, patients are given advice and encouragement to take personal responsibility for their lifestyles, with the support of comprehensive medical check-ups and diagnostic tests. We also focus on prevention instead of repair, through a unique combination of highly competent doctors and cutting-edge technical equipment that seeks to constantly update the clinic’s program of medical check-ups to incorporate the latest research. Our clinic offers a comprehensive range of preventive checks in order to identify diseases at as early a stage as possible and to help patients to live healthy, productive lives. Our preventive check-ups are also available – these focus on early detection of disease in bronchi and lungs, heart and circulation, stomach and intestine, thyroid gland, kidneys and bladder.
We invite you to browse below the range of treatments that our highly experienced doctors administer.
Abdominal Aortic Aneurysm (AAA)
An Abdominal Aortic Aneurysm (AAA), a specific kind of aneurysm, is a condition in which the lining of the blood vessel called the aorta is enlarged within the abdomen. Abdominal aortic aneurysms pose a threat because they are usually silent until a medical emergency occurs.
The abdominal aorta is the largest blood vessel in the body and the main artery that originates in the heart. As the lining weakens from age and other risk factors, the vessel wall thins and expands. The most common location for an AAA is between where the aorta divides to supply blood to the kidneys and where it divides to supply blood to the pelvis and legs.
More than 80% of patients with ruptured abdominal aortic aneurysm (AAA) present without a previous diagnosis of AAA, which contributes to an initial misdiagnosis rate of 24-42%. A rational approach to the diagnostic evaluation is predicated on a high degree of suspicion.
Abdominal Aortic Aneurysm Signs
Before rupture: As an AAA gets bigger, it may cause deep pain in the back or side of the abdomen or a throbbing feeling in the abdomen. Most AAAs cause no symptoms.
After rupture: If an AAA ruptures, symptoms could include sudden and severe pain in the lower abdomen or back, nausea and vomiting, clammy, sweaty skin and light-headedness, or loss of consciousness.
For Abdominal Aortic Aneurysm
A doctor may recommend an abdominal ultrasound screening test if you are a man who is:
- Age 65 to 75 and has ever smoked.
- At least 60 years old and who has a first-degree relative (for example, father or brother) who has had an aneurysm.
AAA Prevention: Don't Smoke
The main risk factor for AAA is smoking—past or present. Quitting smoking reduces the chance of developing an aneurysm or it getting worse.
Men with AAAs also often have clogged and stiffened arteries (atherosclerosis) and high blood pressure, most likely also related to smoking. Although lowering cholesterol and blood pressure would help such men improve their overall cardiovascular health, it won’t prevent aortic aneurysms. But there is still an important benefit of controlling high blood pressure and cholesterol for men at risk of AAAs.
It is better to have an abdominal ultrasound for AAA in order to prevent or diagnose the risk. Aneurysms run in families. If a first-degree relative has had an AAA, you are 12 times more likely to develop an abdominal aortic aneurysm. Of patients in treatment to repair an AAA, 15–25% have a first-degree relative with the same type of aneurysm.
During allergy skin tests, your skin is exposed to suspected allergy-causing substances (allergens) and is then observed for signs of an allergic reaction. Along with your medical history, allergy tests may be able to confirm whether or not a particular substance you touch, breathe or eat is causing symptoms.
Why it's done
Information from allergy tests may help your doctor develop an allergy treatment plan that includes allergen avoidance, medications or allergy shots (immunotherapy).
Allergy skin tests are widely used to help diagnose allergic conditions, including:
- Hay fever (allergic rhinitis)
- Allergic asthma
- Dermatitis (eczema)
- Food allergies
- Penicillin allergy
- Bee venom allergy
- Latex allergy
Skin tests are generally safe for adults and children of all ages, including infants. In certain circumstances, though, skin tests aren't recommended. Your doctor may advise against skin testing if you:
- Have ever had a severe allergic reaction. You may be so sensitive to certain substances that even the tiny amounts used in skin tests could trigger a life-threatening reaction (anaphylaxis).
- Take medications that could interfere with test results. These include antihistamines, many antidepressants and some heartburn medications. Your doctor may determine that it's better for you to continue taking these medications than to temporarily discontinue them in preparation for a skin test.
- Have certain skin conditions. If severe eczema or psoriasis affects large areas of skin on your arms and back — the usual testing sites — there may not be enough clear, uninvolved skin to do an effective test. Other skin conditions, such as dermatographism, can cause unreliable test results.
Blood tests (in vitro immunoglobulin E antibody tests) can be useful for those who shouldn't undergo skin tests. Blood tests aren't done as often as skin tests because they can be less sensitive than skin tests and are more expensive.
In general, allergy skin tests are most reliable for diagnosing allergies to airborne substances, such as pollen, pet dander and dust mites. Skin testing may help diagnose food allergies. But because food allergies can be complex, you may need additional tests or procedures.
The most common side effect of skin testing is slightly swollen, red, itchy bumps (wheals). These wheals may be most noticeable during the test. In some people, though, an area of swelling, redness and itching may develop a few hours after the test and persist for as long as a couple of days.
Rarely, allergy skin tests can produce a severe, immediate allergic reaction, so it's important to have skin tests performed at an office where appropriate emergency equipment and medications are available.
How you prepare
Before recommending a skin test, your doctor will ask you detailed questions about your medical history, your signs and symptoms, and your usual way of treating them. Your answers can help your doctor determine if allergies run in your family and if an allergic reaction is most likely causing your symptoms. Your doctor may also perform a physical examination to search for additional clues about the cause of your signs and symptoms.
Medications can interfere with results
Before scheduling a skin test, bring your doctor a list of all of your prescription and over-the-counter medications. Some medications can suppress allergic reactions, preventing the skin testing from giving accurate results. Other medications may increase your risk of developing a severe allergic reaction during a test.
Because medications clear out of your system at different rates, your doctor may ask that you stop taking certain medications for up to 10 days. Medications that can interfere with skin tests include:
- Prescription antihistamines, such as levocetirizine (Xyzal) and desloratadine (Clarinex).
- Over-the-counter antihistamines, such as loratadine (Claritin, Alavert), diphenhydramine (Benadryl, others), chlorpheniramine (Chlor-Trimeton), cetirizine (Zyrtec, others) and fexofenadine (Allegra).
- Tricyclic antidepressants, such as nortriptyline (Pamelor) and desipramine (Norpramin).
- Certain heartburn medications, such as cimetidine (Tagamet) and ranitidine (Zantac).
- The asthma medication omalizumab (Xolair). This medication can disrupt test results for six months or longer even after you quit using it (most medications affect results for days to weeks).
What you can expect
Skin testing is usually done at a doctor's office. A nurse generally administers the test, and a doctor interprets the results. Typically, this test takes about 20 to 40 minutes. Some tests detect immediate allergic reactions, which develop within minutes of exposure to an allergen. Other tests detect delayed allergic reactions, which develop over a period of several days.
Skin prick test
A skin prick test, also called a puncture or scratch test, checks for immediate allergic reactions to as many as 40 different substances at once. This test is usually done to identify allergies to pollen, mold, pet dander, dust mites and foods. In adults, the test is usually done on the forearm. Children may be tested on the upper back.
Allergy skin tests aren't painful. This type of testing uses needles (lancets) that barely penetrate the skin's surface. You won't bleed or feel more than mild, momentary discomfort.
After cleaning the test site with alcohol, the nurse draws small marks on your skin and applies a drop of allergen extract next to each mark. He or she then uses a lancet to prick the extracts into the skin's surface. A new lancet is used for each allergen.
To see if your skin is reacting normally, two additional substances are scratched into your skin's surface:
- Histamine. In most people, this substance causes a skin response. If you don't react to histamine, your allergy skin test may not reveal an allergy even if you have one.
- Glycerin or saline. In most people, these substances don't cause any reaction. If you do react to glycerin or saline, you may have sensitive skin. Test results will need to be interpreted cautiously to avoid a false allergy diagnosis.
About 15 minutes after the skin pricks, the nurse observes your skin for signs of allergic reactions. If you are allergic to one of the substances tested, you'll develop a raised, red, itchy bump (wheal) that may look like a mosquito bite. A nurse will then measure the bump's size.
After the nurse records the results, he or she will clean your skin with alcohol to remove the marks.
Skin injection test
You may need a test that uses a needle to inject a small amount of allergen extract just into the skin on your arm (intradermal test). The injection site is examined after about 15 minutes for signs of an allergic reaction. Your doctor may recommend this test to check for an allergy to insect venom or penicillin.
Patch testing is generally done to see whether a particular substance is causing allergic skin irritation (contact dermatitis). Patch tests can detect delayed allergic reactions, which can take several days to develop.
Patch tests don't use needles. Instead, allergens are applied to patches, which are then placed on your skin. During a patch test, your skin may be exposed to 20 to 30 extracts of substances that can cause contact dermatitis. These can include latex, medications, fragrances, preservatives, hair dyes, metals and resins.
You wear the patches on your arm or back for 48 hours. During this time, you should avoid bathing and activities that cause heavy sweating. The patches are removed when you return to your doctor's office. Irritated skin at the patch site may indicate an allergy.
Before you leave your doctor's office, you'll know the results of a skin prick test or an intradermal test. A patch test may take several days or more to produce results.
A positive skin test means that you may be allergic to a particular substance. Bigger wheals usually indicate a greater degree of sensitivity. A negative skin test means that you probably aren't allergic to a particular allergen.
Keep in mind, skin tests aren't always accurate. They sometimes indicate an allergy when there isn't one (false positive), or skin testing may not trigger a reaction when you're exposed to something that you are allergic to (false negative). You may react differently to the same test performed on different occasions. Or you may react positively to a substance during a test but not react to it in everyday life.
Your allergy treatment plan may include medications, immunotherapy, changes to your work or home environment, or dietary changes. Ask your doctor to explain anything about your diagnosis or treatment that you don't understand. With test results that identify your allergens and a treatment plan to help you take control, you'll be able to reduce or eliminate allergy signs and symptoms.
Ambulatory EEG / AEEG
An electroencephalogram (EEG) is a recording of brain activity. An ambulatory electroencephalogram (EEG) is a neurodiagnostic test that measures and records the electrical activity in your brain. Unlike an EEG, an ambulatory EEG allows an extended recording. The patient is able to move around and is not required to stay in one place.
- EEG is the abbreviation for electroencephalography. The electroencephalograph is a machine that translates the electrical activity of the brain into a series of wavy lines (a graph) on a computer called the EEG record.
- An EEG measures the electrical activity of the brain, sometimes referred to as brain waves. This test is performed to see how the different parts of your brain function. It records a graph of your brain waves.
- Digital analysis is a procedure that can give additional information about any problems that may be found.
- Analysis and examination of the data obtained allows your doctor to see one of the many ways that your brain functions.
- EEG is not a treatment of any kind. No electricity is transferred to your brain. The EEG only detects activity in the brain.
- If you have a seizure during the test, you should behave as you normally would during a seizure. Family and friends should follow your usual first aid or emergency procedures.
- It can tell us what may be causing your episodes and help with deciding the best treatment for you.
- The doctor can see seizure activity as well as sleep stages during your EEG.
Why Need an EEG?
Classification of seizure type in members who have epilepsy (routine EEG is equivocal) — only ictal recordings can reliably be used to classify seizure type (or types) which is important in selecting appropriate anti-epileptic drug therapy; or Diagnosis of a seizure disorder (epilepsy) — members who have episodes suggestive of epilepsy when history, examination, and routine EEG do not resolve the diagnostic uncertainties (routine EEG should be negative with provocative measures); or Localization of the epileptogenic region of the brain during pre-surgical evaluation — to identify appropriate surgical candidates. The main use of an EEG is to detect and investigate epilepsy, a condition that causes repeated seizures. An EEG will help your doctor identify the type of epilepsy you have, what may be triggering your seizures, and how best to treat you. Less often, an EEG may be used to investigate other problems, such as dementia, head injuries, brain tumours, encephalitis (brain inflammation) and sleep disorders, such as obstructive sleep apnoea.
Different Types of EEG Recordings
Outpatient Short EEG (No Video)
This is usually referred to as ‘routine EEG.’ It is the oldest, cheapest, and the ‘default’ way to obtain an EEG. The limitations of routine EEG are well known and obvious, and have to do with low sensitivity (due to a short-time sample). For the diagnosis of seizures, the yield of a single routine EEG is between 30 and 50%, and increases with repeated EEGs, possibly up to 90% by the fourth EEG. Certainly, some patients with epilepsy will lack interictal epileptiform discharges despite repeated EEGs. Specificity of routine EEG (for epilepsy) is very high in theory, but is low in practice because of the (under-reported) problem of over-reading. Nonetheless, despite obvious limitations, routine EEG is inexpensive and simple, and can be sufficient, even if normal, in most clinical situations, that is, when patients respond to treatment.
Outpatient Short EEG with Video (Video Telemetry)
Virtually, all EEG machines nowadays have a (digital) video recorder, so video should probably be added to any routine EEG, in case a clinical event is captured. If the purpose is mainly to capture the event in question for diagnosis, EEGvideo can be short-term and have a high diagnostic yield. Appropriate to such situations would be, for example, patients with generalized epilepsies of the Lennox–Gastaut type with multiple daily seizures, and other patients with daily events that are strongly suspected to be psychogenic, especially when combined with activation procedures.
Ambulatory electroencephalography (AEEG) monitoring is a relatively recent technology that allows prolonged electroencephalographic (EEG) recording in the home setting. Its ability to record continuously for up to 72 hours increases the chance of recording an ictal event or interictal epileptiform discharges. AEEG is a less expensive alternative to inpatient monitoring, with costs that are 51-65% lower than a 24-hour inpatient admission for video/EEG monitoring.
The Gold Standard: Prolonged EEG-Video Monitoring
For the epilepsy specialist, this is the gold standard and the starting point to care for patients whose seizures do not respond to basic treatment. Because it is both prolonged and with video, this combines an increase in yield of capturing interictal discharges and, even more important, the ability to record the episodes in question. In most cases, EEG-video monitoring will allow us to answer the following questions:
- Are the events epileptic or not?
- If not epileptic, what are they?
- If epilepsy, what type?
- If focal, where is the likely focus?
A common misconception is that prolonged EEG-Video monitoring is performed inpatient. Thanks to the latest technologies, advanced storage and data warehousing facilities has made it possible, cheaper, and convenient to perform outpatient.
Sleep EEG or sleep-deprived EEG
A sleep EEG is carried out while you’re asleep. It may be used if a routine EEG doesn’t give enough information, or to test for sleep disorders. In some cases, you may be asked to stay awake the night before the test to help ensure you can sleep while it’s carried out. This is called a sleep-deprived EEG.
Preparation for an EEG / AEEG
Placement of the EEG Wires for Monitoring
EEG wires will be attached to your head with a special glue so that the electrodes will stay attached for several days. Sometimes, the electrodes can cause some itching to occur and you can take medication to help the itching. Do not scratch your head with the electrodes in place. Benadryl 25 mg to 50 mg can be used for itching. This can be obtained over the counter at your local pharmacy.
Please do not eat potato chips or other snack foods or chew gum, since this will interfere with the EEG – it generates a lot of "noise" on the graph which makes it impossible to detect anything else.
You should wear comfortable clothing while your ambulatory EEG is being performed. Sweat pants and a loose fitting top with buttons down the front are suggested. Tight fitting sleeves and pull over tops will not be permitted. Do not attempt to pull a shirt or other clothing over your head during the ambulatory EEG. The electrodes may become dislodged and the quality of the recording will be affected.
What do I Need to do Before My Test?
- Assemble enough comfortable, appropriate clothes to wear. Most patients wear street clothes or a sweat suit during the day and warm pajamas and socks at night. Remember that the tops should button and be loose fitting.
- Bathe and wash your hair well. Do not leave any hair products in your hair and remove any braids or hair extensions. This will facilitate comfortable placement of the electrodes
What do Results Tell?
Confirmation of Clinical Suspicion of Epilepsy
A clinical suspicion of epilepsy can be confirmed by recording a seizure on AEEG. This is most likely to occur when the patient is experiencing daily or almost daily spells. Studies looking at the diagnostic yield of AEEG indicate that 6-15% of AEEGs record seizures.
Higher yields have been reported from 16-channel AEEG with computer-assisted seizure detection than from older 4- or 8-channel systems without seizure-detection algorithms. A 2001 study in which 502 patients were evaluated with computer-assisted 16-channel AEEG demonstrated that 8.5% of patients had a seizure during the recording period (mean, 28.5 h).
In patients with intractable epilepsy, AEEG has been used to localize seizure onset as part of presurgical evaluation. However, inpatient video/EEG monitoring remains the standard for presurgical evaluation.
Evaluation of Interictal Epileptiform Activity
Detection of interictal epileptiform abnormalities in the absence of recorded seizures can provide supporting evidence for a clinical diagnosis of epilepsy.
Studies have demonstrated that 34.9% of patients with known seizures had a positive AEEG, whereas 15.3% of 216 patients in whom the diagnosis of seizures was considered (ie, patients with episodic alterations of behavior, perception, sensation, or motor functioning) had interictal epileptiform abnormalities on 4-channel AEEG. When a 16-channel recorder was used, 38% of patients who were referred for AEEG had some type of epileptiform abnormality.
AEEG is highly specific; spikes were found on overnight AEEG in only 0.7% of asymptomatic adults without a history of migraine or a family history of epilepsy. In patients with a history of migraine headaches and those with a family history of epilepsy, the incidence of spikes on AEEG was 12.5% and 13.3%, respectively.
Some patients in whom epilepsy is suspected have a normal routine or sleep-deprived EEG. In these patients, AEEG can increase the chance of detecting an epileptiform abnormality. Of patients who previously had normal or nondiagnostic routine EEG, 12-25% have epileptiform activity on AEEG.
A study comparing the usefulness of sleep-deprived EEG and computer-assisted 16-channel AEEG in patients with suspected epilepsy (but a nondiagnostic initial routine EEG) found that sleep-deprived EEG improved detection of epileptiform discharges by 24%, whereas AEEG improved detection by 33%. Of the 46 patients studied, 15% had actual seizures recorded on AEEG, and none had seizures during the sleep-deprived recording.
Patients may have epilepsy without interictal epileptiform abnormalities on EEG, but this occurs in fewer than 20% of patients. In a study using a 4-channel recording system, 3 patients had only seizures recorded without interictal abnormalities. AEEG with 16 or more channels increases the probability that interictal epileptiform abnormalities will be found.
Documentation of Seizures of Which Patients are Unaware
For a patient to have seizures and yet be unaware of them is not uncommon. Brief alterations of awareness occur in both absence and complex partial seizures. AEEG is helpful at identifying seizures that are unrecognized or unreported by the patient.
Absence seizures may be so brief that the patient is unaware of them. A study using AEEG to evaluate absence seizures in pediatric patients found that most paroxysms of generalized spike and wave discharges were asymptomatic.
Patients with complex partial epilepsy are often amnestic for their seizures. The sequelae of a nocturnal generalized convulsive seizure, if present at all, may be so subtle (eg, fatigue, muscle soreness) that the patient is unsure whether a seizure actually occurred.
A study of patients in an epilepsy monitoring unit found that 63% of all seizures were unrecognized by the patients. This difficulty in identifying the occurrence of seizures impedes seizure diagnosis and assessment of treatment adequacy.
Evaluation of Response to Therapy
Because a significant number of patients are unaware of their seizures, responses to treatment are frequently difficult to gauge. Patients with mental retardation or other forms of encephalopathy may be unable to report seizures accurately. In such cases, AEEG can have a significant impact on clinical management.
AEEG is particularly useful in quantitating response to the treatment of absence seizures. If untreated, such seizures typically occur numerous times per day; adequate treatment usually normalizes the EEG.
Evaluation of Nocturnal or Sleep-related Events
Certain diagnoses are difficult to confirm with the typical 20-minute outpatient EEG. The interictal epileptiform discharges of benign rolandic epilepsy, for example, are highly activated by sleep and may not always be achieved adequately in a laboratory. Continuous spike and wave activity during slow-wave sleep is another entity that may demonstrate a relatively normal EEG during waking hours and a strikingly abnormal EEG during deep sleep.
Because of its capacity to record an entire night of sleep, AEEG is invaluable in assessing these clinical situations. Another advantage is that children can be monitored at home.
If a nonepileptic sleep disorder is suspected, PSG is the preferred study because of the added information from monitoring electromyography (EMG), eye movements, electrocardiography (ECG), and respiration.
The history may not differentiate clearly between a sleep disorder and epilepsy. AEEG may record frequent arousals (suggesting sleep apnea) or decreased rapid eye movement (REM) sleep latency (suggesting narcolepsy). In a study of 500 patients who had AEEG, narcolepsy was suggested in 6 patients, including 3 in whom narcolepsy had not been suspected.
Evaluation of Suspected Pseudoseizures
Pseudoseizures, also known as psychogenic seizures or nonepileptic events, are clinical events in which patients perceive altered movement, emotion, sensation, or experience similar to those due to epilepsy but without an electrographic ictal correlate.
Pseudoseizures are surprisingly frequent, occurring in as many as 20% of patients at epilepsy referral centers and in 5-20% of outpatient populations. Some patients have both pseudoseizures and epileptic seizures; coincident events occur in an estimated 10-60% of epilepsy patients.
AEEG can be a useful screening tool in identifying patients who have nonepileptic paroxysmal events. In one study, 36% of patients had event marker activations without associated electrographic changes.
Potential problems exist in using AEEG to definitively diagnose nonepileptic seizures. A 24-hour recording without associated video does not allow evaluation of clinical stereotypy, which is valuable when evaluating patients with unusual seizure manifestations and minimal EEG changes. Scalp EEG may not show electrographic ictal abnormality during some frontal lobe seizures or may show only subtle abnormalities that would be difficult to interpret without associated video.
Seizures and nonepileptic seizures may be associated with movement and muscle artifact that may obscure the underlying EEG. Although AEEG may be a useful initial screening tool for nonepileptic events, inpatient video/EEG monitoring remains the criterion standard in evaluating nonepileptic seizures.
Evaluation of Syncope
AEEG may be helpful in evaluating syncope or near-syncope if an ECG lead replaces 1 of the EEG channels. If cardiogenic syncope is suspected, a Holter monitor or prolonged cardiac event monitor may be more useful clinically. Although arrhythmias have been diagnosed with continuous ambulatory EEG/ECG recording, a study of epileptiform abnormalities in AEEG found that only 1 of 67 patients with syncope, near-syncope, or episodic dizziness had an epileptiform abnormality.
What Should I do if I have a Seizure During the Test?
- Most recorders have an “event” button to press if you have any seizures or different symptoms during the test.
- When the button is pressed, it marks the time on the EEG recording. The doctors can then compare what you feel or what is seen by others to what the EEG shows at the same time.
- If you are not able to press the button during a seizure, someone else can do it for you.
- Newer recorders also have built-in programs to identify epilepsy waves and seizures. Some can even record a video of what happened when the button was pushed.
Autonomic Nervous System (ANS) Testing
Autonomic Nervous System Testing to allow your practice to perform this crucial testing. This equipment measures galvanic skin response and Heart Rate Variability through a simple, quick, and non-invasive test that gives providers the ability to detect neuropathy before it becomes symptomatic.
Peripheral and cardiovascular neuropathy are among the largest concerns for diabetic patients , and it has been repeatedly proven that the earlier this condition can be detected and treated, the more likely a patient is to live a long and healthy life. Current estimates put the likelihood that a diabetic patient showing physical symptoms of peripheral neuropathy will survive through the next five years at between only 25 and 50 percent. By catching this condition through regular testing, health care providers can make a positive difference.
The autonomic nervous system (ANS) regulates physiologic processes, such as blood pressure, heart rate, body temperature, digestion, metabolism, fluid and electrolyte balance, sweating, urination, defecation, sexual response, and other processes. Regulation occurs without conscious control, i.e., autonomously. The ANS has two major divisions: the sympathetic and parasympathetic systems. Many organs are controlled primarily by either the sympathetic or parasympathetic system, although they may receive input from both; occasionally, functions are reciprocal (e.g., sympathetic input increases heart rate; parasympathetic decreases it).
The sympathetic nervous system is catabolic and activates fight-or-flight responses. Thus, sympathetic output increases heart rate and contractility, bronchodilation, hepatic glycogenolysis and glucose release, BMR (basal metabolism rate), and muscular strength; it also causes sweaty palms. Less immediately-life-preserving functions (e.g., digestion, renal filtration) are decreased.
The parasympathetic nervous system is anabolic; it conserves and restores. Gastrointestinal secretions and motility (including evacuation) are stimulated, heart rate is slowed, and blood pressure decreases.
Disorders of the ANS can affect any system of the body; they can originate in the peripheral or central nervous system and may be primary or secondary to other disorders. Symptoms suggesting autonomic dysfunction include orthostatic hypotension, heat intolerance, nausea, constipation, urinary retention or incontinence, nocturia, impotence, and dry mucous membranes. If a patient has symptoms suggesting autonomic dysfunction, cardiovagal, adrenergic, and sudomotor tests are usually done to help determine severity and distribution of the dysfunction.
Cardiovagal innervation testing evaluates heart rate response to deep breathing and to the Valsalva maneuver, via electrocardiogram rhythm strip. If the ANS is intact, heart rate varies with these maneuvers; the ratio of longest to shortest R-R interval (Valsalva ratio) should be 1.4 or greater.
Vasomotor adrenergic innervation testing evaluates response of beat-to-beat blood pressure to the head-up tilt and Valsalva maneuver. The head-up tilt shifts blood to dependent parts, causing reflex responses. The Valsalva maneuver increases intrathoracic pressure and reduces venous return, causing blood pressure changes and reflex vasoconstriction. In both tests, the pattern of responses is an index of adrenergic function.
Autonomic nervous system (ANS) testing, including parasympathetic function (cardiovagal innervation), sympathetic adrenergic function (vasomotor adrenergic innervation).
What else is the benefit of ANS Testing?
- Diagnose the presence of autonomic neuropathy in a patient with signs or symptoms suggesting a progressive autonomic neuropathy, including: Diabetic neuropathy, Amyloid neuropathy, Sjogren’s syndrome, Idiopathic neuropathy, Pure autonomic failure, Multiple system dystrophy.
- Evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy;
- Differentiate the diagnosis between certain complicated variants of syncope from other causes of loss of consciousness;
- Evaluate inadequate response to beta blockade in vasodepressor syncope;
- Evaluate distressing symptoms in the patient with a clinical picture suspicious for distal small fiber neuropathy in order to diagnose the condition;
- Differentiate the cause of postural tachycardia syndrome;
- Evaluate change in type, distribution or severity of autonomic deficits in patients with autonomic failure;
- Evaluate the response to treatment in patients with autonomic failure who demonstrate a change in clinical exam;
- Diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient;
- Evaluate and diagnose sympathetically maintained pain, as in reflex sympathetic dystrophy or causalgia; or
- Evaluate and treat patients with recurrent unexplained syncope to demonstrate autonomic failure.
Botox is used medically to treat certain muscular conditions, and cosmetically to remove wrinkles by temporarily paralyzing muscles. It is made from a neurotoxin called botulinum toxin that is produced by the bacterium Clostridium botulinum. Although Botox is a powerful poison, when used correctly, it has a number of applications.
Fast facts on Botox:
- Botox is the most popular non-surgical cosmetic treatment, with more than 6 million Botox treatments administered each year.
- Botox is a neurotoxin derived from Clostridium botulinum, an organism found in the natural environment where it is largely inactive and non-toxic.
- Botulinum toxin is used to reduce fine lines and wrinkles by paralyzing the underlying muscles.
- People also use Botox to treat excessive sweating, migraines, muscular disorders, and some bladder and bowel disorders.
- Botulism, an illness caused by botulinum toxin, can cause respiratory failure and prove deadly.
- Just 1 gram of botulinum toxin could kill over 1 million people. Two kilograms could kill the entire human population of Earth.
What is Botox?
Clostridium botulinum, the bacterium from which Botox is derived, is found in many natural settings, including soil, lakes, and forests. The bacterium can also be found in the intestinal tracts of mammals and fish and in the gills and organs of crabs and other shellfish. Such naturally occurring instances of Clostridium botulinum bacteria and spores are generally harmless. Problems only arise when the spores transform into vegetative cells and the cell population increases. At a certain point, the bacteria begin producing botulinum toxin, the deadly neurotoxin responsible for botulism.
Neurotoxins target the nervous system, disrupting the signaling processes that allow neurons to communicate effectively.
How Does Botox Work?
Botulinum toxin is one of the most poisonous substances known to man. Scientists have estimated that a single gram could kill as many as 1 million people and a couple of kilograms could kill every human on earth. In high concentrations, botulinum toxin can result in botulism, a severe, life-threatening illness. Botulism, left untreated, may result in respiratory failure and death. Despite botulinum toxin being so toxic, Botox is in huge demand.
Despite this, botulinum toxin has proven to be a successful and valuable therapeutic protein.
Botulinum toxin can be injected into humans in extremely small concentrations and works by preventing signals from the nerve cells reaching muscles, therefore paralyzing them.
In order for muscles to contract, nerves release a chemical messenger, acetylcholine (a neurotransmitter), at the junction where the nerve endings meet muscle cells. Acetylcholine attaches to receptors on the muscle cells and causes the muscle cells to contract or shorten.
Injected botulinum toxin prevents the release of acetylcholine, preventing contraction of the muscle cells. Botulinum toxin causes a reduction in abnormal muscle contraction, allowing the muscles to become less stiff.
Usefulness of Botox
Botulinum toxin is predominantly used as a treatment to reduce the appearance of facial wrinkles and fine lines. Beyond aesthetic applications, Botox is used to treat a variety of medical conditions, including eye squints, migraines, excess sweating, and leaky bladders. Botulinum toxin is currently used to treat over 20 different medical conditions, with more applications under investigation.
Botulinum toxin is currently approved for the following therapeutic applications:
- Blepharospasm (spasm of the eyelids).
- Idiopathic rotational cervical dystonia (severe neck and shoulder muscle spasms).
- Chronic migraine.
- Severe primary axillary hyperhidrosis (excessive sweating).
- Strabismus (crossed eyes).
- Post-stroke upper limb spasticity.
- Detrusor (bladder wall muscle) overactivity – causing urinary incontinence.
- Overactive bladder.
- Hemifacial spasm.
- Glabellar lines (frown lines between the eyebrows).
- Canthal lines (crow’s feet).
Botulinum toxin is also used off-label (not approved) for:
- Achalasia (an issue with the throat that makes swallowing difficult).
- Anal fissure and anismus (dysfunction of the anal sphincter).
- Sialorrhea (producing too much saliva).
- Allergic rhinitis (hay fever).
- Sphincter of oddi (hepatopancreatic) dysfunction (causes abdominal pain).
- Cerebral Palsy.
- Oromandibular dystonia (forceful contraction of the jaw, face, and/or tongue).
- Laryngeal dystonia (forceful contraction of the vocal cords).
Botulinum toxin is sold commercially under the names:
- Botox, Vistabel, Botox cosmetic (OnabotulinumtoxinA or botulinum toxin type A).
- Dysport (AbobotulinumtoxinA or botulinum toxin type A).
- Bocouture, Xeomin (IncobotulinumtoxinA or botulinum toxin type A).
- Myobloc (RimabotulinumtoxinB or botulinum toxin type B).
Botox for Chronic Back and Neck Pain
Botox isn’t just for celebrities anymore — patients with chronic back and neck pain may want to consider using it. The same injection that works to smooth out wrinkles just may work to relieve persistent, life-inhibiting pain caused by muscle tension. In fact, Botox was originally approved by the FDA in 1989 to treat severe muscle contractions caused by cervical dystonia. So before Botox was the new “it” anti-aging treatment, doctors knew it could relax muscles. Botox does that by blocking the neurotransmitters that tell muscles to contract. No signal from the neurotransmitters, no contraction, no tension — no pain.
Botox Injection Preparation
Botox comes as a crystalline substance from the manufacturer, which then has to be reconstituted with saline or another liquid. Practitioners add varying amounts of liquid when reconstituting it. Although there is no right or wrong amount of liquid to add, most physicians add about 2 mL-3 mL (about a half a teaspoon) of liquid to each vial. Some add quite a bit more, which can lead patients to think they are getting more Botox when, in reality, they are getting the same or less amount of Botox than samples reconstituted in a stronger way. It is the total dose of medication, not the volume of liquid, that leads to the desired effect.
Therefore, it is important to remember that if a clinic or medical spa states that they are providing Botox at a certain dollar amount per unit, it is quite possible that they are diluting the Botox and actually not providing the agreed-upon amount. This is much like the concept of a watered-down drink at a bar, but the costs are much larger when it comes to Botox or its alternatives, Dysport and Xeomin.
During the Botox Procedure
The patient is placed in a somewhat raised position on the exam table, and the areas to be injected are cleansed with a nonalcohol cleanser, such as Hibiclens or Betadine. Some physicians will apply a topical anesthetic, such as EMLA cream or some alternative, at this time. The Botox is then injected into the desired areas. Typical injection patterns include about four or five areas on each side of the forehead and two or three areas on either eye area. More areas can be injected by skilled physicians, depending on the type of wrinkles and the desired effect for the patient. It is common for pressure to be applied if an area seems to be bleeding after the injection. While ice is sometimes applied beforehand for comfort reasons, direct pressure is much more effective than ice for control of bleeding and bruising.
After the Botox Procedure
After the injections, the patient will usually lay upright or semiupright on the exam table for about two to five minutes to make sure he or she feels good after the procedure, and then the patient should avoid lying down for two to four hours. If bruising is a concern, it will be important for the patient to avoid taking aspirin or related products, such as ibuprofen (Advil, Motrin) or naproxen (Aleve), if possible after the procedure to keep bruising to a minimum.
There are many physicians who encourage their patients to either work the area several times during the next several days or, alternatively, to not use the affected muscles during the next several days. Many practitioners do not tell the patients to do anything in particular other than to avoid strenuous activity for several hours afterward because of an increased risk of bruising.
Results will be evident within three to 10 days. Photographs may be taken before the procedure so that patients can check their results themselves rather than relying on their memory. It is surprising to see how many people do not recall how they looked before the procedure and are amazed at the difference when shown a picture. Prior to having the procedure done, the patient should realize that Botox does not actually erase lines but relaxes them. What this means is that deeper lines will become somewhat less deep and superficial lines will nearly disappear. This can be likened to the act of steaming a garment’s wrinklesrather than ironing them.
It may be necessary for the patient to have additional procedures, such as the use of filler substances (for example, Restylane, Perlane, Juvederm, Sculptra, or Radiesse) in order to plump up the wrinkles that are now relaxed. Additionally, it may be necessary to have two or three sessions of Botox treatment for deeper wrinkles before results become optimal. The area of the crease between the eyes is a particularly ideal area for Botox use in conjunction with filler as these fixed wrinkles don’t always respond optimally to Botox alone. There is some controversy about using filler in that area as it may block veins or arteries and result in loss of blood and a scar to the area. Generally, the smaller particle fillers, such as Restylane or Juvederm Ultra, are best in the area between the eyes for this reason.
Risks and Side Effects of Botox
Injections with botulinum toxin are generally well tolerated and there are few side effects. In rare cases, an individual may have a genetic predisposition that results in a mild, transient unusual response to the drug.
Around 1 percent of people receiving injections of botulinum toxin type A develop antibodies to the toxin that make subsequent treatments ineffective.
Along with its intended effects, botulinum toxin may cause some unwanted effects. These can include:
- Mild pain, local edema (fluid buildup) and/or erythema (reddening of the skin) at the injection site.
- Malaise – feeling generally unwell.
- Mild nausea.
- Temporary unwanted weakness/paralysis of nearby muscles.
- Temporary upper lid or brow ptosis (drooping).
- Weakness of the lower eyelid or lateral rectus (a muscle controlling eye movement).
- Dysphagia – trouble swallowing.
- Neck weakness.
- Flu-like illness.
- Brachial plexopathy – a condition affecting the nerves either side of the neck and chest.
- Gallbladder dysfunction.
- Diplopia (double vision).
- Blurred vision.
- Decreased eyesight.
- Dry mouth.
Cuts, Lacerations, Wounds, Abrasion, First Aid and Treatment
A cut refers to a skin wound with separation of the connective tissue elements. Unlike an abrasion (a wound caused by friction or scraping), none of the skin is missing the skin is just separated. A cut is typically thought of as a wound caused by a sharp object (such as a knife or a shard of glass).
The term laceration implies a torn or jagged wound. Lacerations tend to be caused by sharp objects. Cuts and lacerations are terms for the same condition.
The term gash can be used for more dramatic effect because it implies a longer or deeper cut.
An avulsion refers to a wound where tissue is not just separated but torn away from the body.
After you suffer a cut you often bleed. Other concerns with a cut include infection, pain, damage to structures beneath the skin, and future scars.
What is Laceration Wound?
A laceration is a wound that occurs when skin, tissue, and/or muscle is torn or cut open. Lacerations may be deep or shallow, long or short, and wide or narrow. Most lacerations are the result of the skin hitting an object, or an object hitting the skin with force. Laceration repair is the act of cleaning, preparing, and closing the wound.
Minor lacerations (shallow, small, not bleeding, and clean) may not require medical attention. Antibiotic ointment and a bandage may be all that is needed. However, most lacerations do require repair.
Cleaning and preparing a laceration for repair is crucial for preventing infection and reducing the appearance of scarring. Cleaning not only washes away dirt, but also removes the germs that could trigger infection. Cleaning is done in the same manner regardless of the technique that will be used for wound closure. Preparation is done to even out jagged edges so that scarring may be less noticeable. Preparation is done as needed.
Sutures are used for wounds that are deep, bleeding, have jagged edges, or have fat or muscle exposed. Iodine is applied to the wound edges, and to the skin surrounding the wound. A surgical drape may be positioned over the wound, and taped to the skin so it does not move around (keeps the area sterile).
If a laceration is deep and underlying tissue or muscle is also lacerated, stitches may be needed under the skin before the wound can be closed. This will rejoin muscle and tissue layers. The stitches used under the skin are absorbed by the body, and do not need to be removed.
Types of Open Wound
- Incisions or incised wounds, caused by a clean, sharp-edged object such as a knife, a razor or a glass splinter.
- Lacerations, irregular tear-like wounds caused by some blunt trauma. Lacerations and incisions may appear linear (regular) or stellate (irregular). The term laceration is commonly misused in reference to incisions.
- Abrasions (grazes), superficial wounds in which the topmost layer of the skin (the epidermis) is scraped off. Abrasions are often caused by a sliding fall onto a rough surface.
- Puncture wounds, caused by an object puncturing the skin, such as a nail or needle.
- Penetration wounds, caused by an object such as a knife entering and coming out from the skin.
- Gunshot wounds, caused by a bullet or similar projectile driving into or through the body. There may be two wounds, one at the site of entry and one at the site of exit, generally referred to as a “through-and-through.”
What are Symptoms of Cuts or Lacerations?
Although it can be obscured by blood, a cut is one of the easiest medical conditions to diagnose. A deep cut, may reveal underlying tissues such as fat, tendon, muscle, or bone. Some people faint at the sight of their own blood (this is a neurological reaction in which a reflex slowing of the heart causes a low blood pressure called vasovagal syncope). Physicians need to distinguish this common faint from people who pass out from loss of blood (hemorrhagic shock).
Treatment for Wound
The treatment depends on the type, cause, and depth of the wound as well as whether other structure beyond the skin are involved. Treatment of recent lacerations involves examination, cleaning, and closing the wound. If the laceration occurred some time ago it may be allowed to heal by secondary intention due to the high rate of infection with immediate closure. Minor wounds like bruises will heal on their own with skin discoloration usually disappears in 1–2 weeks. Abrasions which are wounds with intact skin usually require no active treatment except keeping the area clean with soap and water. Puncture wounds may be prone to infection depending on the depth of penetration. The entry of puncture wound is left open to allow for bacteria or debris to be removed from inside.
Cleaning of Wound
For simple lacerations cleaning can be accomplished using a number of different solutions including tap water, sterile saline solution, or antiseptic solution. Infection rates may be lower with the use of tap water in regions where water quality is high. Evidence for the effectiveness of any cleaning of simple wound however is limited.
Most clean open wounds do not require any antibiotics unless the wound is contaminated or the bacterial cultures are positive. Excess use of antibiotics only leads to resistance and side effects. All open wounds should be cleaned at least twice a day with warm water and soap. Once the wound is cleaned, it should be covered with moist gauze. This should be followed by application of dry gauze and then the wound covered with a bandage. The purpose of a wet to dry dressing allows the bandage to adhere to dead tissue performing a mechanical debridement when removed.This allows new healthy skin to grow and prevents debris from collecting. When the wound is clean, it may be closed with a skin graft. No wound is ever closed if it is suspected to be infected
Closure of Wound
Incisions caused by a knife or a sharp object need to be thoroughly cleaned and the edges trimmed. If the wounds are fresh and less than 12 hours old, they can be closed with sutures or staples. Any wound which is more than 24 hours old should be suspected to be contaminated and not closed completely. Only the deeper tissues can be approximated and the skin should be left open. If closure of a wound is decided upon a number of techniques can be used. These include bandages, a cyanoacrylate glue, staples, and sutures. Absorbable sutures have the benefit over non absorbable sutures of not requiring removal. They are often preferred in children.
Epidural Steroid Injection (ESI)
An epidural steroid injection (ESI) is a minimally invasive procedure that can help relieve neck, arm, back, and leg pain caused by inflamed spinal nerves. ESI may be performed to relieve pain caused by spinal stenosis, spondylolysis, or disc herniation. Medicines are delivered to the spinal nerve through the epidural space, the area between the protective covering of the spinal nerves and bony vertebrae. Pain relief may last for several days or even years. The goal is to reduce pain so that you may resume normal activities and a physical therapy program.
Epidural injections can help control back pain and inflammation, which is especially helpful for people suffering from a bulging disc in the neck or back. When combined with oral medications and physical therapy, the injections can provide enough relief from bulging disc symptoms for the patient to resume normal daily activities in a relatively short amount of time.
If you are suffering from the chronic pain of a bulging disc, you are probably actively searching for a treatment that will take away the pain and help you avoid spine surgery, if at all possible. You should consult your doctor about starting a regimen of epidural injections to help reduce your pain, so you can get back to the active lifestyle you enjoy.
Epidural steroid injections deliver medication directly (or very near) the source of pain generation. In contrast, oral steroids and painkillers have a dispersed, less-focused impact and may have unacceptable side effects. Additionally, since the vast majority of pain stems from chemical inflammation, an epidural steroid injection can help control local inflammation while also “flushing out” inflammatory proteins and chemicals from the local area that may contribute to and exacerbate pain.
What is an Epidural Steroid Injection (ESI)?
A steroid injection includes both a corticosteroid (e.g., triamcinolone, methyl-prednisolone, dexamethasone) and an anesthetic numbing agent (e.g., lidocaine or bupivacaine). The drugs are delivered into the epidural space of the spine, which is the area between the protective covering (dura) of the spinal cord and nerves and the bony vertebrae.
An epidural steroid injection delivers steroids directly into the epidural space in the spine. Sometimes additional fluid (local anesthetic and/or a normal saline solution) is used to help ‘flush out’ inflammatory mediators from around the area that may be a source of pain.
The epidural space encircles the dural sac and is filled with fat and small blood vessels. The dural sac surrounds the spinal cord, nerve roots, and cerebrospinal fluid (the fluid that the nerve roots are bathed in).
Typically, a solution containing cortisone (steroid) with local anesthetic (lidocaine or bupivacaine), and/or saline is used.
- A steroid, or cortisone, is usually injected as an anti-inflammatory agent. Inflammation is a common component of many low back conditions and reducing inflammation helps reduce pain. Triamcinolone acetonide, Dexamethasone, and Methylprednisolone acetate are commonly used steroids.
- Lidocaine (also referred to as Xylocaine) is a fast-acting local anesthetic used for temporary pain relief. Bupivacaine, a longer lasting medication, may also be used. Although primarily used for pain relief, these local anesthetics also act as ‘flushing’ agents to dilute the chemical or immunologic agents that promote inflammation.
- Saline is used to dilute the local anesthetic or as a ‘flushing’ agent to dilute the chemical or immunologic agents that promote inflammation.
Epidural injections are often used to treat radicular pain, also called sciatica, which is pain that radiates from the site of a pinched nerve in the low back to the area of the body aligned with that nerve, such as the back of the leg or into the foot. Inflammatory chemicals (e.g. substance P, PLA2, arachidonic acid, TNF-α, IL-1, and prostaglandin E2) and immunologic mediators can generate pain and are associated with common back problems such as lumbar disc herniation or facet joint arthritis. These conditions, as well as many others, provoke inflammation that in turn can cause significant nerve root irritation and swelling.
Steroids inhibit the inflammatory response caused by chemical and mechanical sources of pain. Steroids also work by reducing the activity of the immune system to react to inflammation associated with nerve or tissue damage. A typical immune response is the body generating white blood cells and chemicals to protect it against infection and foreign substances such as bacteria and viruses. Inhibiting the immune response with an epidural steroid injection can reduce the pain associated with inflammation.
Who is a candidate?
Patients with pain in the neck, arm, low back, or leg (sciatica) may benefit from ESI. Specifically, those with the following conditions:
- Spinal Stenosis: A narrowing of the spinal canal and nerve root canal can cause back and leg pain, especially when walking.
- Spondylolysis: A weakness or fracture between the upper and lower facets of a vertebra. If the vertebra slips forward (spondylolisthesis), it can compress the nerve roots causing pain.
- Herniated Disc: The gel-like material within the disc can bulge or rupture through a weak area in the surrounding wall (annulus). Irritation, pain, and swelling occur when this material squeezes out and comes in contact with a spinal nerve.
- Degenerative Disc: A breakdown or aging of the intervertebral disc causing collapse of the disc space, tears in the annulus, and growth of bone spurs.
- Sciatica: Pain that courses along the sciatic nerve in the buttocks and down the legs. It is usually caused by compression of the 5th lumbar or 1st sacral spinal nerve.
- Cysts: In the facet joint or the nerve root and can expand to squeeze spine structures.
Who Should Avoid Epidural Steroid Injections
ESI has proven helpful for some patients in the treatment of the above painful inflammatory conditions. ESI can also help determine whether surgery might be beneficial for pain associated with a herniated disc. When symptoms interfere with rehabilitative exercises, epidurals can ease the pain enough so that patients can continue their physical therapy.
ESI should NOT be performed on people who have an infection or have bleeding problems (patient taking blood thinners (Coumadin, etc), or patients with a bleeding problem (hemophilia, etc)). The injection may slightly elevate the blood sugar levels in patients with diabetes. It may also temporarily elevate blood pressure and eye pressure for patients with glaucoma. You should discuss this with your physician.
If you think you may be pregnant or are trying to get pregnant, please tell the doctor. Fluoroscopy x- rays used during the procedure may be harmful to the baby.
Epidural steroid injections should also not be performed on patients whose pain could be related to a spinal tumor. If suspected, an MRI scan should be done prior to the injection to rule out a tumor.
Injections may be done, but with caution, for patients with other potentially problematic conditions such as:
- Allergies to the injected solution
- Uncontrolled medical problems such as renal disease, congestive heart failure and diabetes because they may be complicated by the fluid retention that a small percentage of patients experience for a few days after the injections.
Use of high dose aspirin or other anti-platelet drugs (e.g. Ticlid, Plavix), all of which can cause bleeding from the procedure. These medications should be stopped prior to having an injection.
What Happens Before Treatment?
The doctor who will perform the procedure reviews your medical history and previous imaging studies to plan the best approach for the injections. Be prepared to ask any questions at this appointment.
Patients who take take blood thinning medication (Coumadin, Heparin, Plavix, Ticlid, Fragmin, Orgaran, Lovenox, Innohep, high-dose aspirin) may need to stop taking it several days before the ESI. Discuss any medications with your doctors, including the one who prescribed the medication and the doctor who will perform the injection.
The procedure is usually performed in an outpatient special procedure suite that has access to fluoroscopy. Make arrangements to have someone drive you to and from the office or outpatient center the day of the injection.
What Happens During Treatment?
The epidural steroid injection procedure takes place in a surgery center, hospital, or a physician’s clinic. Many types of physicians can be qualified to perform an epidural steroid injection, including an anesthesiologist, radiologist, neurologist, physiatrist, and surgeon.
At the time of the procedure, you will be asked to sign consent forms, list medications you are presently taking, and if you have any allergies to medication. The procedure may last 15-45 minutes, followed by a recovery period.
The goal is to inject the medication as close to the pain site as possible, using either transforaminal or interlaminar injection. The right type of injection depends on your condition and which procedure will likely produce the best results and the least discomfort or side effects.
Step 1: Prepare the Patient
The patient lies face down on an x-ray table. Local anesthetic is used to numb the treatment area. The patient experiences minimal discomfort throughout the procedure. The patient remains awake and aware during the procedure to provide feedback to the physician. A low dose sedative, such as Valium or Versed, is usually the only medication given for this procedure.
Step 2: Insert the Needle
With the aid of a fluoroscope (a special X-ray), the doctor directs a hollow needle through the skin and between the bony vertebrae into the epidural space. Fluoroscopy allows the doctor to watch the needle in real-time on the fluoroscope monitor, ensuring that the steroid medication is delivered as close to the inflamed nerve root as possible. Some discomfort occurs but patients typically feel more pressure than pain.
There are two ways to deliver epidural steroid injections: transforaminal or interlaminar. The best method depends on the location and source of pain.
- Transforaminal ESI (from the side). The needle is placed to the side of the vertebra in the neural foramen, just above the opening for the nerve root and outside the epidural space. Use of a contrast dye helps to confirm where the medication will flow when injected. This method treats one side at a time. It is preferred for patients who have undergone a previous spine surgery because it avoids any residual scars, bone grafts, metal rods, and screws.
- Interlaminar ESI (from the back). The needle is placed between the lamina of two vertebrae directly from the middle of the back. Also called interlaminar, this method accesses the large epidural space overlying the spinal cord. Medication is delivered to the nerve roots on both the right and left sides of the inflamed area at the same time.
Step 3: Inject the Medication
Once the needle is in the proper position, contrast is injected to confirm the needle location. The epidural steroid solution is then injected. Although the steroid solution is injected slowly, most patients sense some pressure due to the amount of the solution used (which in lumber injections can range from 3mL to 10mL, depending on the approach and steroid used). The pressure of the injection is not generally painful.
Following the injection, the patient is monitored for 15 to 20 minutes before being discharged home.
Sedation is available for patient anxiety and comfort. However, sedatives are rarely necessary, as the epidural steroid injection procedure is usually not uncomfortable. If a sedative is used, some patient precautions should be taken, including not eating or drinking for several hours prior to the procedure and having a guardian available for discharge. A patient should contact his or her doctor for specific instructions.
Tenderness at the needle insertion site can occur for a few hours after the procedure and can be treated by applying an ice pack for 10 to 15 minutes once or twice an hour. In addition, patients are usually asked to rest for the remainder of the day on which they have the epidural steroid injection. Normal activities (those that were done the week prior to the epidural injection) may typically be resumed the following day. A temporary increase in the pain can occur for several days after the injection due to the pressure of the fluid injected or due to local chemical irritation.
Most patients can walk around immediately after the procedure. After being monitored for a short time, you usually can leave the office or suite. Someone must drive you home. Typically patients resume full activity the next day. Soreness around the injection site may be relieved by using ice and taking a mild analgesic (Tylenol).
Patients should schedule a follow-up appointment with the referring or treating physician after the procedure to document the efficacy and address any concerns the patient may have for future treatments and expectations.
ESI Pain Relief Success Rate
Patients will find that the benefits of an epidural steroid injection include a reduction in pain, primarily in leg pain (also called sciatica or radicular pain). Patients seem to have a better response when the epidural steroid injections are coupled with an organized therapeutic exercise program.
Epidural Steroid Injection Success Rates
While the effects of an epidural steroid injection tend to be temporary (lasting from a week to up to a year) an epidural steroid injection can deliver substantial benefits for many patients experiencing low back pain.
- When proper placement is made using fluoroscopic guidance and radiographic confirmation through the use of contrast, > 50% of patients receive some pain relief as a result of lumbar epidural steroid injections.
- Pain relief is more often felt for primary radicular (leg) pain and, less prominently, low back pain.
- The pain relief and control brought on by injections can improve a patient’s mental health and quality of life, minimize the need for painkiller use, and potentially delay or avoid surgery.
Success rates can vary depending on the condition that patient has and the degree of radicular leg pain that accompanies it:
- Recent research reports that lumbar epidural steroid injections are successful in patients with persistent sciatica from lumbar disc herniation, with more than 80% of the injected group with disc herniation experiencing relief (in contrast to 48% of the group that received a saline placebo injection).
- Similarly, in a study focused on a group of patients with lumbar spinal stenosis and related sciatica symptoms, 75% of patients receiving injections had more than 50% of pain reduction one year following the injections. The majority also increased their walking duration and tolerance for standing.
- The minimally invasive approach to this surgery offers our patients a safer and effective alternative to traditional open back surgery and our patients have reported a patient satisfaction score of 96.
ESI: Risks and Side Effects
With few risks, ESI is considered an appropriate nonsurgical treatment for some patients. The potential risks associated with inserting the needle include spinal headache from a dural puncture, bleeding, infection, allergic reaction, and nerve damage / paralysis (rare).
Corticosteroid side effects may cause weight gain, water retention, flushing (hot flashes), mood swings or insomnia, and elevated blood sugar levels in people with diabetes. Any numbness or mild muscle weakness usually resolves within 8 hours in the affected arm or leg (similar to the facial numbness experienced after dental work). Patients who are being treated for chronic conditions (e.g., heart disease, diabetes, rheumatoid arthritis) or those who cannot temporarily discontinue anti-clotting medications should consult their personal physician for a risk assessment.
Potential Risks of Epidural Steroid Injections
As with all invasive medical procedures, there are potential risks associated with lumbar epidural steroid injections. In addition to temporary numbness of the bowels and bladder, the most common potential risks and complications include:
- Infection. Severe infections are rare, occurring in 0.1% to 0.01% of injections. such as Osteomyelitis, a Spinal Infection.
- Dural puncture (“wet tap”). A dural puncture occurs in 0.5% of injections. It may cause a post-dural puncture headache (also called a spinal headache) that usually improves within a few days. Although infrequent, a blood patch may be necessary to alleviate the headache. A blood patch is a simple, quick procedure that involves obtaining a small amount of blood from a patient from an arm vein and immediately injecting it into the epidural space to allow it to clot around the spinal sac and stop the leak.
- Bleeding. Bleeding is a rare complication and is more common for patients with underlying bleeding disorders.
- Nerve damage. While extremely rare, nerve damage can occur from direct trauma from the needle, or from infection or bleeding.
Ear Wax Blockage and Removal
Earwax blockage occurs when earwax (cerumen) accumulates in your ear or becomes too hard to wash away naturally.
Earwax is a helpful and natural part of your body's defenses. It cleans, lubricates and protects your ear canal by trapping dirt and slowing the growth of bacteria.
If earwax blockage becomes a problem, you or your doctor can take simple steps to remove the wax safely.
Signs and symptoms of earwax blockage may include:
- Feeling of fullness in the affected ear
- Ringing or noises in the ear (tinnitus)
- Decreased hearing in the affected ear
When to see a doctor
If you're experiencing the signs and symptoms of earwax blockage, talk to your doctor.
Signs and symptoms could indicate another condition. You may think you can deal with earwax on your own, but there's no way to know if you have excessive earwax without having someone, usually your doctor, look in your ears. Having signs and symptoms, such as earache or decreased hearing, doesn't necessarily mean you have wax buildup. It's possible you have another medical condition involving your ears that may need attention.
Wax removal is most safely done by a doctor. Your ear canal and eardrum are delicate and can be damaged easily by excess earwax. Don't try to remove earwax yourself with any device placed into your ear canal, especially if you have had ear surgery, have a hole (perforation) in your eardrum, or are having ear pain or drainage.
Children usually have their ears checked as part of any medical examination. If necessary, a doctor can remove excess earwax from your child's ear during an office visit.
The wax in your ears is secreted by glands in the skin that lines the outer half of your ear canals. The wax and tiny hairs in these passages trap dust and other foreign particles that could damage deeper structures, such as your eardrum.
In most people, a small amount of earwax regularly makes its way to the opening of the ear, where it's washed away or falls out as new wax is secreted to replace it. If you secrete an excessive amount of wax or if earwax isn't cleared effectively, it may build up and block your ear canal.
Earwax blockages commonly occur when people try to clean their ears on their own by placing cotton swabs or other items in their ears. This often just pushes wax deeper into the ear, rather than removing it.
Your doctor can determine whether you have earwax blockage by looking in your ear with a special instrument that lights and magnifies your inner ear (otoscope).
Your doctor can remove excess wax using a small, curved instrument called a curet or by using suction while inspecting the ear. Your doctor can also flush out the wax using a water pick or a rubber-bulb syringe filled with warm water.
If earwax buildup is a recurring problem, your doctor may recommend that you use a wax-removal medication, such as carbamide peroxide (Debrox Earwax Removal Kit, Murine Ear Wax Removal System). Because these drops can irritate the delicate skin of the eardrum and ear canal, use them only as directed.
Some people use ear candling, a technique that involves placing a lighted, hollow, cone-shaped candle into the ear, to try to remove earwax. The theory is that the heat from the flame will create a vacuum seal and the earwax will adhere to the candle.
However, ear candling is not a recommended treatment for earwax blockage. Research has found that ear candling doesn't work, and it may result in injury, such as burns, ear canal obstructions and even perforations.
Talk to your doctor before trying any alternative remedies for removing earwax.
Lifestyle and home remedies
If your eardrum doesn't contain a tube or have a hole in it, these self-care measures may help you remove excess earwax that's blocking your ear canal:
- Soften the wax. Use an eyedropper to apply a few drops of baby oil, mineral oil, glycerin or hydrogen peroxide in your ear canal.
- Use warm water. After a day or two, when the wax is softened, use a rubber-bulb syringe to gently squirt warm water into your ear canal. Tilt your head and pull your outer ear up and back to straighten your ear canal. When finished irrigating, tip your head to the side to let the water drain out.
- Dry your ear canal. When finished, gently dry your outer ear with a towel or hand-held dryer.
You may need to repeat this wax-softening and irrigation procedure a few times before the excess earwax falls out. However, the softening agents may only loosen the outer layer of the wax and cause it to lodge deeper in the ear canal or against the eardrum. If your symptoms don't improve after a few treatments, see your doctor.
Earwax removal kits available in stores also can be effective at removing wax buildup. Ask your doctor for advice on how to properly select and use alternative earwax removal methods.
Don't try to dig it out
Never attempt to dig out excessive or hardened earwax with available items, such as a paper clip, a cotton swab or a hairpin. You may push the wax farther into your ear and cause serious damage to the lining of your ear canal or eardrum.
Preparing for your appointment
You're likely to start by seeing your family doctor or a general practitioner. In some rare cases, however, you may be referred to a specialist in ear disorders (ear, nose and throat specialist).
As you prepare for your appointment, it's a good idea to write a list of questions. Your doctor may have questions for you as well. He or she may ask:
- How long have you been experiencing symptoms, such as earache or difficulty hearing?
- Have you had any drainage from your ears?
- Have you experienced earache, difficulty hearing or drainage in the past?
- Have your symptoms been continuous or occasional?
What you can do in the meantime
Don't attempt to dig out earwax with cotton swabs or other items — such as hairpins or pen caps. This can push the wax farther into the ear and cause serious injury to the ear canal or eardrum.
Electrocardiogram (ECG or EKG)
An electrocardiogram — abbreviated as EKG or ECG — is a test that measures the electrical activity of the heartbeat. With each beat, an electrical impulse (or “wave”) travels through the heart. This wave causes the muscle to squeeze and pump blood from the heart. A normal heartbeat on ECG will show the timing of the top and lower chambers.
The right and left atria or upper chambers make the first wave called a “P wave” — following a flat line when the electrical impulse goes to the bottom chambers. The right and left bottom chambers or ventricles make the next wave called a “QRS complex.” The final wave or “T wave” represents electrical recovery or return to a resting state for the ventricles.
An abnormal EKG can mean many things. Sometimes an EKG abnormality is a normal variation of a heart’s rhythm, which does not affect your health. Other times, an abnormal EKG can signal a medical emergency, such as a myocardial infarction (heart attack) or a dangerous arrhythmia.
What Can EKG or ECG do?
An ECG gives two major kinds of information. First, by measuring time intervals on the ECG, a doctor can determine how long the electrical wave takes to pass through the heart. Finding out how long a wave takes to travel from one part of the heart to the next shows if the electrical activity is normal or slow, fast or irregular. Second, by measuring the amount of electrical activity passing through the heart muscle, a cardiologist may be able to find out if parts of the heart are too large or are overworked.
EKG or ECG can detect:
- The underlying rate and rhythm mechanism of the heart.
- The orientation of the heart (how it is placed) in the chest cavity.
- Evidence of increased thickness (hypertrophy) of the heart muscle.
- Evidence of damage to the various parts of the heart muscle.
- Evidence of acutely impaired blood flow to the heart muscle.
- Patterns of abnormal electric activity that may predispose the patient to abnormal cardiac rhythm disturbances.
When is an ECG (EKG) performed?
- As part of a routine physical examination or screening evaluation.
- As part of a cardiac exercise stress test.
- As part of the evaluation of symptoms of chest pain, shortness of breath, dizziness or fainting, palpitations.
- As part of the preoperative workup for surgery in patients who may be at an age where heart disease could potentially be present.
What Medical Condition Can EKG Diagnose?
- Abnormally fast or irregular heart rhythms.
- Abnormally slow heart rhythms.
- Abnormal conduction of cardiac impulses, which may suggest underlying cardiac or metabolic disorders.
- Evidence of the occurrence of a prior heart attack (myocardial infarction).
- Evidence of an evolving, acute heart attack.
- Evidence of an acute impairment to blood flow to the heart during an episode of a threatened heart attack (unstable angina).
- Adverse effects on the heart from various heart diseases or systemic diseases (such as high blood pressure, thyroid conditions, etc.).
- Adverse effects on the heart from certain lung conditions (such as emphysema, pulmonary embolus [blood clots to lung]).
- Certain congenital heart abnormalities.
- Evidence of abnormal blood electrolytes (potassium, calcium, magnesium).
- Evidence of inflammation of the heart or its lining (myocarditis, pericarditis).
What Does an abnormal EKG Indicate?
Because an EKG measures so many different aspects of the heart’s function, abnormal results can signify several issues. These include:
- Defects or abnormalities in the heart’s shape and size: An abnormal EKG can signal that one or more aspects of the heart’s walls are larger than another. This can signal that the heart is working harder than normal to pump blood.
- Electrolyte imbalances: Electrolytes are electricity-conducting particles in the body that help keep the heart muscle beating in rhythm. Potassium, calcium, and magnesium are electrolytes. If your electrolytes are imbalanced, you may have an abnormal EKG reading.
- Heart attack or ischemia: During a heart attack, blood flow in the heart is affected and heart tissue can begin to lose oxygen and die. This tissue will not conduct electricity as well, which can cause an abnormal EKG. Ischemia, or lack of blood flow, may also cause an abnormal EKG.
- Heart rate abnormalities: A typical human heart rate is between 60 and 100 beats per minute (bpm). An EKG can determine if the heart is beating too fast or too slow.
- Heart rhythm abnormalities: A heart typically beats in a steady rhythm. An EKG can reveal if the heart is beating out of rhythm or sequence.
- Medication side effects: Taking certain medications can impact a heart’s rate and rhythm. Sometimes, medications given to improve the heart’s rhythm can have the reverse effect and cause arrhythmias. Examples of medications that affect heart rhythm include beta-blockers, sodium channel blockers, and calcium channel blockers.
How Does it Work?
Each beat of your heart is triggered by an electrical impulse normally generated from special cells in the upper right chamber of your heart (pacemaker cells). An electrocardiogram records the timing and strength of these signals as they travel through your heart.
An electrocardiogram is also called a 12-lead EKG or 12-lead ECG because it gathers information from 12 different areas of the heart. These views are created by electrodes, typically 10, placed on the skin of your chest and sometimes your limbs. The electrical activity is recorded as waves on a graph, with different patterns corresponding to each electrical phase of your heartbeat.
The EKG machine doesn’t generate electricity. Instead, it conducts and measures electrical activity.
Typically, the heart conducts electricity in a standard pathway from the right atrium to the left atrium. The electrical current then goes to the atrioventricular (AV) node, which signals the ventricles to contract. The current then flows to an area known as the bundle of His. This area divides into fibers that provide current to the left and right ventricles.
Flu Test / Streptococcal Screen (Rapid Streptococcus Screening or Rapid Strep Test)
A streptococcal screen, also called a rapid Streptococcus screening test or rapid strep screen, is a test that determines if you have a type of bacterium called group A Streptococcus (Streptococcus pyogenes) in your throat. This bacterium causes an infection called streptococcal pharyngitis, which is commonly known as strep throat. The definitive diagnosis of strep throat can be made with simple laboratory testing.
A doctor will conduct a physical exam, look for signs and symptoms of strep throat, and probably order one or more of the following tests:
- Rapid Strep Antigen Test. Your doctor will likely first perform a rapid antigen test on a swab sample from your throat. This test can detect strep bacteria in minutes by looking for substances (antigens) in the throat. If the test is negative but your doctor still suspects strep, he or she might do a throat culture.
- Throat Culture. A sterile swab is rubbed over the back of the throat and tonsils to get a sample of the secretions. It’s not painful, but it may cause gagging. The sample is then cultured in a laboratory for the presence of bacteria, but results can take as long as two days.
Why Need a Rapid Strep Test?
Predictive factors that make strep throat more likely include:
- Age between 5 to 15 years
- Illness occurring between late fall and early spring
- Fever of 101 F or higher
- Redness and swelling of the tonsils/throat with tonsillar exudate
- White patches in the throat
- Tiny red spots on the roof of the mouth
- Enlarged and tender lymph nodes in the neck
- Absence of symptoms suggestive of a viral infection, such as cough or runny nose
A doctor may recommend a rapid strep screening test if you have a sore throat and fever. Other signs of a strep infection include:
- difficulty swallowing
- a lack of appetite
- low energy level
- tender or swollen lymph nodes in the neck
In some cases, people with a strep infection have a pink skin rash that feels like sandpaper.
Because strep throat is less common in adults, your doctor may not order a rapid strep screening unless you have a combination of a severe or recurrent sore throat, a fever, and swollen lymph nodes in your throat.
Preparation and Procedure of the Rapid Strep Test
A rapid screen strep test is simple and can be done in your doctor’s office. You should avoid using mouthwash before the test because it can interfere with results. Otherwise, you don’t need to prepare.
Your doctor will examine your mouth to check for red, swollen areas or other signs of infection. Your doctor will ask you to open your mouth wide and may use a wooden tongue depressor to hold your tongue down.
Then, your doctor will take a cotton swab and brush it against the back of your throat, or oropharynx, to obtain a sample for the test. They may do this twice to get more accurate results. The swabs will be tested with a kit to see if the group A Streptococcus bacterium is present.
The test isn’t painful, but it does cause minor discomfort. If your child is having a rapid strep screen, it’s a good idea to hold their arms or have them seated on your lap. You may need to help restrain your child. Also, the position of the swab may trigger a gag reflex.
Analysis of the Result
The rapid strep screen is fairly reliable, but antibiotics and antiseptic mouthwash can affect the test results. Tell your doctor if you’re taking antibiotics.
The rapid screen strep kit takes about 10 minutes to process. If the test is positive, you have group A Streptococcus in your throat and you probably have an infection. In that case, your doctor will write a prescription for a 5- to 7-day course of antibiotics.
If you are an adult with a negative test and your doctor does not suspect strep throat based on available clinical information, you likely don’t have group A Streptococcus infecting your throat. No antibiotics are needed.
In some cases, if you have symptoms of a strep infection but your test comes back negative, your doctor may order a throat culture. A throat culture swabbing is typically used when the doctor still suspects strep throat in a child or teenager despite a negative rapid strep test result.
A throat culture is similar to a rapid screen test, but the sample is processed more in-depth. It’s also more expensive and takes longer to get results. The results can take up to 48 hours because the swabs are cultured, which means that any bacteria on them are allowed to grow. A throat culture can confirm the presence of group A Streptococcus and other bacteria, and it’s generally considered more accurate than a rapid strep screen.
It’s also important to note that a rapid strep screen test only screens for group A Streptococcus, which is one type of bacterium. This means that if your test is negative, you could still have an infection from another type of bacterium or virus.
What happens after the test?
The test is easy and quick. It has no major side effects or risks. If you test positive for strep, your doctor will likely prescribe antibiotic therapy and recommend that you drink warm fluids and gargle with salt water.
If you test negative for group A Streptococcus, but still have a sore throat, your doctor may look at other possible causes, including infections from other bacteria or viruses.
If a strep infection is left untreated, it can lead to more serious medical conditions, including:
- streptococcal pneumonia
- ear infections
- infectious kidney inflammation
- rheumatic fever
- Get plenty of rest: Sleep helps your body fight infection. If you have strep throat, stay home from work if you can. If your child is ill, keep him or her at home until there’s no sign of fever, and he or she feels better and has taken an antibiotic for at least 24 hours.
- Drink plenty of water: Keeping a sore throat lubricated and moist eases swallowing and helps prevent dehydration.
- Eat soothing foods: Easy-to-swallow foods include broths, soups, applesauce, cooked cereal, mashed potatoes, soft fruits, yogurt and soft-cooked eggs. You can puree foods in a blender to make them easier to swallow. Cold foods, such as sherbet, frozen yogurt or frozen fruit pops also may be soothing. Avoid spicy foods or acidic foods such as orange juice.
- Gargle with warm salt water: For older children and adults, gargling several times a day can help relieve throat pain. Mix 1/4 teaspoon (1.42 grams) of table salt in 8 ounces (237 milliliters) of warm water. Be sure to tell your child to spit out the liquid after gargling.
- Use a humidifier: Adding moisture to the air can help ease discomfort. Choose a cool-mist humidifier and clean it daily because bacteria and molds can flourish in some humidifiers. Saline nasal sprays also help to keep mucous membranes moist.
- Stay away from irritants: Cigarette smoke can irritate a sore throat and increase the likelihood of infections such as tonsillitis. Avoid fumes from paint or cleaning products, which can irritate throat sand lungs.
- OTC Medications: Take ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to bring down a fever and ease pain. Don’t give aspirin to children or teens. It can cause a rare but dangerous condition called Reye’s syndrome.
- Warm Liquids: Drink warm liquids such as green tea, tomato soup, black coffee, or unsweetened hot chocolate. Or, suck on something cold such as an ice pop.
- Avoid Citrus: Pass on orange juice and other drinks that have a lot of acid. They’ll sting.
Strep Throat Medications
When the diagnosis of strep throat is confirmed by laboratory testing or when it is highly suspected clinically, antibiotics are generally prescribed. If administered early, antibiotics can help decrease the duration of symptoms (by about 1 day), and they can also make individuals less contagious within 24 hours of initiating treatment. More importantly, antibiotics are effective in preventing the uncommon potential complications of strep throat. Without antibiotic treatment, strep throat will generally improve on its own within 2 to 5 days, as it is a self-limited disease that will run its course without complications in the majority of cases.
The full course of antibiotics should be taken, even if the individual is feeling better after a few days. Premature discontinuation of antibiotics can result in relapse of illness, generation of antibiotic resistant organisms, or in the development of complications from inadequately treated strep throat. The antibiotics that are generally recommended include the following:
This effective, inexpensive antibiotic can be administered orally for 10 days, or a one-time injection can be administered in those individuals who may not be compliant or able to tolerate oral medications. Penicillin derivatives, such as amoxicillin, are also effective.
This class of antibiotics has been found to be very effective in the treatment of strep throat, and is a reasonable alternative to penicillin.
This class of antibiotics (erythromycin, azithromycin (Azithromycin 3 Day Dose Pack, Azithromycin 5 Day Dose Pack, Zithromax, Zithromax TRI-PAK, Zithromax Z-Pak, Zmax) and clarithromycin (Biaxin, Biaxin XL, Biaxin XL-Pak) and are recommended in individuals who have a penicillin allergy.
How to Keep it From Spreading
Have your child stay home from school or daycare until the fever is gone and he has been on an antibiotic for at least 24 hours. Same for you and the workplace. Other tips:
- Don’t share cups, dishes, forks, or other personal items with someone who’s sick.
- Ask children to cover their mouths with a tissue or sleeve whenever they cough or sneeze.
- Have everyone in the house wash their hands or use an alcohol-based hand sanitizer many times daily.
Risk of Ignorance
Yet untreated strep can cause serious diseases, such as:
- Sinus or tonsil infections
- Rheumatic fever, which can damage the heart, brain, and joints
- A kidney disease called glomerulonephritis
Prime Med Clinic of Ozark specializes in providing following tests:
- CBC (Complete Blood Count)
- CMP (Comprehensive Metabolic Panel)
- TSH (Thyroid Stimulating Hormone)
- T3 ( Free or Total Triiodothyronine)
- T4 (Free Thyroxine)
- Vitamin B12
- Vitamin D
- Depakote Level Checkup
- Direct Bilirubin (Dbil Liver Panel) (HEPATIC)
- PSA (Prostate-Specific Antigen)
- A1C (Glycated Hemoglobin)
- Lipid Profile
- Glucose Panel
Pulmonary Function Testing (PFT)
Pulmonary function tests (PFTs) are a group of tests that measure how well your lungs work. This includes how well you’re able to breathe and how effective your lungs are able to bring oxygen to the rest of your body.
Your doctor may order these tests:
- if you’re having symptoms of lung problems
- if you’re regularly exposed to certain substances in the environment or workplace
- to monitor the course of chronic lung disease, such as asthma or chronic obstructive pulmonary disease (COPD)
- to assess how well your lungs are working before you have surgery
PFTs are also known as lung function tests.
Why are these tests done?
Your doctor will order these tests to determine how your lungs are working. If you already have a condition that’s affecting your lungs, your doctor may order this test to see if the condition is progressing or how it’s responding to treatment.
PFTs can help diagnose:
- chronic bronchitis
- respiratory infections
- lung fibrosis
- bronchiectasis, a condition in which the airways in the lungs stretch and widen
- COPD, which used to be called emphysema
- asbestosis, a condition caused by exposure to asbestos
- sarcoidosis, an inflammation of your lungs, liver, lymph nodes, eyes, skin, or other tissues
- scleroderma, a disease that affects your connective tissue
- pulmonary tumor
- lung cancer
- weaknesses of the chest wall muscles
How do I prepare for pulmonary function tests?
If you’re on medications that open your airways, such as those used for asthma or chronic bronchitis, your doctor may ask you to stop taking them before the test. If it isn’t clear whether or not you should take your medication, make sure to ask your doctor. Pain medications may also affect the results of the test. You should tell your doctor about any over-the-counter and prescription pain medications you’re taking.
It’s important that you don’t eat a large meal before testing. A full stomach can prevent your lungs from inhaling fully. You should also avoid food and drinks that contain caffeine, such as chocolate, coffee, and tea, before your test. Caffeine can cause your airways to be more open which could affect the results of your test. You should also avoid smoking at least an hour before the test, as well as strenuous exercise before the test.
Be sure to wear loose-fitting clothing to the test. Tighter clothing may restrict your breathing. You should also avoid wearing jewelry that might affect your breathing. If you wear dentures, wear them to the test to ensure that your mouth can fit tightly around the mouthpiece used for the test.
If you have had recent eye, chest, or abdominal surgery or a recent heart attack, you will likely need to delay the test until you have fully recovered.
Your PFTs may include spirometry, which measures the amount of air you breathe in and out. For this test, you’ll sit in front of a machine and be fitted with a mouthpiece. It’s important that the mouthpiece fits snugly so that all the air you breathe goes into the machine. You’ll also wear a nose clip to keep you from breathing air out through your nose. The respiratory technologist will explain how to breathe for the test.
You may then breathe normally. Your doctor will ask you to breathe in and out as deeply or as quickly as you can for several seconds. They may also ask you to breathe in a medication that opens your airways. You’ll then breathe into the machine again to see if the medication affected your lung function.
A plethysmography test measures the volume of gas in your lungs, known as lung volume. For this test, you’ll sit or stand in a small booth and breathe into a mouthpiece. Your doctor can learn about your lung volume by measuring the pressure in the booth.
Diffusion Capacity Test
This test evaluates how well the small air sacks inside the lungs, called alveoli, work. For this part of a pulmonary function test, you will be asked to breathe in certain gases such as oxygen, helium, or carbon dioxide.
You may also breathe in a “tracer gas” for one breath. The machine can detect when you breathe out this gas. This tests how well your lungs are able to transfer oxygen and carbon dioxide to and from your bloodstream.
A PFT can cause problems if:
- you’ve recently had a heart attack
- you’ve recently had eye surgery
- you’ve recently had chest surgery
- you’ve recently had abdominal surgery
- you have a severe respiratory infection
- you have unstable heart disease
PFTs are usually safe for most people. However, because the test may require you to breathe in and out quickly, you may feel dizzy and there’s a risk that you may faint. If you feel lightheaded, tell your doctor. If you have asthma, the test may cause you to have an asthma attack. In very rare cases, PFTs may cause a collapsed lung.
Mantoux Tuberculin Skin Test (TST)
This can also be known as:
- Purified Protein Derivative
- Latent Tuberculosis Infection Test
- Interferon-gamma Release Assays
- QuantiFERON®-TB Gold (QFT-G)
- QuantiFERON®-TB Gold In-Tube (QFT-GIT)
- Formal Name: Tuberculin Skin Test
- Formal Name: Interferon Gamma Release Assays
Tuberculosis (TB) remains a leading cause of morbidity and mortality in the world, especially in developing countries. A combination of factors including high costs, limited resources and the poor performance of various diagnostic tests make the diagnosis of TB difficult in developing countries. Short of demonstrating viable organisms in body tissues and fluids the tuberculin skin test (TST) is the only method of detecting M. tuberculosis infection in an individual and is used in the diagnosis of TB in individual patients, as well as in epidemiological settings, to measure the prevalence of tuberculous infection in populations. The screening tests measure the body’s immune response to antigens derived from these bacteria, either directly as a skin reaction to a tuberculin skin test (TST) or indirectly with an interferon gamma release assay (IGRA) blood test.
TB may cause an inactive (latent) infection or an active, progressive disease. The immune system of about 90% of people who become infected with TB manages to control its growth and confine the TB infection to a few cells in the body. The bacteria in these cells are inactive but still alive. The person does not have any symptoms and is not infectious but does have a “latent TB infection.”
If, after some time, the immune system of an individual with an inactive infection becomes weakened (compromised), the mycobacteria may begin to grow again, leading to an active case of tuberculosis disease. Active TB does cause illness and can be passed to others through respiratory secretions such as sputum or aerosols released by coughing, sneezing, laughing, talking, singing, or breathing.
Both the tuberculin skin test and the IGRA blood test can detect M. tuberculosis infections, but neither can distinguish between latent and active infections. Additional tests, such as AFB testing, are required to help establish a diagnosis of an active TB infection.
What is latent TB infection?
There are two phases of TB. Both phases can be treated with medicine. When TB germs first enter your body, they cause latent TB infection. Without treatment, latent TB infection can become active TB disease. Anyone can get TB because it spreads from one person to another through the air.
Phase 1 – Latent TB Infection
- TB germs are “asleep” in your body. This phase can last for a very long time – even many years.
- You don’t look or feel sick. Your chest x-ray is usually normal.
- You can’t spread TB to other people.
- Usually treated by taking one medicine for 9 months.
Phase 2 – Active TB Disease
- TB germs are active and spreading. They are damaging tissue in your body.
- You usually feel sick. Your doctor will do special tests to find where TB is harming your body.
- If the TB germs are in your lungs, you can spread TB to other people by coughing, sneezing, talking, or singing.
- Treated by taking 3 or 4 medicines for at least 6 months.
How can I tell if I have latent TB infection?
A Mantoux tuberculin skin test (TST) can show if you have latent TB infection. You could have latent TB infection if you have ever spent time close to someone with active TB disease (even if you didn’t know they were sick). Your health care provider will use a small needle to inject some harmless testing fluid (called “tuberculin”) under the skin on your arm.
How is the TST Administered?
The standard recommended tuberculin test, known as the Mantoux test, is administered by injecting a 0.1 mL of a liquid containing 5 TU (tuberculin units) of purified protein derivative (PPD) into the top layers of skin (intradermally, immediately under the surface of the skin) of the forearm. The use of a skin area that is free of abnormalities and away from veins is recommended. The injection is typically made using a 27-gauge needle, and a tuberculin syringe. The tuberculin PPD is injected just beneath the surface of the skin. A discrete, pale elevation of the skin (a wheal) 6 mm-10 mm in diameter should be produced when the injection is done correctly. This wheal or “bleb” is generally quickly absorbed. If it is recognized that the first test was improperly administered, another test can be given at once, selecting a site several centimeters away from the original injection.
How do I take care of my arm after the TB skin test?
- Don’t cover the spot with a bandage or tape.
- Be careful not to rub it or scratch it.
- If the spot itches, put a cold cloth on it.
- You can wash your arm and dry it gently.
How is the TST Read?
The skin test reaction should be read between 48 and 72 hours after administration. A patient who does not return within 72 hours will need to be rescheduled for another skin test.
The reaction should be measured in millimeters of the induration (palpable, raised, hardened area or swelling). The reader should not measure erythema (redness). The diameter of the indurated area should be measured across the forearm (perpendicular to the long axis).
How Are TST Reactions Interpreted?
Skin test interpretation depends on two factors:
- Measurement in millimeters of the induration
- Person’s risk of being infected with TB and of progression to disease if infected
Classification of the Tuberculin Skin Test Reaction
An induration of 5 or more millimeters is considered positive in
- HIV-infected persons
- A recent contact of a person with TB disease
- Persons with fibrotic changes on chest radiograph consistent with prior TB
- Patients with organ transplants
- Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of >15 mg/day of prednisone for 1 month or longer, taking TNF-aantagonists)
An induration of 10 or more millimeters is considered positive in
- Recent immigrants (< 5 years) from high-prevalence countries
- Injection drug users
- Residents and employees of high-risk congregate settings
- Mycobacteriology laboratory personnel
- Persons with clinical conditions that place them at high risk
- Children less than 4 years of age
- Infants, children, and adolescents exposed to adults in high-risk categories
An induration of 15 or more millimeters is considered positive in any person, including persons with no known risk factors for TB. However, targeted skin testing programs should only be conducted among high-risk groups.
What Are False-Positive Reactions?
Some persons may react to the TST even though they are not infected with M. tuberculosis. The causes of these false-positive reactions may include, but are not limited to, the following:
- Infection with nontuberculosis mycobacteria
- Previous BCG vaccination
- Incorrect method of TST administration
- Incorrect interpretation of reaction
- Incorrect bottle of antigen used
What Are False-Negative Reactions?
Some persons may not react to the TST even though they are infected with M. tuberculosis. The reasons for these false-negative reactions may include, but are not limited to, the following:
- Cutaneous anergy (anergy is the inability to react to skin tests because of a weakened immune system)
- Recent TB infection (within 8-10 weeks of exposure)
- Very old TB infection (many years)
- Very young age (less than 6 months old)
- Recent live-virus vaccination (e.g., measles and smallpox)
- Overwhelming TB disease
- Some viral illnesses (e.g., measles and chicken pox)
- Incorrect method of TST administration
- Incorrect interpretation of reaction
The absence of cell mediated immunity to tuberculin may be due to the lack of previous sensitization or due to a false-negative result for various reasons or due to anergy because of immune suppression. Most children with negative result have not been infected with M. tuberculosis. A small proportion of otherwise normal children with M. tuberculosis infection remain PPD-negative for unknown reasons. From the time of infection to the development of CMI there is a window period of some two to six weeks, when the Mantoux test would be negative. Those that are immunologically compromised, especially those with HIV and low CD4 T-cell counts, frequently show negative results from the PPD test. This is because the immune system needs to be functional to mount a response to the protein derivative injected under the skin.
Negative tests can be interpreted to mean that the person has not been infected with the TB bacteria or that the person has been infected recently and not enough time has elapsed for the body to react to the skin test. A repeat test is not advocated before one week as the tuberculin injected for the first test has a booster effect on the subsequent dose. TST may convert to positive ≤eight weeks after Mycobacterium tuberculosisinfection, an interval that is usually referred to as the “window period”. A negative TST obtained less than eight weeks before does not exclude infection, and a second test is recommended after eight weeks. Also, because it may take longer than 72 h for an elderly individual to develop a reaction, it may be useful to repeat the TB skin test after 96 h and again at one week to adequately screen these individuals. Immunocompromised persons may be unable to react sufficiently to the Mantoux test, and either a chest X-ray or sputum sample may be required.
Interpretation in children: A correctly applied Mantoux test can be invaluable in the assessment of a child with suspected TB. The interpretation of the result, however, is often difficult, with different workers using different induration sizes to indicate a positive reaction. Although the test itself is neither 100% sensitive nor 100% specific, the predictive value of a positive reaction is very high in such a group. Malnutrition has previously been shown to affect the results of tuberculin testing. As in other studies, underweight children in this study were significantly more likely to have a negative Mantoux result.
Who Can Receive a TST?
Most persons can receive a TST. TST is contraindicated only for persons who have had a severe reaction (e.g., necrosis, blistering, anaphylactic shock, or ulcerations) to a previous TST. It is not contraindicated for any other persons, including infants, children, pregnant women, persons who are HIV-infected, or persons who have been vaccinated with BCG.
You should have a TB skin test if:
- you have had frequent close contact with someone who has active TB disease,
- you have lived in a country where many people have TB,
- you work or live in a nursing home, clinic, hospital, prison, or homeless shelter, or
- you have HIV infection or certain other health problems.
What if I’ve had BCG vaccine?
Even if you have had BCG vaccine, you can have a TB skin test.
- People who have had BCG vaccine still can get latent TB infection and active TB disease.
- BCG vaccine may help protect young children from getting very sick with TB. This protection goes away as people get older.
- BCG vaccine sometimes causes a positive TB skin test reaction. But if you have a positive reaction to the TB skin test, it probably is from TB germs in your body – not from your BCG vaccine.
How Often Can TSTs Be Repeated?
In general, there is no risk associated with repeated tuberculin skin test placements. If a person does not return within 48-72 hours for a tuberculin skin test reading, a second test can be placed as soon as possible. There is no contraindication to repeating the TST, unless a previous TST was associated with a severe reaction.
What is a Boosted Reaction?
In some persons who are infected with M. tuberculosis, the ability to react to tuberculin may wane over time. When given TST years after infection, these persons may have a false-negative reaction. However, the TST may stimulate the immune system, causing a positive or boosted reaction to subsequent tests. Giving a second TST after an initial negative TST reaction is called two-step testing. When sensitization to mycobacteria has occurred many years earlier, an initial intradermal injection of tuberculin may produce a negative or weakly positive response due to there being too few sensitized lymphocytes in circulation to produce a significant local response. If the test is repeated, a larger reading may be obtained due to the immune response being ‘recalled‘ or ‘boosted’ by the first test. The second boosted reading is the correct one – that is, the result that should be used for decision-making or future comparison. Boosting is maximal if the second test is placed between one and five weeks after the initial test, and it may continue to be observed for up to two years.
Reversion is defined as the change to a negative Mantoux result following a previous positive result. Generally this phenomenon is uncommon in healthy individuals, occurring in less than 10% of such people with a previously positive Mantoux.
Reversion is more common
- in older adults (estimated at 8% per year)
- when the initial Mantoux is less than 14 mm
- in those where the initial positive reaction was a boosted result (identified by two-step testing).
Whereas boosting is a recall of the hypersensitivity response in the absence of new Infection, conversion is the development of new or enhanced hypersensitivity due to infection with tuberculous or non-tuberculous mycobacteria, including BCG vaccination.
Mantoux conversion is defined as a change (within a two-year period) of Mantoux reactivity which meets either of the following criteria:
- a change from a negative to a positive reaction
- an increase of greater than or equal to 10 mm.
- conversion has been associated with an annual incidence of TB disease of 4% in adolescents or 6% in contacts of smear-positive cases
There is debate about the time required for the immunological changes that produce Mantoux conversion following infection. After inadvertent vaccination with M. tuberculosis (the Lubeck disaster), children developed positive reactions in three to seven weeks. Other studies have shown clinical illness, with a positive tuberculin test, from 19 to 57 days after exposure, with a mean of 37 days.
Therefore, when testing TB contacts for conversion, the second tuberculin test is done eight weeks after the date of last contact with the source case. (In the past, the traditional window period, or interval, of 12 weeks was used.)
Why is Two-Step Testing Conducted?
Two-step testing is useful for the initial skin testing of adults who are going to be retested periodically, such as health care workers or nursing home residents. This two-step approach can reduce the likelihood that a boosted reaction to a subsequent TST will be misinterpreted as a recent infection.
Can TSTs Be Given To Persons Receiving Vaccinations?
Vaccination with live viruses may interfere with TST reactions. For persons scheduled to receive a TST, testing should be done as follows:
- Either on the same day as vaccination with live-virus vaccine or 4-6 weeks after the administration of the live-virus vaccine
- At least one month after smallpox vaccination
Though rare there have been reports of anaphylactic reaction and foreign body reaction involving a Mantoux test site. There is a very slight risk of having a severe reaction to the test, including swelling and redness of the arm, particularly in people who have had TB or been infected previously and in those who have previously had the BCG vaccine. Allergic reactions are also rare complications. Live bacteria are not used in the test so there is no chance of developing TB from the test. Local reactions such as regional lymphangitis and adenitis may also occur on rare occasions.
Situations where TST is not recommended
Mantoux testing is not recommended in the following situations:
- Past Mantoux reactions greater than or equal to 15 mm: repeating the test will provide no new diagnostic information and will create discomfort
- Previous TB disease: no useful diagnostic information will be gained and significant discomfort is likely
- Infants under 12 weeks old: a positive reaction is very important, but a negative reaction may indicate that the child is too young to mount a response, and the test will need to be repeated if exposure has occurred. Pre-vaccination Mantoux testing before 12 weeks of age is not necessary unless the baby has been exposed to TB
Ultrasound (also termed sonography, ultrasonography, and Doppler study) is a non-invasive diagnostic medical imaging technique that uses high frequency sound waves to produce images (sonogram) of organs and structures inside the body. Health care professionals use it to view the heart, blood vessels, kidneys, liver, and other organs. During pregnancy, doctors use ultrasound to view the fetus. Unlike x-rays, ultrasound does not expose you to radiation.
Using an ultrasound machine (ultrasonography), a technician or doctor moves a device called a transducer or wand (probe) over part of your body. The transducer emits sound waves which bounce off the internal tissues, and creates images from the waves that bounce back. Different densities of tissues, fluid, and air inside the body produce different images that can be interpreted by a physician, typically a radiologist (a physician who specializes in imaging technologies). Many studies are done by a trained technologist (sonographer) and then interpreted by a radiologist.
Moreover, ultrasound technology has advanced to allow for different types of imaging:
- Doppler is a special type of ultrasound that creates images of blood flow through vessels.
- Bone sonography helps doctors diagnose osteoporosis.
- Echocardiograms are used to view the heart.
- 3D imaging adds another dimension to the ultrasound image, creating three-dimensional interpretations rather than the flat two-dimensional images that are made with traditional ultrasound.
Why is Ultrasound Needed?
Pregnancy ultrasound (fetal ultrasound or baby ultrasound) is used to assess the progression of a fetus. It is used to find out the number of fetuses in the womb, the age of the fetus, the location of the placenta, the fetal position, movement, breathing and heart rates, and the amount of amniotic fluid in the uterus. Most women have at least one ultrasound during pregnancy. The exams can be done trans-vaginally (early in a pregnancy), but most are done trans-abdominally. 3D and 4D ultrasound have limited medical uses, such as when a specific problem is suspected. Currently 3D and 4D ultrasounds are popular for “keepsake” sonogram pictures of the baby in the womb. The best time for a 3D ultrasound for fetal photos is when the baby is about 26 weeks. The FDA warns against the use of ultrasound for nonmedical reasons. Although there has been no proof of risk, the long-term effects of these ultrasounds have not been studied. Doppler ultrasounds are used to measure blood flow and may be used if there is a suspicion that the fetus is not growing properly.
Vaginal ultrasound, pelvic ultrasound, or transvaginal ultrasound is used to diagnose growths or tumors of the ovary, uterus, and Fallopian tubes. It can be used to assess non-pregnancy related issues as well:
- lower abdominal pain
- ovarian cysts
- uterine fibroids
- uterine growths
- pelvic prolapse
Echocardiography (heart ultrasound) is a common way to evaluate the overall function of the heart. It is used to evaluate the flow of blood through the chambers and valves of the heart. It also assesses the strength of the heart beat and the volume of blood pumped through. Doppler ultrasound echocardiography is often used for the following:
- heart valve problems, such as mitral valve prolapse or aortic stenosis;
- congestive heart failure;
- blood clots due to irregular heart beats such as in atrial fibrillation;
- abnormal fluid collections around the heart, such as pericardial effusions; and
- pulmonary artery hypertension.
Ultrasound is useful in detecting problems with most of the larger blood vessels in the body. Using Doppler ultrasound technology, the flow of blood through the vessels can be observed and measured. Narrowing of vessels (stenosis) or widening of vessels (dilatation, also referred to as aneurysms) can be detected. Ultrasound testing of blood vessels includes:
- carotid ultrasound
- abdominal aorta ultrasound for abdominal aortic aneurysm
- blood clots in veins (superficial or deep venous thrombosis, or DVT).
- an ultrasound scan can reveal whether a lump is a tumor. This could be cancerous, or a fluid-filled cyst.
Abdominal ultrasound is used to evaluate the solid organs within the abdominal cavity, including the liver, gallbladder, pancreas, kidneys, and bladder.
- Renal ultrasound is used to evaluate the function and structure of the kidneys. Swelling around the kidney with blockage in the urinary tract can be seen with ultrasound, making abdominal ultrasound useful in detecting kidney stones.
- Liver ultrasound is used to find abnormalities in the liver tissue and ducts.
- Gallbladder ultrasound can screen for gallstones or an infected gallbladder.
- Appendix ultrasound is used in children or pregnant women, where it is necessary to avoid radiation from aCT scan (computerized tomography).
- Testicular ultrasound: Used to diagnose testicular torsion, epididymitis (testicle infection), and testicular masses.
The thyroid and parathyroid glands can be imaged to detect nodules, growths, and tumors.
Used to image the breasts and to guide biopsy of breast masses in order to evaluate for breast cancer.
Ultrasound can be used to evaluate the structures in the back of the knee to determine if a Baker’s cyst is present.
An eye ultrasound is used to look at the back of the eye (retina). It is often used when a patient hascataracts that make looking into the eye difficult. The test may help diagnose retinal detachment. It can also assist in cataract surgery.
Ultrasound can be used to help find certain types of foreign bodies that may become lodged in the skin.
It can help diagnose problems with soft tissues, muscles, blood vessels, tendons, and joints. It is used to investigate a frozen shoulder, tennis elbow, carpal tunnel syndrome, and others.
- Most scans take between 20 and 60 minutes. It is not normally painful, and there is no noise.
- In most cases, no special preparation is needed, but patients may wish to wear loose-fitting and comfortable clothing.
- If the liver or gallbladder is affected, the patient may have to fast, or eat nothing, for several hours before the procedure.
- For a scan during pregnancy, and especially early pregnancy, the patient should drink plenty of water and try to avoid urinating for some time before the test.
- When the bladder is full, the scan produces a better image of the uterus.
- The scan usually takes place in the radiology department of a hospital. A doctor or a specially-trained sonographer will carry out the test.
- Wear loose or comfortable clothes.
- Remove all jewelries in the area where ultrasound is to be done.
- It’s a non-invasive painless procedure that is expected to be very safe.
X-rays are a type of radiation called electromagnetic waves. X-ray imaging creates pictures of the inside of your body. The images show the parts of your body in different shades of black and white. This is because different tissues absorb different amounts of radiation. Calcium in bones absorbs x-rays the most, so bones look white. Fat and other soft tissues absorb less, and look gray. Air absorbs the least, so lungs look black.
Different types of X-rays are used for different purposes. For example, your doctor may order a mammogram to examine your breasts. Or they may order an X-ray with a barium enema to get a closer look at your gastrointestinal tract.
Uses and Types of X-ray
Abdominal x-ray is a commonly performed diagnostic x-ray examination that produces images of the organs in the abdominal cavity including the stomach, liver, intestines and spleen and may be used to help diagnose unexplained pain, nausea or vomiting.
When an abdominal x-ray is performed to provide pictures of the kidneys, ureters and bladder, it’s called a KUB x-ray.
Abdominal x-ray is also performed to help diagnose conditions such as:
- kidney and urinary bladder stones and gallstones
- intestinal blockages
- perforation of the stomach or intestine
- ingestion of foreign objects
- abdominal aortic aneurysm
Abdominal x-ray may also be used to help properly place catheters and tubes used for feeding or to decompress organs such as the gallbladder and kidneys.
Arthrography is a type of medical imaging used to help evaluate and diagnose joint conditions and unexplained pain. It is very effective at detecting disease within the ligaments, tendons and cartilage. It may be indirect, where contrast material is injected into the bloodstream, or direct, where contrast material is injected into the joint.
Arthrography is used to identify abnormalities within the:
Bone Densitometry (Bone Density Scan)
Bone densitometry, also called dual-energy x-ray absorptiometry or DEXA, uses a very small dose of ionizing radiation to produce pictures of the inside of the body (usually the lower spine and hips) to measure bone loss. It is commonly used to diagnose osteoporosis and to assess an individual’s risk for developing fractures.
Bone density testing is strongly recommended if you:
- are a post-menopausal woman and not taking estrogen.
- have a personal or maternal history of hip fracture or smoking.
- are a post-menopausal woman who is tall (over 5 feet 7 inches) or thin (less than 125 pounds).
- are a man with clinical conditions associated with bone loss.
- use medications that are known to cause bone loss, including corticosteroids such as Prednisone, various anti-seizure medications such as Dilantin and certain barbiturates, or high-dose thyroid replacement drugs.
- have type 1 (formerly called juvenile or insulin-dependent) diabetes, liver disease, kidney disease or a family history of osteoporosis.
- have high bone turnover, which shows up in the form of excessive collagen in urine samples.
- have a thyroid condition, such as hyperthyroidism.
- have a parathyroid condition, such as hyperparathyroidism.
- have experienced a fracture after only mild trauma.
- have had x-ray evidence of vertebral fracture or other signs of osteoporosis.
Bone X-Ray (Radiography)
A bone x-ray makes images of any bone in the body, including the hand, wrist, arm, elbow, shoulder, spine, pelvis, hip, thigh, knee, leg (shin), ankle or foot.
A bone x-ray is used to:
- diagnose fractured bones or joint dislocation.
- demonstrate proper alignment and stabilization of bony fragments following treatment of a fracture.
- guide orthopedic surgery, such as spine repair/fusion, joint replacement and fracture reductions.
- look for injury, infection, arthritis, abnormal bone growths and bony changes seen in metabolic conditions.
- assist in the detection and diagnosis of bone cancer.
- locate foreign objects in soft tissues around or in bones.
Catheter angiography uses a catheter, x-ray imaging guidance and an injection of contrast material to examine blood vessels in key areas of the body for abnormalities such as aneurysms and disease such as atherosclerosis (plaque).
Catheter angiography is used to examine blood vessels in key areas of the body, including the:
- abdomen (such as the kidneys and liver)
- legs and feet
- arms and hands
Physicians use the Catheter angiography procedure to:
- identify abnormalities, such as aneurysms, in the aorta, both in the chest and abdomen, or in other arteries.
- detect atherosclerotic (plaque) disease in the carotid artery of the neck, which may limit blood flow to the brain and cause a stroke.
- identify a small aneurysm or arteriovenous malformation (abnormal communications between blood vessels) inside the brain or other parts of the body.
- detect atherosclerotic disease that has narrowed the arteries to the legs and help prepare for endovascular intervention or surgery.
- detect disease in the arteries to the kidneys or visualize blood flow to help prepare for a kidney transplant or stent placement.
- guide interventional radiologists and surgeons making repairs to diseased blood vessels, such as implanting stents or evaluating a stent after implantation.
- detect injury to one or more arteries in the neck, chest, abdomen, pelvis or extremities in patients after trauma.
- evaluate arteries feeding a tumor prior to surgery or other procedures such as chemoembolization or selective internal radiation therapy.
- identify dissection or splitting in the aorta in the chest or abdomen or its major branches.
- show the extent and severity of the effects of coronary artery disease and plan for a surgical operation, such as a coronary bypass and stenting.
- examine pulmonary arteries in the lungs to detect pulmonary embolism (blood clots, such as those traveling from leg veins) or pulmonary arteriovenous malformations.
- look at congenital abnormalities in blood vessels, especially arteries in children (e.g., malformations in the heart or other blood vessels due to congenital heart disease).
- evaluate obstructions of vessels.
Chest X Ray
It is used to evaluate the lungs, heart and chest wall and may be used to help diagnose shortness of breath, persistent cough, fever, chest pain or injury. It also may be used to help diagnose and monitor treatment for a variety of lung conditions such as pneumonia, emphysema, lung cancer, heart failure, tuberculosis, sarcoidosis, and lung tissue scarring, called fibrosis.
Blockages prevent your heart from getting oxygen and important nutrients. This procedure is used to diagnose coronary heart disease and coronary microvascular disease after chest pain, sudden cardiac arrest, or abnormal results from tests such as an electrocardiogram (EKG) of the heart or an exercise stress test. It is important to detect blockages because over time they can cause chest pain, especially with physical activity or stress, or a heart attack.
A cystogram is an x-ray examination of the urinary bladder, which is located in the lower pelvic area; which can show the bladder’s position and shape, and the exam often is used to diagnose a condition called reflux, which causes repeated urinary tract infection. Cystograms also are used to detect polyps or tumors in the bladder.
Discography, also called discogram, uses imaging guidance to direct an injection of contrast material into the center of one or more spinal discs to help identify the source of back pain. It also is used to help guide the treatment of abnormal intervertebral discs – sponge-like cushions located between the vertebrae of the spine.
Fluoroscopy is a study of moving body structures. It’s much like an X-ray “movie” and is often done while a contrast dye moves through the part of the body being examined. A continuous X-ray beam is passed through the body part and sent to a video monitor so that the body part and its motion can be seen in detail. Fluoroscopy, as an imaging tool, allows healthcare providers to look at many body systems, including the skeletal, digestive, urinary, cardiovascular, respiratory, and reproductive systems.
Fluoroscopy is used in many types of exams and procedures including:
- Barium X-rays. In barium X-rays, fluoroscopy used alone allows the healthcare provider to see the movement of the intestines as the barium moves through them.
- Cardiac catheterization. In cardiac catheterization, fluoroscopy is used to help the healthcare provider see the flow of blood through the coronary arteries to check for arterial blockages.
- Electrophysiologic procedures. During clinical electrophysiologic procedures, fluoroscopy is used to to treat patients with arrhythmias.
- Arthrography. X-ray to view a joint or joints.
- Placement of intravenous (IV) catheters (thin, hollow tubes put into veins or arteries). For IV catheter insertion, fluoroscopy is used to guide the catheter into a specific location inside the body.
- Hysterosalpingogram. X-ray of the uterus and fallopian tubes.
- Percutaneous vertebroplasty/kyphoplasty. A procedure used to treat compression fractures of the vertebrae (bones) of the spine.
Fluoroscopy is also used for:
- Lumbar puncture
- Locating foreign bodies
- Guided injections into joints or the spine
Intravenous Pyelogram (IVP)
Intravenous pyelogram (IVP) is an x-ray exam that uses an injection of contrast material to evaluate your kidneys, ureters and bladder and help diagnose blood in the urine or pain in your side or lower back. An IVP may provide enough information to allow your doctor to treat you with medication and avoid surgery.
The IVP exam can enable the radiologist to detect problems within the urinary tract resulting from:
- kidney stones
- enlarged prostate
- tumors in the kidney, ureters or urinary bladder
- scarring from urinary tract infection
- surgery on the urinary tract
- congenital anomalies of the urinary tract
Lower Extremity Radiography
Lower extremity radiography is another way of saying x-ray images of the toes, feet, ankles, lower leg, knee, upper leg or hip. These types of examinations are performed to detect conditions such as fractures, soft tissue damage and arthritis.
Lower GI Series (Barium Enema)
A lower GI series is a procedure in which a doctor uses x-rays and a chalky liquid called barium to view your large intestine.
A lower GI series can help a doctor find the cause of:
- bleeding from your anus
- changes in your bowel activity
- chronic diarrhea
- pain in your abdomen
- unexplained weight loss
A lower GI series can also show:
- cancerous growths
- a fistula
Myelography uses a real-time form of x-ray called fluoroscopy and an injection of contrast material to evaluate the spinal cord, nerve roots and spinal lining (meninges). It is particularly useful for assessing the spine following surgery and for assessing disc abnormalities in patients who cannot undergo MRI.
Myelography is most commonly used to detect abnormalities affecting the spinal cord, the spinal canal, the spinal nerve roots and the blood vessels that supply the spinal cord, including:
- to show whether a herniation of the intervertebral disk between the successive vertebral bodies is compressing the nerve roots or the spinal cord.
- to depict a condition that often accompanies degeneration of the bones and soft tissues surrounding the spinal canal, termed spinal stenosis. In this condition, the spinal canal narrows as the surrounding tissues enlarge due to the development of bony spurs (osteophytes) and thickening of the adjacent ligaments.
Myelography can also be used to assess the following conditions when MR imaging cannot be performed, or in addition to MRI (when MR does not provide sufficient information):
- tumors involving the bony spine, meninges, nerve roots or spinal cord
- infection involving the bony spine, intervertebral discs, meninges and surrounding soft tissues
- inflammation of the arachnoid membrane that covers the spinal cord
- spinal lesions caused by disease or trauma
Panoramic Dental X-Ray
A panoramic x-ray is a commonly performed examination by dentists and oral surgeons in everyday practice and is an important diagnostic tool. It covers a wider area than a conventional intraoral x-ray and, as a result, provides valuable information about the maxillary sinuses, tooth positioning and other bone abnormalities. This examination is also used to plan treatment for full and partial dentures, braces, extractions and implants.
A panoramic x-ray can also reveal dental and medical problems such as:
- advanced periodontal disease
- cysts in the jaw bones
- jaw tumors and oral cancer
- impacted teeth including wisdom teeth
- jaw disorders (also known as temporomandibular joint or TMJ disorders)
Radiography of the Paranasal Sinuses
The paranasal sinuses are a group of air-filled cavities located in the facial area. The maxillary sinuses are located under each of the eyes, the frontal sinus is located in the area of the forehead directly above the nose, the ethmoidal sinuses are located in the area of the eyes and the upper part of the nose, and the sphenoid sinuses are located deeper within the midpoint of the head. Radiography of the paranasal sinuses is performed to detect sinusitis (inflamamation of the sinuses), as well as to detect fluid in the sinuses or polyps.
X-ray images of the skull are taken when it is necessary to see the cranium, facial bones or jaw bones. These examinations often are performed when a patient has experienced a head injury, is having head pain or is suspected of having a sinus infection. Among other things, x-ray exams of the skull can show fractures.
Upper Extremity Radiography
Upper extremity radiography is the production of x-ray images of the fingers, hand, wrist, elbow, forearm, upper arm or shoulder. These types of examinations are performed to detect conditions such as fractures, soft tissue damage and arthritis.
Upper Gastrointestinal (GI) Series
An upper GI series can help a doctor find the cause of:
- nausea and vomiting
- pain in the abdomen
- problems swallowing
- unexplained weight loss
An upper GI series can also show:
- abnormal growths such as cancer
- esophageal varices
- gastroesophageal reflux
- a hiatal hernia
- scars or strictures
Venography is an x-ray examination that uses an injection of contrast material to show how blood flows through your veins. Your doctor may use it to find blood clots, identify a vein for use in a bypass procedure or dialysis access, or to assess varicose veins before surgery.
Virtual colonoscopy is a procedure in which a radiologist uses x-rays and a computer to create images of your rectum and colon from outside the body. Virtual colonoscopy can show ulcers, polyps, and colorectal cancer.
Factors that make you more likely to develop colorectal cancer include:
- someone in your family has had polyps or cancer of the colon or rectum
- a personal history of inflammatory bowel disease, such as ulcerative colitis or Crohn’s disease
- other factors, such as if you weigh too much or smoke cigarettes
Preparation for X-Ray
Tell your doctor and the technologist if:
- there is a possibility you are pregnant
- you have an intrauterine device (IUD)
- you have recently had a barium sulfate contrast material x-ray
- taken medicines such as Pepto Bismol
- if you have metal implants from prior surgeries, as this can block X-rays from passing through your body and creating a clear image.
If you’re having an X-ray to examine your gastrointestinal tract, your doctor may ask you to fast for a certain amount of time beforehand. You will need to avoid eating anything while you fast. You may also need to avoid or limit drinking certain liquids. In some cases, they may also ask you to take medications to clear out your bowels.
Leave jewelry at home and wear loose, comfortable clothing. You may be asked to wear a gown.
Some drugs should be stopped one or two days before (in case of) myelography. These include certain antipsychotic medications, antidepressants, blood thinners, and some other drugs. The most important type of medication that must be stopped is blood thinners (anticoagulants). If you are taking blood thinners, you should speak with your physician about alternative methods of maintaining anticoagulation while you are undergoing a myelogram.
You should talk with your doctor about any medical conditions you have and all prescribed and over-the-counter medicines, vitamins, and supplements you take, including:
- arthritis medicines
- aspirin or medicines that contain aspirin
- blood thinners
- diabetes medicines
- nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen
- vitamins that contain iron or iron supplements
As in colonoscopy, a health care professional will give you written bowel prep instructions to follow at home before the procedure. A health care professional orders a bowel prep so that little or no stool is present in your intestine. A complete bowel prep lets you pass stool that is clear and liquid. Stool inside your colon can prevent the x-ray machine from taking clear images of the lining of your intestine.
You may need to follow a clear liquid diet the day before the procedure. The instructions will provide specific direction about when to start and stop the clear liquid diet. In most cases, you may drink or eat the following:
- fat-free bouillon or broth
- gelatin in flavors such as lemon, lime, or orange
- plain coffee or tea, without cream or milk
- sports drinks in such flavors as lemon, lime, or orange
- strained fruit juice, such as apple or white grape—doctors recommend avoiding orange juice and red or purple beverages
Procedure of X-ray
An X-ray technologist or radiologist can perform an X-ray in a hospital’s radiology department, a dentist’s office, or a clinic that specializes in diagnostic procedures such as Prime Med in Ozark.
Once you’re fully prepared, your X-ray technician or radiologist will tell you how to position your body to create clear images. They may ask you to lie, sit, or stand in several positions during the test. They may take images while you stand in front of a specialized plate that contains X-ray film or sensors. In some cases, they may also ask you to lie or sit on a specialized plate and move a large camera connected to a steel arm over your body to capture X-ray images.
It’s important to stay still while the images are being taken. This will provide the clearest images possible.
The test is finished as soon as your radiologist is satisfied with the images gathered.