Health Guides

Berkeley HeartLab: Our office is proud to offer “next generation” blood testing for helping prevent and treat heart disease. The Berkeley HeartLab offers tests developed by Drs. Ronald M. Krauss and H. Robert Superko at the famed Lawrence Orlando Berkeley National Laboratory at the University of California-Berkeley. These go beyond the usual “lipid panel.” Those tests are total cholesterol, triglycerides (2 ‘fat’ chemicals in the blood) and the “good” or high density lipoprotein (HDL), as well as the “lousy” or low density lipoprotein (LDL).

The Berkeley tests include the pattern of the LDL: small, dense dangerous pattern B, or less risky pattern A. They also help tell what trait you might have inherit-ed, which can help your brothers, sisters or children. At least 80% of heart and artery problems are inherited. If you’ve got one of these, there’s a 50% chance you’ll pass it to your kids.
Your child may have your chin and your spouse’s eyes -- you can see that. But you won’t know about their heart risk unless you get checked.

Who Needs These Tests? YOU Do If:

• You’ve had a heart attack, stroke, aneurysm or signs of clog-ged arteries in the heart (“angina”) or in the legs (“claudication”).
• Someone in your family has had a heart attack or angina.
• You’ve got diabetes or another sugar problem and your cholesterol picture is not perfect.
• You’ve got two or more risk factors for heart disease such as high blood pressure, smoking, inactivity, “high powered” type A personality, high triglycerides or low HDL.

What Will We Do With The Results? We hope to keep you from having a heart attack! Using these tests at Stanford, Dr. Superko’s group was able to reduce future heart events by 43% over 4 years! Now a study of patients who had heart attacks in Tyler, Texas shows that individualized therapy guided by these tests saves money: some $4120 per patient was saved in one year over standard care! That savings reflects better lives: less hospitalizations, less surgery, less angioplasty. Other studies have shown that you can “unclog” arteries with targeted therapy.

We’ve Launched an Intensive Effort to accomplish this. We can arrange for the studies with Berkeley. We will provide appropriate nutritional counseling (diets are different for different problems, and in some cases, a very low fat diet can make things worse!) with sophisticated computer support.

BHL Testing Requires Careful Preparation: a 12-14 hour fast is required, a questionnaire must be completed, and we have to know ahead of time in order to arrange for special handling in our office and FedEx.

How Much Will it Cost? The Advanced Cardiovascular panel is $375. Medicare covers some of this. Otherwise, please be prepared to pay for this in advance, as many insurances have not yet decided on coverage. We think you’re worth the investment! Our dietician’s and our services are covered under Medicare and most insurance.

At this writing reports indicate a low, but not zero risk of this deadly ancient bacterial disease. Most patients have had the less dangerous skin infection, and have been exposed to spores sent in the mail. But anthrax lung disease in a NY Eye & Ear worker and in a 94 year old Connecticut woman is unexplained at this time, and preparation for additional patients is prudent.

What is Anthrax? It is a bacterial illness caused by exposure to the naturally occurring spores – either a skin pustule that turns black, or a respiratory illness that mimics influenza. There is also an intestinal form, which hasn’t been seen at this writing.

Who is at Risk? The highest risk appears to be in postal workers near government or major media offices. Next highest risk is in those who work in such offices, particularly those who open the mail.

What are the Symptoms? Cough, fever, chills and muscle aches start 3 days to 6 weeks after exposure to the spores. Patients are sick for about 2-3 days, then appear to be getting better for 1-2 days. Then they "crash" with severe damage to the lungs, "air hunger" and a death rate of 80%+.

What is the Treatment? Ciprofloxin (Cipro) is the only currently licensed antibiotic. Penicillin, doxycycline (Doryx, etc), Avelox and Tequin also work on the strains seen so far. Speed is of the essence in starting treatment!

What Can be Done?
First, get your flu shot! The best way to decide on anthrax vs. flu is to avoid all such symptoms, and since flu is so frequent, and the vaccine so effective, get it!
For serious respiratory illness, we’ll see you right away and assess your risk. We have the ability to test for anthrax and for flu. But the most important test is how you do! We’ll ask you to call us the following days, and we’ll carefully track your progress. We are convinced that the problems seen so far would largely have been avoided with follow-up. IF antibiotics are needed, it’ll be for 60 days.

Is Anthrax Contagious? NO!! It cannot be spread person to person.

Is There a Vaccine? Yes, but it’s not available for civilian use. And none has been made since 1998.

Smallpox:
This would be a whole different level of problem. For one thing, it is highly contagious person to person. The attack rate is about 90% just by being in the same room! The disease was last seen in 1977. One of the final patients was in a German hospital; he was promptly isolated, but still infected 11 other people on 3 floors! There’s no known effective treatment - only an untested antiviral medicine, cidofovir (Vistide). Those who were vaccinated over 20 years ago may have immunity, but may NOT. There are some 12-15 million doses of vaccine in the country. They won’t be used unless definite cases are seen, and then they will go to military and public safety people first. If smallpox starts and you have a rash, DO NOT come in! We’ll send someone to you!

Botulism: the toxin of this spore forming germ can cause muscle paralysis, including breathing failure. But the germ is treatable with antibiotics, and there is an antitoxin.

Plague: is another treatable germ; but it CAN be spread from person to person. In the most serious form a pneumonia develops after 2-4 days. A vaccine is being developed.

Tularemia: is another treatable germ that causes a flu-like illness, then pneumonia. It can NOT be carried person to person. Untreated, 35% die, but treatment is generally effective.

by Geri Brewster, RD, MPH, CDN

Let me begin by explaining all the parameters:

Total cholesterol (TC): Originally this is all that was looked at and the goal was to keep it under 200, except people still had heart disease. So, the scientific community began to look at High Density Lipoprotein (HDL - the good cholesterol), and the ratio of total to good. A ratio of 4 or less is considered protective (25% or more of TC). But, people were still getting heart disease. So, they began to look at the Low Density Lipoprotein (LDL - the “bad” cholesterol) and came up with a breakdown: if there is no known heart disease and one or no risk factors it should not exceed 160. If there’s no known heart disease but two or more risk factors it should not exceed 130, and with known heart disease it should not exceed 100.

The risk factors: smoking, diabetes, hypertension, HDL less than 35, and family history of early onset heart disease (a cardiac event in males before 55 and in females before 65), being a man over 45 or being a woman over 55.

Because we could all live well and healthily into our 90s by preventing arteriosclerotic heart disease, I say we fine tune every parameter to our benefit:

• LDL is made up of 2 types: the smaller molecular pattern B type which is readily oxidized and adheres to the artery walls and the larger molecular pattern A which is more easily swept from the bloodstream by the HDL (there are a bunch of other remnants fIoating as well which is why the HDL and LDL added together do not equal the TC). Sophisticated testing is available to determine if you are pattern A or B, but it's generally not done unless you've had an event or unless you've got an aggressive internist. Anyway, most pattern B people are also triglyceride formers. Triglyceride levels should always be less than 200.
• Triglycerides generally represent excess fat and sugar calories that get converted to and stored as fat. In that conversion process they become triglyceride-rich particles which have a great affinity for adhering to the artery walls and speeding up the process of hardening them. Triglycerides are also an important ingredient in LDL particles which is why overweight people usually have high LDL’s and why weight loss usually results in decreasing LDL (unless routine daily exercise is part of the equation, bringing down the TC may result in bringing down both HDL and LDL and the ratio doesn't improve, so the risk remains high).
• Two additional tests to discuss with your internist:
  • A homocysteine level. Homocysteine is a by-product of protein metabolism which makes the wall of the arteries stickier, easing the adherence of oxidized LDL and speeding up the process of hardening of the arteries. You want your homocysteine level to be less than 9.
  • A Doppler of your carotid arteries. This non invasive test looks at the interior of the carotid arteries of the neck--the ones that, if blocked, lead to a stroke. If there is any plague deposited in these arteries, there is a 70% likelihood that the coronary arteries have developed plaque also.

The following supplement recommendations are well regarded by top cardiologists and internists and supported in the literature:

• Antioxidants to prevent the oxidation of the LDL cholesterol that you have: Vitamin E 400 IU, Vitamin C 500 mg timed release in the morning (do not take C with calcium, take calcium in the afternoon and before bed). If your homocysteine level comes back higher than 9, you'll need a prescription for 1 mg of folic acid. In the interim, 400 mcg (available over the counter) is fine along with 50 mg B 6 and 100 mcg of B 12. These nutrients decrease homocysteine, making the interior walls of the arteries Teflon like and more resistant to the adherence of oxidized LDL. No-flush or timed release niacin, 250 mg with food, helps convert pattern B to pattern A and is also available by prescription by the name of Niaspan in order to consume higher doses without the flush.
• Soluble fiber found primarily in oatbran and legumes (peas, beans and lentils). Daily oatmeal is OK, but doesn’t really make a big difference. I usually advise 500-1000 mg oatbran tablets with each meal. It binds with bile acids in the colon so you excrete them. This prevents their reabsorption by the body which then uses the bile to manufacture its own LDL cholesterol. So, you can dramatically cut down on what your body is making.
• Omega 3 fatty acids from fish oils, found supplementally in MAX EPA 1000 mg - take with food, or in fatty fish such as salmon, halibut, sardines, tuna steak, swordfish twice a week. Omega 3's are especially effective in preventing the damage from excess circulating triglycerides. They, like Vitamin E are also natural blood thinners. Omega 3's are also natural anti- inflammatories.
• Olive oil is rich in monounsaturates, a good fat, and red wine and red wine vinegar are also good for their natural antioxi-dant compounds.
• Benecol and TakeControl spreads are now available in supermarkets. These use a natural plant sterol to decrease LDL. Benecol also comes as a salad dressing. Three servings a day can decrease LDL by 14% they say--it*s pricey, about $8 for 2 weeks for 3 servings a day.

Stay away from saturated fats, partially hydrogenated vegetable oils (found in most commercial baked goods and convenience products), simple sugars and late day eating. Anything that is more than 30% fat calories is usually a no. However, nuts, which are a fat, do contain monounsaturates which are good along with a host of other great nutrients. So, 1 to 3 oz of nuts at 4 PM for 200-400 cal to take the edge off of overeating at dinner is OK.

What is Diabetes?
Diabetes mellitus is the increase in blood sugar that happens either because there’s too little insulin (type 1 diabetes) or because the body’s cells can’t use insulin properly (type 2). Insulin is made by beta cells in the Islets of Langerhans in the pancreas, deep within the abdomen.

Who Gets It?
Some 15.7 million people - 5.9% of us - have it in the U.S. It’s even more common in those over 65: 18.4%. You are more likely to get type 2 if: ‚

• you’re over 45
• there’s a family history of it
• you’re overweight
• you don’t exercise much
• you have cholesterol issues
• your heritage is African, Hispanic, Asia/Pacific Island or Native American
• you had gestational diabetes (increased sugar during pregnancy)

“Pre-Diabetic” Conditions include Impaired Glucose Tolerance, (IGT), found in 20 million Americans or 11% of us. They have the same heart and blood vessel risks that diabetics have. About 40-45% of those over 65 have IGT or type 2 diabetes! Impaired Fasting Glucose is when a fasting sugar is above 110, but less than the 126 which defines diabetes. Some will have IGT, some not (they “just have a high number”).

How Does It Hurt You?

• Diabetes kills 187,000 yearly
• 12-24,000 go blind annually
• 27,900 start dialysis annually
• 56,000 have an amputation
• heart attack & stroke are 2-4 times more likely: 77,000 yearly
• impotence can run 50-60%

Costs of Diabetes were estimated at $98 billion in 1997: $44.1 billion for treatment and $54 billion for disability and death.

What Do I Recommend on Checking Your Sugars?

• You should have a fasting (at least 8 hours and preferably 12) blood sugar at age 45 -- sooner if diabetes is in your family, or if your have any of these other risk factors. Venous blood processed in a good lab (our accuracy is 0.2 mg) is the best way to do it. If you’re high risk, you should get checked at least every 2-3 years.
• If your sugar is over 126 mg, this should be confirmed with a second test.
• If your sugar is between 110 and 126, I recommend a formal Glucose Tolerance Test (that’s the one with the over-sugared cola or orange drink) to see if you’re diabetic or Impaired Glucose Tolerance or “just a high number.”

Here’s How We’ll Help:

• Diet: with our dietician - we'll aim for at least an annual review of your diet.
• Blood Pressure should be 130/85 or less
• Sugar Checks you’ll be checking your blood yourself
• Urine Checks looking for early damage (“protein leak”): a level under 30 is ideal.
• Long-Range Sugar Check every 3-6 months with a hemoglobin A-1C (a protein in your red blood cells) under 6% Ideal under 7% Excellent under 8% Good under 9% Fair (but needs help) under 10% Suboptimal Over 10% Poor!
• Eyes: a yearly check with an eye doctor is needed
• Feet: checked regularly for sensation, blood flow and ulcers
• Lousy LDL Cholesterol should be under 100
• Smoking: if you do, we’ll help you stop!

Provider Recognition:
Dr. Grimshaw won recognition in 1999, and again in 2001 from the American Diabetes Association and the National Committee for Quality Assurance. It means that we met goals for sugar and blood pressure control and education.

Carbohydrates: The Good, The Bad, and The Ugly
“But I thought all carbohydrates were good,” is something we hear a lot. The Ornish, the Pritikin and other diets have pushed the idea that very low fat (and high carb) diets are the answer to heart disease and diabetes.  Unfortunately, ‘taint so!

The Problems: non-fat or low-fat foods, especially snacks, use simple sugars instead of fat for flavor.  And these sugars are Bad!   They

• promote tooth decay
• cause blood sugar “spikes”
• raise insulin levels  (especially in type 2 diabetes or Impaired Glucose Tolerance)
• raise triglycerides (which are so toxic to the linings of your blood vessels that they can be paralyzed for 4 hours after such a meal).

The Insulin Issue: Insulin brings sugar down in the blood by helping cells (particularly muscle and liver) bring sugar inside, to be stored as glycogen.  If your cells have enough glycogen, the extra sugar gets stored as fat.  Excess insulin can:

• promote the creation of toxic trigylcerides
•  inhibit the burning of body fat
• inhibit the use of fatty acids for energy
• inhibits the release of growth hormone (GH).  GH is essential to muscle growth and renewal. GH is released in large amounts after you exercise and right as you fall asleep.  Eating a simple sugar snack after exercise or within a few hours of sleep will abort the GH release

And so you ultimately store more body fat, have less stamina and decreased metabolism and increased weight gain when you eat foods high in simple sugars!

Enter Atkins and Variants:
The above is the basis for the high protein, low carbohydrate diets of Dr. Robert Atkins, our old friend Dr. Joseph Hickey, and others.  If you don’t eat sugar, you don’t get the insulin spike, the triglyceride release, and the growth hormone response is normal.  In essence, your body thinks it’s starving, and you burn stored fat!  Readers of these pages know that there’s been little long-term testing of the Atkins approach.  But short term trials of up to 18 months have shown no problems.  Many physicians - including some (but not all) cardiologists - are quite leery. 

Can We Finesse This? For selected patients, we use a modified carbohydrate restricted diet.  This is high in:

• lean animal protein such as chicken
• fish rich with omega 3 fats
• nuts
• avocados
• low carb vegetables
• egg white

Talk With Us!  We’ll tailor your diet to YOUR needs, based on blood pressure, cholesterol and sugar control as well as heart and vessel risks, body mass and your own experiences.  We could try to “tell you” what to do (which never works).  Instead, we’ll ask you what you’ve done, what you’re doing,  and what you hope to do. This works!

The Glycemic Index (GI) is a measure of the rate at which carbohydrates are converted into blood glucose.  Obviously, from what we’ve been discussing, foods that cause a rapid rise in blood sugar - a high glycemic index - will worsen diabetic control and raise triglycerides (another way besides cholesterol that you carry fat in your blood).  An index under 100 is considered good.  Generally, the higher the fiber, the lower the GI. 

Some foods with good GI’s:

• whole grain bread
• dried peas
• lentils and beans
• barley
• high protein pasta (Barilla)
• peanuts
• soybeans
• sweet potato
• milk
• plain yogurt
• grapefruit
• cherries

Foods with bad GI’s:

• white bread
• white pretzels
• white rice
• corn flakes
• Rice Krispies
• dates
• fruit juice

Joslin Diabetes Center, Boston, Mass.
Provided by Robert S. Grimshaw, Jr. M.D.

ASPECTS OF FOOT CARE
How often do you tell someone that you're going to jump into a project "feet first?" When was the last time you thought about how to "put your best foot forward?" How frequently have you told someone about the "fancy footwork" you had to perform because you "put your foot in your mouth?" To use another popular American phrase, they can be your "Achille's heel." Why? Because diabetes can cause the arteries in your legs and feet to become hardened and clogged, preventing blood from circulating properly. It can also affect the nerves in your feet, causing a loss of sensation. Without adequate feeling or circulation in your feet, even minor cuts and scratches, callouses, corns and toenail injuries can become serious problems. To protect yourself from these kinds of problems you need to carry out a daily foot care program that includes: washing and examining your feet each day; applying moisturizing creams to dry skin; filing toenails regularly; treating cuts and scratches promptly; taking care of corns and callouses; managing athlete's foot promptly; attending to warts; and, selecting footwear carefully. Perhaps feet are such a useful part of the American language because they're such an important part of our anatomy. But for people with diabetes, feet can also pose special challenges.

NERVE DAMAGE AND FOOT PROBLEMS
The nerves are your body's communication system, carrying information back and forth between the brain and other body parts. Some nerves, called sensory nerves, carry messages of pain, touch or temperature up to the brain. Other nerves, called motor nerves, carry instructions for movement from the brain down to the muscles in your legs, feet and hands. One of the purposes of this communication system is to protect you. Let's suppose again that you cut the bottom of a foot on a piece of glass while walking on the beach. Sensory nerves would immediately send a message of pain to your brain. Your brain would then send a quick message via the motor nerves to the muscles in the appropriate leg, telling you to pick your foot up off the sand. Almost before you were aware of what was happening, your brain would have prescribed the first step in treating the injury: "Stop walking on your cut foot!" Diabetic neuropathy is nerve damage believed to be caused by chronic high blood sugars. If neuropathy affects your sensory nerves, you may suffer a loss of feeling in parts of your body. Frequently, the feet are affected. As a result, a cut or wound on the bottom of your foot will not hurt and may go unnoticed. You may continue walking on the injury, causing additional damage with every step, and preventing the wound from healing. Diabetic neuropathy can also affect the motor nerves, though less frequently than the sensory nerves. The muscles in the feet and legs may be involved. In severe cases, some of the muscles may become weak, which can make walking difficult.

PREVENTING NERVE DAMAGE
Why does diabetic neuropathy occur? Scientists and clinicians currently believe that the nerves are damaged by the high levels of glucose in the blood. The nerves are constructed like electric wires. The nerve, itself, is like the metal part of a wire. Other cells surround it, just as insulation covers a wire. These cells are called Schwann cells. In people with diabetes, excess glucose gets into the Schwann cells and is changed into sorbitol. (The sorbitol produced in the Schwann cells is unrelated to the sweetener of the same name found in many dietetic foods.) It is believed that sorbitol causes the cells to swell, irritating the nerve and eventually destroying it. Because chronic high blood sugars are believed to be the root cause of nerve damage in diabetic neuropathy, the most important thing you can do to try and prevent this condition from developing is keep blood sugars within normal ranges through good diabetes management. Even people with generally good diabetes control can develop neuropathy, however, so it is important to keep an eye out for signs of trouble.

SIGNS OF DIABETIC NEUROPATHY
Numerous symptoms may occur continuously or irregularly when diabetic neuropathy affects your feet and legs. You may lose sensation and your feet may feel numb. At other times, you may feel shooting pains, pricking, tingling and/or burning on the skin of your feet and legs. These pains and sensations can be mild, or so severe that they can be almost unbearable. Sometimes both sets of symptoms are present.

FOOT CARE WITH NEUROPATHY
In and of itself, diabetic neuropathy is not dangerous. The danger lies in being unaware that you have lost feeling in your feet, and allowing a foot injury to be neglected as a result. If you have neuropathy you need to protect yourself against this risk. Since the automatic alarm system in the foot. is not functioning, replace it with a manual one--good foot care that includes regular foot inspections! A practical way to set up a manual alarm system is to change shoes and socks every three to four hours. There are three advantages to doing this. --If you have limited or no sensation in your feet, this gives you frequent opportunities to look for any problems which may occur. If you find a foot injury, it can be treated immediately. --By changing your shoes several times a day, you can shift the pressure points on your feet that the shoes cause. --Changing shoes and socks every three or four hours can help to eliminate damage to the skin and reduce the risk of infection and sores which the friction of continually worn shoes-can cause. (All shoes begin to allow the foot to slide parallel to the sole of the shoe after three to four hours of continuous use. This increases friction which may cause blistering and skin breakdown.)

THE MUSCULOSKELETAL SYSTEM AND FOOT PROBLEMS
The musculoskeletal system includes the bones and joints and the muscles, tendons and ligaments that connect muscle to bone or bone to bone. The system gives form and shape to your bone and enables you to move around. Any problem in the structure of the musculoskeletal system-such as a birth deformity--may disrupt the smooth-gliding joint actions, exert abnormal forces on various parts of the feet and lead to further changes in foot structure and shape.

SIGNS OF PROBLEMS
Some of the more frequent changes which occur are hammertoes, bunions and metatarsal deformities. A hammertoe is a condition in which the toe is contracted (drawn together) at one or more joints. A bunion is a deformity in which the big toe has moved laterally toward the other toes and the first joint of the toe bulges outward. A metatarsal deformity is a problem in one of the five large metatarsal bones behind the toes which make up the center of the foot. Common metatarsal deformities such as flat feet and high arches cause pain and discomfort in and around the ball of the foot. They may also cause heel spurs. PREVENTING FURTHER FOOT PROBLEMS Walking on deformed feet or trying to wear shoes which are designed for normally shaped feet may be painful and can lead to further foot damage. If you have diabetic neuropathy, you may not feel the pain, and be unaware of additional damage. If you have foot deformities along with poor circulation and/or loss of sensation, seek professional foot care on a regular basis. Most musculoskeletal conditions can be managed without surgery. Wearing appropriate shoes, taking care of your feet each day, and getting regular professional care, will in most cases enable you to do all you like doing without problems. Surgery should be used for musculoskeletal problems only if the pain is disabling or further damage is occurring.

CHARCOT FOOT - A SPECIAL PROBLEM
Charcot foot is musculoskeletal condition which affects approximately one of every 700 people who have diabetes. It is usually limited to people who have moderate to severe loss of feeling in their feet. Charcot foot is more common among people who are overweight, but can occur in thin people. No one is quite sure how Charcot foot begins. However, it is thought to be caused by either an incidental trauma or a misstep or twist of the foot which injures some of the ligaments that support the arch or the foot. Once the ligaments have been damaged, the bones begin grinding against one another and the arch may collapse. The damage often goes unnoticed because the person has already lost feeling in their foot. With the collapse of the bones in the arch, the weight bearing is distributed differently along the sole of the foot, causing irritation and blistering, which may lead to sores and infection. If your foot swells without explanation and is warm to the touch with no apparent break in the skin, there is a good possibility you have Charcot foot. When these symptoms occur, be sure your physician or podiatrist examines your foot. Rest is the primary treatment for Charcot foot. Depending on the severity of the damage, no weight should be placed on your foot for 8-16 weeks. If both feet are affected, you may not be able to walk at all until the damage heals. Permanent foot deformities may be avoided if the condition is diagnosed and treated early. If a significant permanent deformity does occur, you will need special molded shoes to protect your foot.

YOUR SKIN AND FOOT PROBLEMS
The skin is your body's barrier against infection, so potential and actual skin injuries need immediate attention. This is especially important if you have diabetes because poor circulation may have decreased your body's infection-fighting and healing capacity. Small wounds that lead to infections and larger non-healing wounds can eventually result in the loss of a part or all of a foot.

PREVENTING SKIN PROBLEMS
A system of regular foot care will help you prevent many of the minor skin problems that, if unattended, can lead to major problems.

WASHING YOUR FEET
To protect your skin, wash your feet each day and check yourskin for injuries. Wash your feet in warm, soapy water. Don't soak your feet - that will soften your skin and make it more susceptible to infection. Use a mild hand soap and don't use HOT water. Test the water temperature with your wrist so you don't scald your feet if you have neuropathy and have lost sensation in your feet. Rinse your feet well after washing and dry them carefully, especially between the toes. After you have washed and dried your feet, examine them closely in a good light. If you cannot bend over to see the bottom of your feet; place a hand mirror on the floor and hold each foot, in turn, over it so that you can see the reflection in the mirror. If you have poor eyesight, ask someone to examine your feet for you. Keep an eye out for the common problems that often threaten the protective function of your skin. These include dry skin, toenail injuries, cuts and scratches, callouses and corns, dermatitis (athlete's foot), and warts. Descriptions of these problems and how to care for them appear below.

DRY SKIN
Dry skin may lead to cracks which bleed and become infected. The moisture content of a person's skin depends on heredity and environmental factors. Some people have skin that rarely needs moisturizers. others need to use creams several times a day to prevent the skin from drying. Creams such as Nivea, Eucerin, or Alpha-Keri help restore moisture to the skin. Creams are better than lotions because they hold moisture in the skin for a longer period of time. Apply cream starting at the heel and work towards your toes. This will help you avoid leaving excess amounts of cream between the toes which can lead to a wearing away of the skin and possible infection. Dry skin around the edges of your heels is especially prone to cracking. Sometimes dry heels are treated by applying a liberal amount of cream to the dry areas before going to bed, covering the area with a piece of clear plastic wrap and wearing a sock over the wrap during the night. This procedure can be repeated two or three times a week, depending on the degree of dryness. If severe dryness persists, consult your podiatrist or a dermatologist. If your feet perspire, use talcum, baby powder or mild foot powder to absorb the moisture. Be sure the powder doesn't collect between your toes.

TOENAILS
Most people with diabetes can care for their own toenails. However, you should probably have someone else care for your nails if you have poor circulation, have lost sensation in your feet, have extremely poor eyesight or have severe arthritis in your hands and back. Ask a family member or friend to help you or have regular appointments with a podiatrists. If you, a family member or a friend care for your toenails, file them with a diamond-type file (Emery board). A scissors orclippers should not be used since any instrument which will cut your nails could also cut your skin. File nails to the ends of your toes, but no shorter. Shape them according to the contours of your toes and the toes next to them. If abnormal toenail growth leads to ingrown toenails and infections, seek help from a podiatrist. An infected ingrown toenail can become a serious problem if not treated appropriately. Often it requires removal of a portion of the nail, drainage of the infection, antibiotics and bandaging with frequent dressing changes until healed. Fungal infections which lead to the discoloration and thickening of toenails should also be treated by a podiatrist. Treatment usually involves regular trimming and filing in order to keep the nails as thin as possible. Sometimes surgery is necessary to remove the nail in order to prevent continuing pain and infections. over-the-counter remedies for these fungal infections are usually not effective. There are effective oral medications, but the side effects do not warrant their use unless the fungal infection has spread over large portions of your body. They should be used only in consultation with your podiatrist or physician.

CUTS AND SCRATCHES
If you have a cut or scratch on your foot, wash the affected area with warm water and soap promptly. Do NOT SOAK. Apply a mild antiseptic such as ST/37, Bactine, or Johnson's First Aid Cream. Never use strong antiseptics such as iodine, Betadine (unless diluted according to the instructions of your physician) , Mercurochrome, boric acid, Epsom salts, creosol or carbolic acid. Cover the affected area with a dry sterile dressing. Secure the dressing with paper tape or a Telfa bandage.

DO NOT USE ADHESIVE TAPE, INCLUDING BAND-AIDS, ON YOUR SKIN.
Do not apply heat treatments such as a hot water bottle or heating pad to the cut or scratch. Stay off your feet as much as possible and call your physician if the affected areas do not improve within 24-30 hours. If redness, swelling, increased warmth or a yellowish drainage occurs, contact your physician immediately. Do not assume the condition is improved just because there is no pain.

CALLOUSES AND CORNS
Callouses and corns are caused by friction on the foot from the sole or toebox of a shoe. They usually occur because of faulty foot mechanics or because deformities such as bunions and hammertoes have caused parts of your foot to rub against the shoe. The thickened skin characteristic of callouses and corns can be painful for people with normal sensation in the feet. The pain can be relieved by thinning the callous or corn, wearing shoes which leave room for crooked toes, and using toe pads to minimize friction. If you have lost feeling in your feet, you may not notice any pain from callouses and corns. If you neglect them, however, they may blister, break and become infected. Further neglect may lead to sores which can quickly affect the bone. Blisters should be treated by immediately removing the cause of the friction and applying antiseptics. Avoid walking when you have blisters on the bottom of your feet. open sores require strict bed rest, antibiotics, dressing changes and sometimes hospitalization. Sores should never be soaked.

DERMATITIS (ATHLETE'S FOOT)
Dermatitis is a skin disease which reduces the skin's ability to provide a barrier against bacteria and to fight infection. Any dermatitis condition on the feet needs to be identified, treated and cured in order to prevent a breakdown of the skin. One of the more common forms of dermatitis is athlete's foot, which causes the skin between the toes to redden. Blisters may form, accompanied by fluid drainage and painful itching. Over-thecounter antifungal agents such as Tinactin and Desinex are usually sufficient to heal the condition. If these remedies don't help after seven to ten days, consult a dermatologist or podiatrist. A stronger medication such Halotex, Lotrimin or Loprox may be needed. You will need a prescription for these drugs.

WARTS
Warts are caused by a virus which has a tendency to grow in the skin. Plantar warts occur on the plantar or bottom surface of the foot. You may have difficulty distinguishing between a wart and thick callous. Ask your physician or podiatrist if you have a growth and are not certain whether it is a wart or callous. Warts will usually disappear if left alone. For this reason, and since many of the methods used to remove warts are worse than the condition itself, it is best not to treat warts unless they begin to spread or become painful to walk on. None of the methods used to treat warts are 100 percent effective. The most successful methods are surgical removal and caustic acid therapy, but they are only 80 to 90 percent effective. Sometimes several methods must be used before warts can be successfully and permanently removed.

SHOES AND SLIPPERS
Wearing sturdy, appropriate footwear is another important way to protect the skin covering your feet from injury. Most of the surfaces you walk on, such as concrete and asphalt, are hard. Unlike walking in the sand, where the foot sinks into the surface and the ground comes up to meet it, a foot walking on a hard surface tends to collapse down on to the surface. The best shoes for use on hard surfaces are those that are soft and supportive. They provide an interface between the foot and the walking surface. Athletic shoes with soft uppers, cushioned soles and firm counters around the heel provide the necessary support. However, all shoes begin to lose their cushioning and supportive capability after 4-5 hours of continuous wear. For this reason, it is best to change shoes in the middle of the day to help maintain maximum cushioning and support. Although they may be the height of fashion, do not wear sandals, clogs or flipflops. Avoid pointed shoes which squeeze the toes together. Break new shoes in gradually. This will prevent blisters from forming. When you wear slippers around your home, make certain they have sturdy toes in order to prevent stubbing your toes. While the temptation may be strong, do not go barefoot at the beach or anywhere else for that matter. You will need specially molded shoes with extra room in the toebox if your feet are significantly deformed. Your podiatrist or physician will advise you about the kind of shoes you need.

SOCKS AND STOCKINGS
Cotton and wool socks or stockings, or hosiery made from combining cotton and wool along with synthetics are best if you have diabetes. They provide some additional degree of cushioning and also help to prevent friction between the shoes and prominent bony protrusions on the feet. Wear a clean pair each day. Socks and stockings should be correct size and free of seams and darns. You should avoid wearing socks or stockings with constricting tops that might further slow circulation. Constricting garters and girdles are a no-no too. If your feet sweat, change your socks several times a day.

A LAST WORD
Foot care takes a little more time and attention if you have diabetes than if you don't. But like everything about having this condition, the extra attention now is well worth the long-term return. Just because you have diabetes doesn't mean you can't do all the things you want to do. And healthy feet will take you wherever you want to go--up a mountain, across a continent . . . or just around the corner.

Continuing our series on popular supplements, from the American College of Physicians meeting and other sources.  Remember, purity and potency are not guaranteed under American law because these are considered foods.  I don’t recommend any supplements without careful thought and consultation.

Saw Palmetto: (Serenoa repens)

The berry of the scrubby palm found from Texas to Florida.  Its main use is for benign prostate enlargement, in a dose of 160 mg twice daily.  Evidence of effectiveness is fair with open label (patients and doctors knew who was getting what) studies showing reduction in urinary symptoms for up to 3 years.  Side effects include rare stomach upset and less impotence than finasteride (Proscar).  It appears to work by much the same mechanism as that drug: inhibiting the conversion of testosterone to the 5-alpha dihydrotestosterone metabolite.  Two cautions: 1) some people use it instead of thyroid hormone replacement (which can make them very sick if they’re hypothyroid); and 2) please get a prostate check (including PSA) BEFORE taking it (so we don’t miss a chance to catch early prostate cancer).

Garlic: (Allium sativum)

Garlic in doses of 600-900 mg extract (1800-2700 mg raw garlic) has been touted for blood pressure, clot inhibition and pain relief, and was even used as an antibiotic by the Soviet Army during WWII when penicillin ran out.  But the best evidence of effect is in reducing cholesterol (9-12% drop in total cholesterol in several studies).  Side effects are few, but include possible bleeding.

Ginger: (Zingiber officinale)

Frequently used for nausea; it’s also used for motion sickness and flu symptoms.  The dosage is 940 mg up to 3 times a day; studies have shown modest effects; drugs are more effective.  Ginger, however, has few side effects, mostly stomach upset.

Feverfew: (Tanacetum parthenium)

Used for migraine.  The usual dose is 1 dried leaf.  It appears to inhibit the release of the neurotransmitter serotonin by platelets.  A 1988 Lancet study showed a 24% reduction in migraines, when feverfew was used for prevention.  Side effects are few, including mouth sores if the leaf is chewed.  Locally, New York Medical College neuro-ophthalmologist Dr. Scott Forman has tried it for ophthalmic migraine (which affects vision, with no usual headache). And, he told me recently, it's good for many types of migraine.

Caution: garlic, ginger and feverfew can all increase the effect of the blood thinner Coumadin and should be avoided by Coumadin patients.  They also should not be used for 2 weeks before any elective surgery.

Echinacea: (Echinacea purpurea, E. Pallida, E. angustifolia)

Used for cold and flu symptoms.  Dose is up to 9 300-400 mg capsules a day.  Evidence of effectiveness is weak, partially because of trouble making a reliable extract and the “bite” that it has, which makes placebo trials difficult.  Side effects include allergic reactions (especially in those known to be allergic to ragweed or daisies), at least one death due to a lupus flare, and possible reactions in those with HIV, multiple sclerosis and tuberculosis.


Goldenseal: (Hydrastis canadensis)

Root and rhizome is used for diarrhea and upper respiratory infections. Dose is up to six 500-600 mg capsules.  Large doses can cause skin ulceration, uterine contractions, stomach upset, hypertension and seizures. Clinical evidence of effect is scant.


Dong Quai: (Angelica senensis)

Used for sleep, a laxative and as an estrogen supplement.  The dose is 1.5 grams 3 times a day.  There are few adverse effects and little evidence of any beneficial effect.

Forever Female -- The Case For Estrogen:
A striking case can be made for the use of hormonal replacement therapy in post-menopausal women:

Quality of Life--You Live Better:
a) You don't get (as) fat -- and if you do gain weight, you put it on your hips and buttocks (pear shape), not the more dangerous area of the waist (apple shape).
b) Your skin looks younger with less wrinkles are more moisture.
c) You remain stronger (bone, muscle, cartilage).
d) You have less joint aches (arthralgias)
e) You get less urinary infections.
f) You have less vaginal dryness.
g) You have less pain on intercourse.
h) You think more clearly -- there is early evidence that the incidence of Alzheimer's disease is reduced in women on estrogen.
i) You feel more energy, less fatigue, sleep better, have less head-aches, palpitations and flushes.
j) You keep more of your teeth.

Quantity of Life --You Live Longer:
a) Decreased heart disease. The rate of coronary disease goes down 50%.  This compares with a relative risk of menopause of 317%!  And recent additional data shows women who’ve had bypass surgery are more likely to survive on estrogen -- 98.8% vs 82% for nonusers after 5 years.
b) Decreased stroke.  The stroke rate on estrogen is 31% less, and death rate from stroke 63% less.
c) Decreased diabetes. In one analysis, risk dropped by 32%.
d) Increased bone strength, decreased fracture risk.  As we have noted in these pages before, one million post-menopausal women will break a bone this year.  300,000 will break a hip.  100,000 will wind up in a nursing home, and 60,000 will die.  Vertebral compression fractures, which lead to substantial loss in height,  will occur in nearly one woman in four after menopause.
e) Decreased risk of hypertension.
f) Decreased risk of colon cancer.
g) Decreased risk of ovarian cancer (by 37% in one 1994 study).
h) Decreased risk of blocked arteries to the legs. (Peripheral vascular disease.)
On balance, a study in the Journal of the AMA says, women gain between 4 and 41 months of life with estrogen.

What's the Downside?
As always, there is no perfect pill.
a) Uterine cancer. This risk occurs only with the use of estrogen only in women who still have a uterus.  It  has now been eliminated by use of progestins either simultaneously or in a cycle that mimics a normal period. 
b) Breast cancer.  This remains quite controversial, but there is substantial evidence of a small, but measurable, rise in breast cancer in women on estrogen.  This makes biologic sense, since a large number of breast cancers are dependent on estrogen for growth.  But it's a small effect -- a relative risk between 15 and 74% higher.  This compare with a 100% increase with obesity, a 100% increase with never having had children,  a 200% increase with a high fat diet, and 500% increase with excess alcohol! And analysis of 122,000 women in Boston’s Nurses’ Health Study showed that only women who drank had the increased breast cancer risk.

Forms of Estrogen Include: pills (Premarin,  others), combinations (PremPro), patches (Climera, Alora,  Estraderm) and creams.  The data on pills is better than that for patches and creams. 

Sources: Sandra Raff, M.D., director of endocrinology at New Britain (Conn) Hospital, JAMA, others. 

The "Silent Disability"
Hearing loss, "is the number one disability among the elderly," according to Dr. David Nielsen, executive VP of the American Academy of Otolaryngology. People with it, he says, "just muddle through, struggling with communication." We hear about it when another family member complains about "being ignored" or about the TV volume being too loud. And all too often patients with hearing loss are thought to be losing memory and "going Alzheimer’s" or to be depressed. In a year 2000 survey by the National Council on the Aging, those with untreated hearing loss and their families reported more sadness, depression, worry, anxiety and paranoia.

The numbers are staggering: 20-26 million in the U.S.

Causes of Hearing Loss:

• Noise - loud noise over time can cause significant hearing loss, beginning in the higher frequency ranges. This is a significant worry in fans of loud music who come back from concerts saying their ears are "ringing." This means hearing is being damaged.
• Wax - build up can easily be relieved by us or an ENT consultant
• Smoking
• Medications - some 200 drugs are known to damage the inner ear. Among the most frequent are those used for cancer treatment or serious infections; the damage may be permanent. High dose aspirin, quinine and certain "water pills" (such as Lasix/furosemide) can cause temporary damage. More rarely prednisone-type medication, certain anesthetics and some mood-altering drugs can affect hearing. Typically, high frequencies are lost first.
• Otosclerosis is basically arthritis of the middle ear bones
• Meniere’s disease affects the inner ear with deafness & vertigo
• Trauma
• Acoustic neuroma is a tumor affecting the nerve of hearing and balance
• Autoimmune inner ear disease results from an attack by the body’s immune system
• Aging is also a factor

What Can Be Done?
First, Prevention:

• Limit Noise
• Clean out wax
• Don’t smoke!
• Regular hearing checks (which we’ll be glad to do!)

Then, Treatment:

• We’ll get you help: Ear, Nose and Throat and audiology consultations.
• Hearing aids: 4 styles:
  • 1) over the ear (biggest)
  • 2) in the ear
  • 3) in the canal
  • 4) completely in the canal (smallest)
• Each comes analog (basically an amplifier, and less expensive) or digital (computerized to bring out speech, and more expensive).
• You have 45 days after purchase to return hearing aids in NY State Aids take time to get used to – often 6-12 months. They do not return the wearer to his or her youth. But they do improve the quality of life. Patients are safer, and they may even help prevent or slow down dementia.

The Future? Surgically implantable aids have been approved by the FDA and cochlear implants (in effect, bionic ears) are in study.

Our office is frequently asked if there are “any risks” in taking herbs that are available over the counter in health food stores or supermarkets. The brief answer is “if there are effects, there will be side effects.”

Source: March 1997 Internal Medicine News

Quick: what has

• 26 bones
• 33 joints
• 20 muscles
• 150 ligaments
• 250,000 sweat glands that release a cup of moisture a day
• daily endures the cumulative force of hundreds of tons
• trudges about 115,000 miles in a lifetime?

You’re right – your foot! Our feet are important to all of us, but are especially at risk in those with poor blood flow or diabetes. Of some 16 million diabetics, 15% will be hospitalized for foot problems. The reasons:

• Poor Sensation: Neuropathy (due to diabetes or other causes) leads to injuries because you don’t know you’ve been hurt, can cause toes to curl up and other deformities.
• Poor Circulation: Lessened arterial blood flow means that feet can’t fight infection and injuries are slow to heal. If you’re getting pain in your calves on walking, we should check your blood flow – there’s a lot we can (and should) do!

From callus to ulcer - what you don't want

What WE’LL Do:
At your physical, we’ll ask about your feet; alert us to any issues
We’ll check your feet for sensation, pulses and ulcers

If you’re diabetic:
Get our foot guide
We’ll check your feet more often
We’ll discuss a podiatrist (foot specialist)For more see the "Diabetic Foot Guide" in the Our Guide section. Other resources are the American Diabetic Association (diabetes.org) and the Joslin Clinic (Joslin.org).

What YOU Should Do:

• Wash every day, and dry carefully between toes
• Check daily for cuts sores, calluses & blisters
• Test the water first - don’t make the temp too hot
• CHANGE YOUR SHOES 2-3 times during the day – they lose resilience
• Wear socks if cold, and choose them carefully: well padded, ½" longer than your longest toe
• Don’t use hot water bottles, heating pads or electric blankets (you can be burned)
• No garters! (they cut off blood flow)
• Cut toenails straight
• Don’t rip hangnails
• Wear comfortable, flat shoes that fit, and break them in slowly
• Buy shoes at the END of the day, when your feet are swollen (if they’re comfortable then, they’ll likely be so all day!)
• Check shoes daily for pebbles, tears, etc
• Never walk barefoot!
• Keep your feet dry by dusting with non-medicated powder If your feet are too dry and the skin is cracking, moisten with Nivea, Eucerin or Alpha-Keri (NO PERFUMES!)
• If you’re diabetic, control your sugar
• DON’T SMOKE!!!
• If you lose sensation, tell us!
• See us at the FIRST sign of infection or inflammation.

Recipe for hypertonic saline (saltwater) for home or office irrigation:

• To 1 (quart) of warm distilled water, add:
• 2 -3 heaping teaspoons of sea salt and
• 1 teaspoon of Arm & Hammer baking soda.

The nose should be irrigated 2 - 3 times per day with a bulb syringe, large medical syringe (or a turkey baster!) or water pik with irrigator tip. Stand over a sink and squirt the saltwater into the nose in such a fashion that you are able to spit some of the saline out of your mouth.

Aim the stream of saline as though you are trying to squirt the back of your head, NOT the top of your head. It is acceptable to breath the saltwater directly into your nose.

Warm saltwater is preferred, as it is much more comfortable. The amount of salt added will depend on your tolerance. However, the more salt that is added the greater the decongestant effect. The bicarbonate is a buffer which makes the saltwater less irritating.

The benefits of hypertonic saline irrigation are three-fold:

1. It is a solvent. It cleans mucus, crusts and other debris from the nasal passages.
2. It decongests the nose. Because of the high salt concentration, fluid is pulled out of the membrane. This shrinks the membrane, which improves nasal air flow and opens sinus passages.
3. It improves nasal drainage. Studies have shown that saltwater cleaning of the nasal membranes improves ciliary beating so that normal mucus is transported better from the sinuses through the nose and into the throat.

If you are also using a nasal steroid, such as Beconase, Vancenase or Nasacort, you should always cleanse the nose first with the saltwater before utilizing the nasal steroid. The nasal steroid is most effective when sprayed onto clean nasal membranes, and it reaches deeper into the nose after cleansing and decongesting.

Provided by Robert S. Grimshaw, Jr. M.D. from recipe by Timothy Siglock, M.D.

Some 30% of older Americans who live in their communities fall every year, as do more than half of nursing home residents. Falls are the 6th leading cause of death in the elderly, killing some 10,000 a year. And they cost some $13 billion a year. So reports Mt. Sinai’s Dr Helen Edelberg. In fact, falls cause about 40% of all nursing home admissions.

Why do people fall? Only 10% of falls occur due to a single event; most occur due to multiple factors:

• arthritis
• muscle weakness
• foot disorders
• vision loss
• balance loss
• medication effects
• Parkinson’s disease
• other nerve disorders
• acute illness

Home Issues Are Important, Too:

• Stairs - 10% of falls occur on stairs, usually the last step
• Slippery floors
• Beds too high or too low Trip risks: cords, etc. Inadequate lighting

What Can Be Done?
1) Indoors:

• Eliminate clutter, especially on the floor
• Floors should be smooth, not slippery
• Carpets & rugs should be tacked or have skidproof backing NO THROW RUGS!!
• Stairs should be well lit and have handrails on both sides. Fluorescent tape on the edges of the top and bottom steps can help.
• Grab bars should be beside tubs, showers and toilets (there’s no ‘good’ place to fall in the bathroom!)
• Tub seats and hand-held shower heads help also
• Place rubber mats or non-skid strips in tubs and showers
• Furniture should be out of the flow of traffic in the house, stable and without sharp corners
• Improve lighting - add ceiling fixtures, use sound/motion activated lamps, increase wattage
• Use night lights
• Keep a flashlight at the bed
• Don’t use step stools, or if you must, make it sturdy with a handrail and wide steps
• Carpeting and curtains can minimize echoes and sharp noises
• Avoid shiny surfaces/glare
• Colors: yellow, orange & red are easiest for people with poor vision; contrasts help for doorways, stairs and walls
• Use a portable phone
• Get a "Lifeline" button-type emergency call service OR arrange for daily contact with a friend or family member.

2) Outdoors:

• In rain/snow/ice, use a cane or a walker
• Wear warm boots with rubber soles
• Carry salt or kitty litter in your pocket or car in icy weather
• Stay away from slippery floors in public buildings.

3) Exercise Helps!

• Balance and gait training help. So does walking (improves endurance) and Tai Chi meditative movements. In an Australian study, group exercise was the single most important intervention in a fall prevention effort. When combined with home hazard reduction and vision improvement, falls dropped 14% annually.

Restless leg syndrome is a feeling of deep discomfort at rest. Patients will describe the feelings as creeping, crawling, itching, tingling, burning, pulling and jitters. 80% report the involuntary movements. While the cause is not known, abstaining from smoking, alcohol and caffeine usually helps. We should make sure there’s no drop in iron, folate or vitamin B-12, and check for medication effects, thyroid and kidney disease. Therapies include stretching, Sinemet, Klonopin, and Neurontin. Occasionally, quinine can be helpful – but really only for leg cramps, not for true Restless Legs.

To stretch, lean against a wall, placing your feet about a yard from the base of the wall while on the balls of your feet, then slowly come down onto your heels, with your knees locked. Do this for about 30 seconds. This will stretch the muscles in the back of your legs.

Sinemet, Klonopin and Neurontin are prescription items. From the Mayo Clinic Proceedings, Dr. Siong-Chi Lin and colleagues report that the anti-Parkinson drug pramipexole (Mirapex) may be very useful. They started with 1/2 of a 0.25 mg pill nightly 2 hours before bedtime. Only 1 of their 16 patients couldn’t take the drug. Most noted less leg restlessness including involuntary “jumping” and better sleep. The main side effect was fatigue or stiffness. The pills cost about $1 each.

For quinine, the easiest source is Schweppe’s Tonic Water - one glass at bedtime. Other sources can include the prescription Quinam tablets at bedtime.

Irritation of the inner ear, called “benign positional (or paroxysmal) vertigo” - BPV - or labyrinthitis is one of the most common emergencies we see.  Nationally, this affects about 160,000 people annually.  

It frequently follows an upper respiratory infection, though it can occur with no preceding illness.  Often, there is no warning. Patients feel as if they’re spinning, or as if the room they’re in is spinning.  And frequently they’re quite nauseated, enough to vomit. The cause of BPV is free-moving particles in the fluid (endolymph) in one of the 3 semicircular canals that  make up the organ of balance, the inner ear or labyrinth.  

Treatment can be with antihistamines such as Antivert (meclizine), a patch  behind the ear (Transderm Scop) and physical maneuvers. Sometimes (very rarely)  surgery is recommended.

We use Cawthorne exercises in the office and a series of movements called a modified Epley maneuver or “Canalith Repositioning Procedure”. The idea of both physical maneuvers  is to move the loose particles from the posterior canal where they’re causing trouble back into the sump or utricle, where they don’t.  A recent study at the Mayo clinic showed that ½ of patients will respond to the Epley maneuver alone; those treated with a sham procedure had a response of only 19%.  It should be noted that usually 1/3 of patients have episodes of  vertigo for more than 1 month after their first visit.

Patients can use a cervical collar and should sleep sitting up for the 1st 2 nights.  They should not sleep on the symptomatic side for an additional five days and should avoid excess head turning for 1 week after the initial visit.  

In another study, patients were taught how to do the Epley themselves, and did it 3 times daily until they got relief for 24 hours. There was a 64% response in a week.

For more: www.charite.de/ch/neuro/vertigo.html