If you’re reading this article, you or someone you know probably has a knee problem. Maybe you’ve injured your knee while skiing or playing sports, or perhaps you’re one of the millions of Americans who suffer from arthritis. You may have recently undergone knee surgery or are contemplating having surgery. Whatever the nature of your problem, you’re not alone.According to the American Academy of Orthopaedic Surgeons, some 4.2 million initial visits to doctors were made for knee problems in 1992 (the latest statistics available). That same year, another 1.3 million initial visits were made to emergency rooms because of knee injuries or knee pain. This is not surprising given the fact that nearly half of all people between 25 and 75 years old have experienced knee pain.Many of them end up in my office. I am an orthopedic surgeon who specializes in the diagnosis and treatment of knee problems. At the Insall Scott Kelly Institute for Orthopaedics and Sports Medicine, affiliated with Beth Israel Medical Center in New York, I treat hundreds of patients each year for a wide variety of knee complaints. Knee problems don’t discriminate. In my capacity as team doctor for the New York Knicks and former physician for the New York Rangers, my patients include some of the best-conditioned, finest athletes in the world. But I spend the majority of my time treating the so-called weekend athletes—people who sit at their desks all week long and, come Saturday or Sunday, play hard and sometimes get hurt. I also see a fair number of sedentary people who are not the slightest bit athletic and who have problem knees for different reasons.Why are knee injuries so common? In order to answer this question, I need to explain a bit about the anatomy of the knee joint. By definition, a joint is a point in the body where two or more bones connect. In the case of the knee, however, the story is far more complex. The thigh bone (femur) connects to two bones: the shinbone (tibia), which lies directly underneath, and the fibula, a long bone on the outside of the leg. Another small bone, called the patella, or kneecap, sits on top between the two. Bones are connected to other bones by ligaments, thick fibrous bands of tissue. Muscles, which move the bones, are connected to them by tendons. The entire bone ends are lined in a smooth material called articular cartilage, which prevents the bones from rubbing against each other and allows them to glide smoothly.You may think that the knee is merely a hinge that connects the upper leg to the lower leg, but it is far more than that. The knee is actually an exquisitely designed machine. With every step you take, your knee is providing both stability and mobility. Your knee is designed to allow for a full range of motion— it moves from front to back, side to side, and up and down. It enables you to walk on a level surface, run up stairs, pivot, twist, and turn. You can kick your leg forward or fling it backward. You can stand, dance, swim, ski, or bicycle, thanks to your knees.Your knees work very hard. The average person takes between 12,000 and 15,000 steps per day. With each step, your knees sustain a force of anywhere between two and seven times your body weight, depending on what you’re doing. If you spend your day walking on carpet, the forces exerted through the knee are lower than if you’re walking on hard pavement. If you jog or run, walk up stairs, or use a stair machine, the forces exerted through your knee can exceed 2,000 pounds! Over time, if your knee is continually bombarded and overworked, it will begin to “complain.”I don’t mean to suggest that knee injuries are inevitable— far from it. One of the reasons I am writing this book is to show how many knee injuries can be prevented, and a good portion of this book is devoted to prevention. A good muscle-strengthening program is the best defense against knee injuries, I show you exactly what you need to do to protect against knee injuries. In addition, many people inadvertently do things that put their knees in jeopardy. Throughout this article, I offer advice on how to avoid activities that are true “knee killers.” This article is also designed to help people whose knees are already “killing” them and are in the midst of considering their treatment options.I am also writing this article because I feel that today, more than at any other time in our modern history, patients need to be fully informed. The cost-cutting environment in which medicine is being practiced is, in my opinion, detrimental to patient care. Physicians are often rushed and burdened with paperwork. Many insurance companies are so zealous to cut costs that they are actually discouraging patients from seeking appropriate care and refuse to pay for it when they do. Many patients in health maintenance organizations are finding it increasingly difficult to see a specialist of any kind, and knee surgeons are no exception.As good as a general practitioner or internist may be, he or she cannot have the breadth of knowledge required to treat knee problems. The typical generalist has had at most a three-week rotation in all of orthopedic medicine as part of his or her medical training. The practice of orthopedics today, however, is highly technical and highly specialized. A physician who is not performing knee surgery and who is not up on the current literature is not going to be adept at making a diagnosis or designing a treatment plan. More and more, it is incumbent upon patients to arm themselves with the right information so that they can advocate for themselves. If present trends continue, only the most-educated, aggressive patients will be able to navigate through the health care system and get the care they need. In recent years, there have been spectacular changes in the practice of orthopedic medicine that have revolutionized the diagnosis and treatment of knee problems. Knee surgery no longer means weeks or months of immobilization and a lengthy recovery period. More and more, surgery is being performed on an outpatient basis, and most people can walk out of the hospital with nothing more than an Ace bandage on their knee. A procedure called arthroscopy makes it possible for surgeons to perform intricate surgery through an incision about the size of a buttonhole. In many cases, a patient may come in for surgery in the morning, be up and around by afternoon, and go back to work the next day. A remarkable prosthesis—the total knee replacement—enables people who were once crippled with arthritis to enjoy pain-free mobility. Today, hundreds of thousands of Americans have total knee replacements, and many are not only walking, but are playing doubles tennis and even engaging in other sports.In addition, there have been advancements made in the nonsurgical treatment of knee problems that are equally impressive, notably in the field of exercise rehabilitation. Under the direction of Robert Gotlin, D.O., the rehabilitation center at the Beth Israel Hospital, North Division, has made enormous strides in the treatment of knee problems. With the right exercise program, knee patients are able to regain motion and strength faster than ever before. With Dr. Gotlin’s help, I have included several rehabilitation programs for common knee problems in this book.I have found that very often patients worry needlessly about the wrong things and ignore the really important ones. For example, patients are often very preoccupied with knee noise; they think that every creaking and cracking sound is an indication of a serious problem. It is not—noise without pain and swelling is not significant. But I can’t tell you how many patients are certain that they have a “bum knee” because they hear these sounds. Pain is another symptom that is often misunderstood. People usually assume that pain is a sign of a serious problem. Paradoxically, when it comes to the knee, there is often no correlation between pain and degree of injury. A relatively healthy knee can hurt constantly, and yet a seriously “sick” knee may cause very little discomfort. Although this concept is difficult for patients to grasp (especially if they are the ones feeling the pain), once they become acquainted with the unique anatomy of the knee, which I explain in the next chapter, they will understand why pain is not the best way to diagnose a knee problem. They will also learn how to better manage their pain and, hopefully, reduce their discomfort to a minimum.This book is not intended to replace your physician. Rather, the goal of this book is to help you work better with your physician. A knowledgeable patient will ask the right questions and will have realistic expectations about what to expect from each potential treatment. In the end, a well-informed patient will be able to make the right treatment choices and will be better prepared to work with his or her physician in a constructive way.*1\185\2*

The physician’s diagnosis of seizures or epilepsy is made only by reviewing the history of the episode or by seeing an episode. There is no test for epilepsy.Certain tests, such as the electroencephalogram (EEG) or video-monitoring can be very helpful in determining the type of seizure and in assisting the physician to decide the type of medication to use. Scans of the brain, such as the CT scan or the MRI, can, at times, be useful in localizing an abnormality that may be causing the seizures. Since most children with epilepsy will have these tests on one or more occasions, it is helpful for you as a parent to understand their utility and their limitations. First, the most common of such tests, the EEG.We know that the firing of neurons in the brain is carefully modulated by the balance of excitation and inhibition of cells, and that groups of cells work together, interacting by exciting or inhibiting one another. The EEG (electroencephalogram) measures the electricity given off by the brain cells as they interact. The tiny amounts of electricity generated by the brain cells detected on the scalp, if amplified many hundreds of times, can be transformed by the EEG machine and recorded by pens on sheets of graph paper.In most children without epilepsy, EEG recordings resemble wiggly lines, the tiny waves varying slightly in height. In most people with epilepsy, abnormalities can be seen on the EEG. These are little bursts of electrical activity, called “sharp waves” or “spikes,” that interrupt normal rhythm. These bursts are the result of the electrical discharge of a somewhat larger population of cells all firing simultaneously, actually small, micro-electrical seizures within very tiny areas of the brain. They are not clinically detectable seizures because the spikes and sharp waves do not represent enough cells firing simultaneously to “alter the function or behavior” of the person.If your child already has had a seizure, he probably has also had an EEG. It doesn’t hurt and it shouldn’t, therefore, be frightening. If your child has not had an EEG, he should be told what to expect. The explanation should, of course, be tailored to the child’s age and level of understanding. Going to a strange place is frightening, so is separation from parents. And having “gook” put in your hair and wires on your head can be alarming. If the child knows exactly what will happen and why, he will be reassured, even intrigued, by the procedure. So will you.The EEG technician who performs the test usually has had special training in working with children. He or she will explain that because the wires are to be put in special places the child’s head will be measured. The wires will be stuck to the scalp either with a form of clay or paste or with collodion, a mixture that smells and acts like airplane glue. This procedure often will be done with the young child sitting in the mother’s lap or, with the older child or adult, sitting in a chair or lying on a padded table. There is no pain or discomfort. Many children report that the worst part of the test is getting the “junk” out of their hair afterward!*75\208\8*

Even when completely at rest, the body needs a certain amount of energy. The amount of energy your body uses at complete rest is known as your basal metabolic rate (BMR). About 60 to 70 percent of all the calories you consume on a given day go to support your basal metabolism: heartbeat, breathing, maintaining body temperature, and so on. So if you are consuming about 2,000 calories per day, between 1,200 and 1,400 of those calories are burned without your doing any significant physical activity. But unless you exert yourself enough to burn the remaining 600 to 800 calories, you will gain weight. Your BMR can fluctuate considerably, with several factors influencing whether it slows down or speeds up. In general, the younger you are, the higher your BMR, partly because in young people cells undergo rapid subdivision, which consumes a good deal of energy. BMR is highest during infancy, puberty, and pregnancy, when bodily changes are most rapid. BMR is also influenced by body composition. Muscle tissue is highly active – even at rest – compared to fat tissue. In essence, the more lean tissue you have, the greater your BMR, and the more fat tissue you have, the lower your BMR. Men have a higher BMR than women do, at least partly because of their greater tendency toward lean tissue.
Age is another factor that may greatly affect BMR. After the age of 30, BMR slows down by about 1 to 2 percent a year. Therefore, people over 30 commonly find that they must work harder to burn off an extra helping of ice cream than they did when in their teens. “Middle-aged spread,” a reference to the tendency to put on weight after the age of 30, is partly related to this change. A slower BMR, coupled with an inclination to be less active and priorities (family and career) that come before fitness and weight, puts the weight of many middle-aged people in jeopardy.
In addition, the body has a number of self-protective mechanisms that signal BMR to speed up or slow down. For example, when you have a fever, the energy needs of your cells increase, and this increased activity generates heat and speeds up your BMR. In starvation situations, the body tries to protect itself by slowing down BMR to conserve precious energy. Thus, when people repeatedly resort to extreme diets, it is believed that their bodies “reset” their BMRs at lower rates. Yo-yo diets, in which people repeatedly gain weight and then starve themselves to lose the weight, lowering their BMR in the process, are doomed to failure. When they begin to eat again after the weight loss, they have a BMR that is set lower, making it almost certain that they will regain the weight they just lost. After repeated cycles of such dieting and regaining weight, these people find it increasingly hard to lose weight and increasingly easy to regain it, so they become heavier and heavier.
According to a recent study by Kelly Brownell of Yale University, middle-aged men who maintained a steady weight (even if they were overweight) had a lower risk of heart attack at than men whose weight cycled up and down in a yo-yo pattern. Brownell found that smaller, well-maintained weight losses are more beneficial for reducing cardiovascular risk than larger, poorly maintained weight losses.
In addition, new research supports the theory that by increasing your muscle mass, you will increase your metabolism and burn more calories each time you exercise.
*14/277/5*

You should test your blood or urine whenever you are worried about your diabetes. Do not sit there worrying. Find out what is happening to your blood glucose so that you can do something about it. Experiment by testing after an unusual day, a different meal, a family upset, or a new hobby. See how your moods, your work, your meals and your activities affect your diabetes. Write the results of your tests down so that you can refer back to them. Many manufacturers provide free diaries in which to do this.
When we study diabetics in research projects we may make a twenty-four hour glucose profile. This means that we take a tiny sample of blood every hour from a little plastic tube in a vein and plot the blood glucose level on a graph. A glucose profile is shown in the diagram. Notice the peaks after every meal and the low levels at night.
Blood testing every hour is not necessary in day-to-day life and would give you very sore fingers! Most people test the glucose in their blood or urine before each main meal – before breakfast, before lunch, before the evening meal – and also before going to bed. If you test after meals you will have higher results but these should still, ideally, be below 8 mmol/1 or 140 mg/dl. Some people test only once a day, but at a different time each day – before breakfast on Monday, before lunch on Tuesday, before the evening meal on Wednesday and so on. It is important to build up a picture of what is happening throughout the day. Discuss the timing of your tests with your doctor.

I thought the idea was to make life easier!    It is. You will soon become skilled at testing your blood or urine and it will only take a few minutes. The time spent and the momentary discomfort of finger pricks is well repaid by the peace of mind you gain from knowing what is going on. Why keep yourself in the dark?

Finding out what is happening
•       The first step in taking command of your diabetes is to learn how to measure your blood glucose level and to continue to keep a close eye on it.
•       The most direct way of doing this is to do finger prick blood glucose tests.
•        Urine tests can also be helpful, provided you understand their limitations.
•       When you have found out what is happening to your blood glucose level you can use the knowledge to get the very best out of your treatment and to adjust it to suit what you want to do each day.

*10/102/5*

The incidence of tamoxifen side effects is quite small compared to most other chemotherapeutic agents used in the treatment of breast cancer. It is a comparison of apples and oranges, however. Most patients who receive chemotherapy have active or advanced disease, whereas tamoxifen is usually given to patients who are judged free of disease. Therefore, any adverse effects of tamoxifen would be considered to significantly affect the quality of a patient’s life. Most of the side effects are related to tamoxifen’s antiestrogenic activity, although the drug is known to have some estrogenic effects as well. For the most part, tamoxifen has been particularly well tolerated in clinical trials, with only a handful of patients (3 to 4 percent) having to withdraw because of acute adverse effects. Overall, the incidence of hormone-related side effects is much lower in postmenopausal patients. In premenopausal patients, tamoxifen may produce symptoms similar to menopause, with menstrual irregularities occurring in as many as 20 to 35 percent of patients.
*30\320\2*

Learning to avoid activities that increase your joint inflammation is crucial, but if you do find that you have some post-activity inflammation, try applying cold packs (or wrapped “blue ice”) to the warm joints for 20 minutes. Always wrap ice in towels before placing it next to your skin.
There are several approaches to controlling inflammation. Most notably, your physician will prescribe medications for controlling inflammation. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to decrease pain and inflammation over a period of days. Other medications that are intended to induce more sustained improvement (DMARDs) may help pain, but they work over weeks to months by inducing control of the rheumatoid process.
Narcotics mask pain without changing the underlying condition, and so your physician may be reluctant to prescribe large amounts of these medications for you. This is not because he or she is heartless; rather, totally masking pain would not be in your joints’ best interests. Remember, pain can provide a valuable message; if you don’t feel pain, you will not receive your body’s warning signal, and you may overexert yourself and cause serious damage to your joints.
Another reason your physician will want to avoid having you use narcotics on a long-term basis is the addictive potential of these medications. If you develop a physical requirement for these medications, you may find that you have relinquished control over your body and given it to the prescribing physician. This places you in the uncomfortable position of having to convince your doctor that you are in severe pain so that he or she will continue to prescribe narcotics for you.
If you can use your mind’s capacity to control pain, you will be in charge.
*45/209/5*

Some people have great difficulty in stopping in the early days of going to NA or AA. They should not despair. If they talk frankly about it to the recovering addicts, they will probably find somebody else who had the same problem – and yet who is now clean and well.
The most important thing is not to lie about your using or drinking. If you lie to other recovering addicts and alcoholics, you cut yourself off from the help you need. If you can be honest about the fact that you are still using or drinking, then you will find great kindness and help from NA and AA members. Some of them had the same difficulty in stopping.
People who find they cannot seem to stop, despite going to NA and AA meetings, should consider whether going into a specialist clinic or hospital might help them. Sometimes a few weeks away helps stop the habit of using or breaks the continued drinking. Ask recovering people which clinics or hospitals helped them.
But many people who have difficulty in stopping are not really doing what is suggested. They are not going to enough meetings, or they are not using the phone to make contact between meetings. They are simply not putting into practice what recovering addicts suggest.
Remember, if you are not actually using drugs or drinking this very minute, then you have stopped. All you have to do is not to start again.
Your twenty-four hours can start from now. All you have to do is to concentrate your efforts on not taking the next pill, drink, fix or smoke – just for today.

*90\116\2*

How to stop-If you are addicted to barbiturates, stopping abruptly is extremely dangerous. You must have medical supervision. Most doctors know about barbiturate dependence, and will help you stop.
Withdrawal symptoms-If the pills are withdrawn too rapidly, withdrawal symptoms from barbiturates can include delirium, hallucinations and fits. That is why withdrawing from barbiturates must be done under medical supervision. Other symptoms include restlessness, cramps, sickness and vomiting, shaking, insomnia and a feeling of great weakness.
Advice-Consult your doctor or find a clinic that can help you withdraw safely from these drugs.
Get to as many Narcotics Anonymous and Alcoholics Anonymous meetings as possible. After withdrawal, make sure you do not substitute benzodiazepine tranquillisers or sleeping pills for barbiturates. Stay off all drugs and alcohol. Occasionally, doctors take the view that this does not matter, but it is folly to risk getting addicted all over again. Coming off tranquillisers is extremely painful, and it will mean having to go through withdrawal twice.

*72\116\2*

The emergence of West Nile virus in New York City in 1999 and the subsequent outbreak in Louisiana in 2002 have made encephalitis a “hot topic” and forced clinicians to reevaluate their knowledge on this subject. Encephalitis refers to an inflammation of the brain and is distinguished from meningitis by the presence of abnormalities in brain function, which may include altered mental status, motor or sensory deficits (sometimes focal but generally diffuse), or behavioral or speech disturbances. Nearly 100 different agents have been associated with encephalitis, but viral pathogens remain the most common cause.
Encephalitis resulting from viral infection manifests as two distinct disease entities:
-    Acute viral encephalitis – causes direct infection of neurons with subsequent inflammation and neuronal destruction, mainly in the gray area.
-    Post-infectious encephalomyelitis – follows a variety of primarily viral infections and is associated with inflammation and demyelination of the white matter.
Clinicians should develop a broad differential diagnosis when assessing a new patient who presents with symptoms and signs of encephalitis.
*19/348/5*

The alcoholic learns, as do others with a chronic disease, the importance of being able to identify situations, and their responses to them, that may signal a flare-up. For the alcoholic, this entails maintaining a continuing awareness of the alcoholic status, if sobriety is to continue. The alcoholic certainly will not continue to see the counselor for a lifetime as a reminder of the need to be vigilant. However, each one will need to develop other alternatives to succeed in staying sober.
“Why do I drink ” This is the recurrent theme of many active alcoholics and those beginning active treatment. In our experience, focusing on this question, even when it seems most pressing to the client, is of little value. It takes the client off the hot seat. It looks to the past and to causes “out there.” The more important question is the nitty-gritty of the present moment: “What can be done now?” If there is a time to deal with the “whys,” it comes during the continuing treatment phase. Don’t misunderstand. Long hours spent studying what went wrong, way back, are never helpful. Rather, the reason can be discerned from the present, daily-life events, on those occasions when taking a drink is most tempting. Dealing with these can provide the alcoholic with a wealth of practical information about himself for his immediate use. Dealing with the present is of vital importance. The alcoholic, who has spent his recent life in a drugged state, has had less experience than most of us (which isn’t much) in attending to the present. His automatic tendency is to analyze the past and/or worry about the future. The only part of life that he can hope to handle effectively is the present.
A client’s hope for change often must be sparked by the counselor’s belief in that possibility. Your attitudes about your clients and their potential for health exerts a powerful influence. This doesn’t mean you cannot and will not become frustrated, impatient, or angry at times. Whether therapy can proceed depends on what you do with these feelings. You can only carry them so long before the discomfort becomes unbearable. Then you will either pretend they aren’t there or unload them on the client. Either way your thinking can become “she can never change,” “this guy is hopeless,” or “she’s just not ready.” When that happens, counseling is not possible even if the people continue meeting. A better approach is to have a coworker with whom you can discuss these feelings of impotence and frustration. Doing this makes it easier to say “I know he can change, even if I can’t imagine how it will happen. Certainly, stranger things have happened in the history of the world.” At this point therapy can proceed. However, if an impasse in working with a particular client isn’t broken through, the client should be referred to a coworker.
Treatment is a process involving people. People have their ups and downs, good days, bad days. Some that you think will make it, won’t. Some that you are sure don’t have a chance will surprise you. There will be days when you will wonder why you ever got into this. On others it will seem a pretty good thing to be doing. Remembering that it is an unpredictable process may help you keep your balance.
*101\331\2*