DEAR DOCTOR. ROACH: I am a 50 year old woman in good health who was recently diagnosed with gout. All I had was excruciating pain in my left big toe that came on in spurts and then subsided into a dull ache followed by another burst of pain. This pain was as bad as kidney stones worse than childbirth. Why is gout so painful and what can be done to minimize recurrences in the future?
Dear Reader: Gout is caused by crystals that build up in the joints and occasionally other soft tissues. The crystal is uric acid – strictly speaking, it is monosodium urate – and they look like needles under a microscope. They cause an intense inflammatory reaction with redness, swelling, pain, warmth and loss of function.
Most people with acute gout will agree that the pain is exquisite and among the most painful they have ever experienced. Any movement can cause extreme pain, and I have had many patients use a shoebox (or something similar) to protect their feet from gout pain, which is made worse even by a sheet on the big toe. This is the most common place where an acute gout attack occurs. There are many, many nerve endings in the big toe and in and around other joints where gout occurs.
Diet and medication together form the basis of treatment. Uric acid is a product of the purine metabolism. Purines are part of DNA and are found in high amounts in meat and seafood. Recent studies have shown that dietary restrictions are most beneficial in obese people with gout, and most with well-controlled gout can tolerate meat and seafood without significant risk of flare-ups. However, legumes like beans, peas or lentils reduce the risk of gout attacks. Weight loss is effective in reducing gout attacks in obese people.
Drug treatment for gout is appropriate for people with recurring (two or more per year) or disabled flares. those with uric acid deposits in the soft tissue called tophi; and those with kidney disease due to gout. Drugs such as allopurinol, which lower uric acid levels, are good for preventing gout attacks, but paradoxically, can cause or worsen an acute attack. Anti-inflammatory drugs, or colchicine, are more commonly used for acute seizures and sometimes at the beginning of preventive treatment such as allopurinol.
DEAR DOCTOR. ROACH: There is a lot of information about systolic blood pressure, but what about diastolic blood pressure? My top number is always okay, but the bottom number is regularly between 82 and 88. I have been diagnosed with diastolic dysfunction and I want more information on this bottom number, which is not mentioned as often as the top number.
Dear Reader: The left ventricle, which pumps blood to the body, has two phases: systole, when the chamber pushes blood out and the aortic valve is open, and diastole, when the aortic valve is closed and the ventricle fills again. The maximum blood pressure, represented by the top number, is systolic, while the bottom number (diastolic) is blood pressure when the left ventricle is filling. Both the systolic and diastolic numbers are important because increases in both cases increase the risk of heart disease and stroke.
However, unless the systolic number is elevated and the diastolic number averages 85, the extent of your risk is small.
Increases in diastolic blood pressure are usually a problem with the blood vessels in the body, while diastolic dysfunction indicates a decreased ability of the heart to relax, sometimes referred to as a “stiff ventricle”. Prolonged high blood pressure is a great risk for diastolic dysfunction. Diastolic dysfunction and high diastolic blood pressure do not need to be linked, but they are often.
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