Dear Dr. Garner,

I am very worried that I have Parkinson’s disease. My hands are shaking all the time, and it’s getting me more and more nervous. My aunt had Parkinson’s disease and ended up in a nursing home.
I went to the doctor, and he told me I have something called essential tremor. Is there a way to tell the difference between essential tremor and Parkinson’s disease for sure?

Parkinson Phobic Prospect Park West

Dear Parkinson Phobic,
Shaking of the hands is a well known part of Parkinson’s disease. There are, however, many other causes for shaking of the hands. Some include reactions to medication, low blood sugar, excessive alcohol consumption, an overactive thyroid, stress, anxiety, fatigue and too much coffee or tea. It is the type of tremor, and the associated medical conditions, that classifies the underlying disease.
Your doctor has made a diagnosis of essential tremor. This is based upon your history and physical exam. There are marked differences between Parkinson’s disease and the condition with which you have been diagnosed.

Pronounced During Simple Tasks
In essential tremor, the shaking of the hands is most pronounced when one attempts to do simple tasks, such as drinking a glass of water, tying shoelaces, shaving or writing. Essential tremor can cause alterations of the voice and shaking of the head. In essential tremor, shaking usually occurs in the hands with either one or both hands affected. The head can develop tremors in either the “yes, yes” or “no, no” position.
In Parkinson’s disease, the key symptom is shaking of the hands, which is worse when the patient is at rest, and tends to disappear when the patient does a task such as drinking or holding other objects. Parkinson’s disease often starts with a back and forth rubbing of the thumb and forefinger. A person’s posture becomes stooped, and balance is difficult. There is a slowing or freezing of movement in Parkinson’s disease, and the face shows little or no expression. Speech becomes soft and mumbling.
About half of essential tremor cases are due to genetic mutation, which is inherited. It is often seen in family members. If you have one parent who has a gene mutation for essential tremor, then you have a 50 percent chance of developing the disorder. Parkinson’s disease has a much lower prevalence of inheritance.
The exact cause of Parkinson’s disease is unknown, but there is some genetic mutation associated with it. In addition, environmental triggers, such as exposure to toxins (pesticides and other herbicides) or certain viruses, may trigger Parkinson’s signs and symptoms. Both illnesses are treated with medications. Both diseases affect people in their middle to older age.
For those patients who do not respond to medication, there is a treatment known as deep brain stimulation. The process involves inserting a long, thin electrical device into the portion of the brain responsible for the shakes. A wire device is connected to what looks like a pacemaker under the skin in the chest. It sends out painless electrical impulses to interrupt the abnormal signals from the brain that may be causing the tremor. While there are side effects with this treatment, it has proven to be a great benefit to many.
The take-home message regarding your condition is that essential tremor typically has a less aggressive course than Parkinson’s disease. The tremor can usually be controlled with medication and is not associated with the generalized medical problems. I hope that this discussion helps shed light regarding essential tremor and its comparison with Parkinson’s disease. The key part is to see your doctor so that symptoms can be kept to a minimum and the progression slowed.
Until next week, be well.

Dr. Steven Garner is a Fidelis Care provider who is affiliated with New York Methodist Hospital, Park Slope. He also hosts “Ask the Doctor” on NET, Tuesdays at 8 p.m. on Ch. 97 Time Warner and Ch. 30 Cablevision.

by Dr. Steven Garner, M.D.

Dear Dr. Garner

My husband and I are totally confused with the changes in when to get mammograms and PSAs. We have been diligent about the tests, but now hear they’re no longer recommended. 

What is your opinion?

Confused Couple
In Canarsie

Dear Confused,

You are not the only ones confused. Many doctors feel the same way.

The confusion is the result of two government task forces. One reviewed mammograms and the other reviewed the PSA test, which detects a chemical in the blood that may increase with prostate cancer.

Their conclusions have caused much angst in the medical community, as well as the public in general.

First let me address the PSA changes that were recommended last week.  I was just discussing them with my good friend and loyal Tablet reader, Dr. Antonio Mascatello.

The panel recommended that routine screening with the blood test for PSA, no longer be performed.   They felt that the test caused useless anxiety among men. They argued that many men have prostate cancer and never die from it, because it grows slowly.

They also noted that due to the PSA test results, men were subjected to biopsies and treatment that often left them incontinent and impotent.

I totally disagree with this recommendation. The PSA has been shown to save lives in several large studies.  The test allows a man to be proactive about his health. The key to success in having the exam is to do it in conjunction with a doctor you trust. PSA may be high in cases where there is a benign condition, such as an enlarged prostate, constipation and infections.  The result must be carefully evaluated to ensure that the patient is fully informed of options available.

It is true that prostate cancer can be aggressive, or may never cause a patient any harm. This is why many doctors merely follow the patient without doing any further tests or work-up.

I think most men would like to have an idea of the functioning of their prostate gland, rather than to be totally in the dark about possible early cancers.

Let us not kill a test which may save thousands of lives, just because there is confusion in interpreting the result. Hopefully, we will have more accurate tests as time goes by, but at the present, at least this one, non-invasive blood test is available to provide an early warning signal for men to protect against this disease. Have your husband follow up with his doctor to determine what is best for him. There is no one size fits all approach to prostate health.

As far as mammograms, there is no doubt in anyone’s mind that mammograms save lives. The government committee argued in its report that there were false results from the mammograms, which subjected a women to unnecessary biopsies and possible harmful effects.

I could not disagree more with their conclusion that women between the ages of 40-50 should not get routine yearly mammograms. Breast cancer for women in their 40s tends to be more aggressive than in older patients.  Why would we not want to discover these cancers as early as possible?

Recent studies from Sweden have shown a significant drop in deaths from breast cancer with routine screening of women in their 40s.

The American Cancer Society and the American College of Radiology continue to recommend mammograms beginning at age 40, and then yearly.  It is important to check with your doctor, as the screening should be tailored to one’s family history. If there is a strong history of breast cancer (mother or sister) then the screening may begin even earlier and may include tests such as an MRI, that not everyone will require.

The committee also recommended against self-breast exam. Again, I strongly disagree. The self-breast exam allows a woman to become familiar with her breasts and makes her a partner in the health care process. We have seen many cancers detected through self exams, which, if not performed, would have delayed diagnosis and possibly reduced chances for full recovery.

Dear Dr. Garner,

I am a healthy 65-year-old man or at least I thought so. About the only health issue anyone could accuse me of was being a little underweight.

While crossing 86th St. last week, I felt a twinge of pain in my back. It persisted for three days before I visited my doctor. He took an X-ray and said I had fractured my backbone, and that my bones looked weak on the X-ray. He has scheduled me for an additional X-ray, but he said he thinks I have osteoporosis. Isn’t that a woman’s disease.  What is going on here?

Bones Brittle and Breaking in Bensonhurst

Dear Breaking in Bensonhurst,

It is true that more cases of osteoporosis occur in women than in men. However, it is a misconception that men will never experience this disease. In fact, more than two million men in the United States have osteoporosis, and most don’t know it. After age 50, six percent of all men will experience hip fractures and five percent will have a fracture of their backbone, due to osteoporosis.

I hope that your question will serve as a wake-up call for men, so they might realize they are not immune from this terrible disease.
It is known as a “silent disease” because it progresses without symptoms until a fracture occurs. Men tend to experience the disease later in life than women, because they have larger skeletons to begin with and their bone loss starts later because they don’t have the drastic hormone drop at menopause that women do.

The cause of osteoporosis is related to the fact that bone is constantly changing. Old bone is removed and replaced by new bone. Until people reach the age of 30, more bone is made than is lost.

Men in their 50s do not experience the rapid loss of bone mass that women do in their years following menopause. By the age of 65, however, men and women lose bone mass at the same rate.

Very little new bone is made, and as a result, the bones become fragile and are likely to fracture. The most common areas to fracture are the hip, spine and wrist. Twenty percent of patients will die within a year of experiencing a hip fracture.

Fortunately, there are new medications available to treat osteoporosis.  Some are taken by mouth.

Unfortunately, those taking pills often complain of severe heartburn and other side effects and stop taking the medication. There are also injectable medications which serve as an alternative to pills.

There are some conditions/circumstances which predispose a person to develop osteoporosis, such as:
• Steroid medications for conditions such as arthritis or asthma
• Low testosterone levels
• Excess alcohol consumption
• Heavy smokers
• Chronic lung disease and asthma
• Anti-seizure medications
• Immobilization
• Certain cancers
• Thyroid disease
• Arthritis

Some people may not have any of the above, but simply experience weak bones from normal aging

The good news is that osteoporosis can be effectively treated if it is detected before significant bone loss has occurred. Your doctor will do a complete medical history, X-rays and urine and blood tests. He has probably ordered a bone density test (DEXA Scan), which is a simple way in just minutes to determine how strong one’s bones are.

While women receive this test at the time of menopause, doctors often neglect to order it for men. As a result, the diagnosis is not often made until there is a fracture or back pain.

It is very important for men to inform their doctors of any risk factors they might have. A simple way to check for undiscovered osteoporosis is to measure one’s height every six months. Any loss should alert the patient and doctor to immediately evaluate for osteoporosis.

by Dr. Steven Garner, MD

Dear Dr. Garner, 
My wife and I recently went on a trip to Hawaii.
Unfortunately, after the long flight there, I spent my vacation in the hospital with something known as deep vein thrombosis.
What is this and how I can ensure this doesn’t happen again?
Worried in Williamsburg

Dear Worried,
For those who don’t know what deep vein thrombosis is, it is merely a term for blood clots that develop in the veins. In your case, they developed in the veins of the legs.
The symptoms, which I’m sure you experienced, include leg pain, swelling of the affected leg, increased warmth of the leg, and  a red color of the skin of the leg.  This can be a very serious condition as the clots from the legs can break loose and travel to the lungs, causing a pulmonary clot or embolus, which can lead to death. It therefore becomes essential that the proper diagnosis and treatment occurs as quickly as possible.
The condition was originally known as “coach-class syndrome,” because it was felt that the cramped conditions in coach, with the bending of the legs, caused an increased likelihood of developing clots. We now know that this condition does not spare the first-class passenger either.
Flying conditions, including prolonged sitting and pressure changes, predispose people to developing clots. In addition, because of the air flow system in the plane, most people become dry and dehydrated. Alcohol consumption contributes to the dehydration. All of these factors put passengers at increased risk.
You can take simple steps to prevent this condition when you fly:
1. Stay well hydrated and avoid alcohol.
2. Never cross your legs on the plane.
3. Get up to walk at least every 30 minutes. From your seat, you can exercise by pointing your toes up and down every 30 minutes. You should feel your calf muscles contracting.
4.  Some people suggest taking an aspirin before you fly. If it is a long flight, and you don’t have a history of ulcers, I would recommend this.
Certain conditions cause people to be more likely to develop clots. These include: estrogen use; pregnancy; recent surgery; leg trauma, particularly a fracture; cancer; and a history of previous blood clots.
The diagnosis of blood clots can be done in about a minute. with a Doppler ultrasound test.
It is important to have the test done at a facility with a licensed and credentialed staff that can institute treatment if warranted.
The main treatment is a blood thinner known as heparin, which helps to prevent the likelihood that a clot from the legs will travel to the lungs. This treatment must be started as soon as possible to be effective, and to  prevent permanent damage to the veins.
If you follow the tips above, you should not have this problem again.

Dear Dr. Garner,
In recent years, some of the veins on my legs have become very visible, so much so that I’m too embarrassed to wear shorts. Do you have any suggestions?
Spider Vein Embarrassment in Sunnyside

Dear Spider Veins,
For those who don’t know what spider veins are, they are tiny blood vessels that may appear on the face, legs and ankles.  They are bluish, purple or red and often form web-like netting just below the skin’s surface. They’re more of an unattractive nuisance than an actual health problem.
Spider veins are not to be confused with varicose veins, or veins near the surface of the skin on the legs, which have become permanently distended and filled with blood. The veins have valves that usually prevent blood from flowing backwards due to gravity. When a valve malfunctions or vein wall weakens, blood collects in the vein, forcing it to bulge.
Varicose veins are bluish or purple in color and can protrude from the leg. They may cause discomfort such as swelling, throbbing, heaviness, night cramps and long-term complications, such as ulcerations or bleeding.
The main cause of both spider veins and varicose veins is heredity.  The risk of developing these leg vein problems increases for women who are pregnant. Obesity and lack of exercise, which weakens the system of leg veins, are also factors.
Once spider and varicose veins develop, there is no way for the body to cure them.
However, you can prevent varicose and spider veins from spreading by:
• Wearing sunscreen to limit spider veins on the face.
• Exercising regularly to boost leg strength and circulation.
• Controlling your weight.
• Keeping your legs uncrossed while sitting.
• Not standing or sitting for long periods of time.
• Wearing elastic support stockings and avoiding tight clothing.
• Eating a low-salt diet, rich in high-fiber food.
Sclerotherapy, otherwise known as “injection therapy,” and/or laser treatments can be used to treat spider veins in the legs. They are effective and have a high success rate. However, more abnormal veins can develop as there is no cure for weak vein valves.

Dr. Steven Garner is a Fidelis Care provider who is affiliated with New York Methodist Hospital, Park Slope. He also hosts “Ask the Doctor” on The NET, Tuesdays at 8 p.m. on Channel 97 Time Warner and Channel 30 Cablevision.

Dr. Steven Garner, MD

Dear Dr. Garner,
I really enjoy fish, particularly sushi. It’s one of my summer dinner staples since I don’t like to cook when the temperature rises.
However, I’m concerned about mercury poisoning.
What is your advice for people who love fish, but don’t want to consume too much mercury? What are some of the symptoms that might occur when someone’s mercury levels are too high?
Mercury Worries
in Midwood

Dear Mercury Worries,
The answer to your question is not black and white. Fish and shellfish are important parts of a healthy diet. They contain essential nutrients, are low in fat, and contain Omega-3 fatty acids, essential for heart health. A well- balanced diet that includes a variety of fish and shellfish, can contribute to overall well-being.
The problem is that nearly all fish and shellfish contain traces of mercury. The mercury comes from the natural environment, such as the crust of the earth, and also from industrial waste.
Quantity and Mercury Levels
The risks from mercury depend on the amount of fish and shellfish eaten and the levels of mercury in the fish. The FDA recommends that pregnant women avoid certain types of fish known to be high in mercury. These include: shark, swordfish, King mackerel and tilefish.
They also suggest eating two or three servings per week of fish and shellfish that are low in mercury. Five of the fish with the lowest levels are shrimp, canned light tuna, salmon, pollock and catfish.
A commonly eaten fish, albacore tuna has more mercury than canned light tuna. If you prefer albacore tuna, do not exceed six ounces (one average meal per week). It is important to check local advisories regarding mercury safety of fish caught by family and friends in local rivers and ocean areas. If no advice is available, then eat up to six ounces (one average meal) per week. Fish sticks and fastfood sandwiches commonly have very low levels of mercury.
Symptoms of mercury poisoning include: depression, fatigue, memory loss, confusion, the shakes, a metallic taste and hair loss.
When patients who have these symptoms stop eating fish with high levels of mercury, their symptoms resolve. While no reliable data is available in humans regarding mercury and cancer, studies in rats and mice show mercury can cause increase in several types of tumors, and has caused increased numbers of kidney tumors in male mice.
To find out your level of mercury, your blood, urine and hair samples would need to be analyzed. These tests can be ordered by your doctor and are easy to do. To present a balanced view, governmental agencies believe that as long as one does not consume excessive amounts of the fish highest in mercury then fish can be safely eaten, and its extensive health benefits can be realized.
As a matter of fact, the FDA is considering changing its policy for the majority of fish, realizing their health benefits can outweigh the risks. This new policy would increase the recommended portions of fish per week.
Be Wary When Dining Out
One story reported a couple of years ago regarding sushi was quite disturbing. Sushi from restaurants in New York City were analyzed and results showed mercury levels so high that the FDA could take legal action to remove the fish from the market. The offending sushi was tuna sushi. Mercury levels in bluefin tuna were the highest.
The response from restaurant owners varied from vowing to look for fish with lower mercury levels to not selling tuna sushi any more.
At a popular Park Slope sushi restaurant, the owner said he was aware that bluefin tuna had higher mercury concentrations and that the restaurant typically told parents with small children not to let them eat “more than one or two pieces.”
Here’s what I would suggest:
1. Avoid consuming large quantities of tuna sushi.
2. Eat two to three servings of fish each week, avoiding fish known to have high mercury levels.
3. When using tuna from a can, purchase “light tuna” as opposed to albacore tuna.
4. Pregnant women and children should discuss with their physicians the benefit of eating fish, versus getting essential nutrients from other sources.
I believe most physicians will suggest a moderate approach — not excluding fish, but encouraging eating fish low in mercury two or three times a week.
5. If you’ve been a big sushi eater, and have any symptoms mentioned, ask your physician about testing your mercury level.
Dr. Steven Garner is a Fidelis Care provider who is affiliated with New York Methodist Hospital, Park Slope. He also hosts “Ask the Doctor” on The NET, Tuesdays at 8 p.m. on Channel 97 Time Warner and Channel 30 Cablevision.