Ask the Doctors

Dear Doctors: I get a cramp in my left calf when I run for more than 20 minutes. When I slow down, it goes away. I told my doctor about it, and she wants to do something called an ankle brachial index. What will it entail? I think it’s a heart test. What does my calf have to do with my heart?

Dear Reader: Your doctor has recommended you undergo an ankle brachial index test because she suspects the calf pain you are experiencing when you exert yourself may signal a condition called peripheral artery disease. Also known as PAD, it occurs when the arteries that deliver blood to the limbs become narrow. It can affect either the arms or the legs but occurs more often in the blood vessels in the legs.

A common cause of PAD is atherosclerosis, which is a buildup of plaque in the artery walls. Other risk factors include high blood pressure, unhealthy blood lipid values, diabetes and a history of tobacco use.

Narrowed arteries impede the flow of blood, and, thus, of oxygen and nutrients to the affected tissues. When the narrowing is minor, symptoms may not appear. But when the demand for oxygen and nutrients rises, as happens when you exercise, the decreased flow of blood can lead to the cramping pain you described. A muscle pain that eases when you slow your exertion is also something that occurs in PAD.

Diagnosis of the condition typically begins with a physical exam and a review of your medical history. It also includes the ankle brachial index test you have been asked to undergo. This is a noninvasive and painless test. It is done by measuring the blood pressure in your legs and in your arms and performing a calculation that results in a ratio. When there is narrowing of a peripheral artery that serves one of the limbs, blood pressure in that artery will be affected.

For the test itself, you will be asked to lie down on an examining table and rest for a short time. When the test begins, a specialized inflatable blood pressure cuff will be used to take the blood pressure in each arm. The cuff will also be used to measure the blood pressure in each of your ankles. The technician will also be using a hand-held ultrasound device that produces images and expands the window of time during which the pulse can be heard. When there is significant blockage to an artery, it can be necessary to measure the blood pressure in the big toe.

A calculation of .90 to .99 indicates mild PAD. Numbers lower than that suggest greater obstruction of the affected artery. Results lower than .90 can indicate a need for imaging tests, such as ultrasound or an angiogram. Minor blockage may be addressed with lifestyle changes that include diet and exercises. Medications to reduce blood clotting risk and improve blood lipid numbers may be prescribed. More severe blockages may require surgery. Your doctor will review your test results with you and, based on what they reveal, will recommend treatment.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctors: I was recently diagnosed with Paget's disease after suffering fatigue symptoms and muscle soreness in my neck, pelvic and lower-leg areas. I am sore and lethargic upon waking up in the morning. What can you tell me about Paget's, treatments and research advances?

Dear Reader: The full name of the condition you have been diagnosed with is Paget’s disease of bone. Also known as osteitis deformans, it is a chronic bone disorder. When someone has Paget’s disease, it means the process of bone remodeling, which is the cycle of bone growth, has become abnormal. The result is that over time, bones can become larger, weaker and misshapen.

To understand the condition, we should begin with bone remodeling. This is the lifelong process by which our bodies replace old or damaged bone with new bone. It not only keeps the skeletal structure strong and resilient, but it also helps maintain the optimal balance of calcium and phosphorus in the body. Specialized cells known as osteoclasts degrade the bone and facilitate the absorption of the resulting minerals, primarily calcium, into the bloodstream. Another type of specialized cells, called osteoblasts, produce a protein-rich compound known as osteoid. This, along with various growth factors, is deposited on the bone. It fills in the gaps with new bone, which renews and strengthens the skeletal structure.

In Paget’s disease, the balance between bone removal and bone building gets disrupted. Bone building begins to occur at a faster pace than bone removal. The resulting new bone is brittle, weak and sometimes causes bones to become abnormal in shape. The disorder usually affects just one or several bones, not the entire skeleton. The most common areas are the skull, legs, spine and pelvis.

Symptoms of Paget’s disease include the fatigue and discomfort you have experienced. Sometimes, changes to bone shape are visible. People living with Paget’s are more susceptible to bone fractures, kidney stones and osteoarthritis. Depending on the area affected, hearing loss and pinched spinal nerves are possible.

The causes of Paget’s disease are not yet understood. The disorder can run in families, and researchers have recently identified possible links to certain genes. Environmental factors and even viral infection are being explored as possible contributors.

The disease is more common in men than women and occurs most often after age 50. Unfortunately, there is no cure at this time. Instead, the abnormal cycle of bone growth is managed with medications. These include bisphosphonates and calcitonin, which slow bone remodeling. Pain medications may be used to ease discomfort, and surgery can become necessary to correct bone deformity.

Lifestyle changes can help, as well. Calcium and vitamin D improve bone strength, but due to the increased risk of kidney stones, it’s a good idea to get medical guidance regarding diet. Moderate exercise helps maintain a healthful weight, which eases stress on fragile bones. Weight-bearing and strengthening exercises are also important.

People living with Paget’s are at increased risk of fractures, so identify and remove any tripping hazards in the home. The disorder can affect other parts of the body, so be aware of new symptoms, and be sure to seek help when needed.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctors: I saw where a doctor wrote a book about what happened to his skin when he stopped bathing for a few years. He said our skin has a microbiome, and he wanted to learn more about it. Is that the same thing as the gut microbiome? What does taking a bath have to do with it?

Dear Reader: You’re referring to an unusual and fascinating multiyear experiment conducted by Dr. James Hamblin, a physician with a specialty in public health. A lecturer at the Yale School of Public Health, Hamblin became curious about how daily showers and baths, along with the array of skin lotions and potions people use, affect the skin microbiome. His five-year quest to learn more involved giving up the daily soap-and-hot water showers that are the standard in the United States today, and the use of all personal-care products.

Needless to say, this unusual self-experiment generated headlines. And although they suggested Hamblin abstained from all personal hygiene, that’s not exactly true. Hamblin writes that he continued to regularly wash his hands with soap to protect against viral and bacterial pathogens, and he followed basic hygiene practices by rinsing off with water. He admits a certain amount of body odor was involved, but says it wasn’t too off-putting. He also writes about beneficial changes to his skin that resulted from these new bathing practices. He said his skin became more supple and less oily, and that he experienced fewer flares of eczema, a form of chronic skin inflammation.

At the crux of all this, as you point out, is the human skin microbiome. That is the collection of bacteria, viruses, fungi and microscopic creatures living on the exterior surface of our bodies. Research shows they contribute to the health of our skin and our bodies. And, yes, this is the same basic principle involved in the gut microbiome.

It turns out that each person hosts a unique array of skin microbes, and that these core colonies are formed by the time we are toddlers. They feed on oils and other secretions emitted by the skin and the dead skin cells that slough off as new skin is formed. The skin is a tough environment. It’s not surprising that the soaps, chemicals and abrasives routinely used in bathing can have a direct and immediate effect on the skin microbiome, and perhaps have an adverse effect on its natural balance.

A daily bath or shower has become a given in our culture. For many people, it is the standard of proper hygiene. But historians tell us daily bathing became possible, and then increasingly common, with the advent of modern plumbing at the turn of the 20th century.

While it isn’t necessary to go to the no-showers extreme that Hamblin did, you can make small adjustments to help preserve your skin microbiome. Don’t over-wash, which removes oils needed to feed your microbe friends. The overuse of abrasives can literally strip beneficial microbial colonies from the skin. You can also protect your skin from within by eating a balanced diet, staying hydrated and getting regular exercise.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)