Thrombosis Development After mRNA COVID-19 Vaccine Administration: A Case Series
Dear Doctor: New Infrared Vein Finders, Bedside Ultrasounds Make Putting In IVs Much Easier
DEAR DR. ROACH: A recent column was about a person who fainted when getting blood drawn. My problem is that no one seems to be able to put an IV into me. Any ideas? -- L.L.
ANSWER: Some people just don't have very prominent veins, and they can be hard to find. Phlebotomy nurses are the best at finding veins and getting IVs in. As an intern, I feared those few times when the phlebotomy nurse couldn't find a vein, as it usually meant putting an intravenous catheter into a central vein, which is a minor surgical procedure done at the bedside with some risks.
Now, infrared vein finders and bedside ultrasounds have made putting in IVs much easier, and the requirement for central veins is much less common.
Since I wrote that column, the most common additional suggestions I received were to take oneself to a happy place in your mind during the blood draw and to ask the phlebotomist to use your hand rather than your arm.
DEAR DR. ROACH: You recently wrote that the antihistamine Zyrtec might be helpful for interstitial cystitis (IC). A recently published review found no benefit. Would you readdress your opinion? -- D.M.
ANSWER: The review that you sent looked at the same studies I did to make its recommendation, but they came to a different conclusion. While the data are the same, I framed my answer a little differently.
The study showed that in patients with IC, the use of antihistamines helped some people -- 31% improved with an antihistamine, while 20% improved on a placebo. But the studies could not conclude with 95% confidence that the results may have been due to chance. (They were only 75% sure.) The study only included 61 people, which makes proving a benefit difficult.
It is possible that with a larger trial, the benefit would be powerful enough to reject with a high level of certainty the hypothesis that antihistamines are no better than a placebo. I should note that the same study failed to show a significant benefit of Elmiron, which had 34% of its subjects improve compared to 18% with a placebo. Elmiron costs over $1,000 a month and has a small risk of serious retinal disease with long-term use. Larger studies did confirm the benefit of Elmiron, although it was even lower than the benefit seen in the smaller study.
The review authors chose to say that there is no benefit to antihistamines, but that's not exactly true. Thirty-one percent of people benefitted, but this was not a large enough proportion to meet statistical significance. Thus, there is no statistically proven benefit, but these small trials ought to at least lead to larger studies to further elucidate whether there really is a benefit.
In the meantime, clinicians have to consider the possible benefits against the known harms of the treatment. In the case of an over-the-counter oral antihistamine, even a small possibility of benefit seems worth a try, since the potential for harm is miniscule. (Similarly, I received letters from IC sufferers who noted that probiotics and turmeric helped them. There are no strong data to support their use, but they are pretty safe and unlikely to cause harm.)
Finally, the main objective for me was not to say that antihistamines are a great treatment, but to bring awareness to a condition that many people aren't even aware they have. This is a condition that many doctors aren't comfortable diagnosing, and it also causes terrible symptoms for many patients.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.Cornell.Edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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What Is A Femoral Hernia?
Medically reviewed by Jay N. Yepuri, MD
A femoral hernia occurs when part of your intestine or abdominal tissue pushes through a weak spot in your lower abdominal wall. Small femoral hernias usually do not cause symptoms, but if the hernia is larger, you may notice a lump in your groin area near your upper thigh. You may also feel discomfort lifting heavy objects, have trouble standing up, or experience pain during physical activities. To relieve symptoms, healthcare providers recommend surgery.
It's worth noting that femoral hernias are rare, accounting for only 2% to 4% of all groin hernias. Women and people assigned female at birth (AFAB) are up to 10 times more likely to develop a femoral hernia than men and people assigned male at birth—and the risk increases with age.
Types of Femoral HerniasHealthcare providers classify femoral hernias based on the severity of the hernia. The common types of femoral hernias include:
Reducible: Occurs when it is possible to push the herniated tissue into its place within the abdominal cavity with manual pressure
Irreducible (incarcerated): Develops when herniated tissue is trapped between the upper thigh and groin, and pushing it back into the abdominal cavity is not a possibility
Strangulated: Happens when the blood supply to the herniated tissue is limited or completely cut off
Symptoms of a femoral hernia will often vary based on the size of the hernia. About one-third of people with a femoral hernia have no noticeable symptoms, especially those who develop small hernias. Moderate to large-sized femoral hernias may cause symptoms such as:
If a femoral hernia becomes incarcerated (stuck) in the femoral canal (located in the groin area near the upper thigh), you may develop symptoms such as:
Sudden and intense groin or thigh pain
Nausea or vomiting
Abdominal pain
Distended (abnormally swollen) abdomen
Inability to pass gas
Difficulty passing bowel movements
Seek immediate medical attention if you develop symptoms of an incarcerated femoral hernia. An incarcerated femoral hernia requires emergency surgery to repair and prevent complications.
CausesA femoral hernia occurs when a portion of your intestine or abdominal tissue pushes through a weak spot near the groin in the lower abdominal wall. The herniated tissue passes through an opening called the femoral ring into the femoral canal, which is a narrow, cone-shaped space through which the femoral vein and lymphatic drainage pass.
What causes a weakened spot in the abdominal wall in people with femoral hernias isn't always clear. Evidence suggests some people may be born with anatomical differences that increase the risk of a femoral hernia. In some cases, the abdominal wall may weaken over time due to factors such as:
Constipation and straining to pass bowel movements
Chronic cough
Heavy lifting
Obesity
Difficulty urinating due to an enlarged prostate
Several factors can also increase your risk of developing a femoral hernia, such as:
Sex: Women and people assigned female at birth are about 10 times more likely to develop a femoral hernia than men and people assigned male at birth, likely because the female pelvis has a wider shape.
Age: The risk of femoral hernias increases with age. Most femoral hernias occur in people assigned female at birth between the ages of 60 and 70.
Underlying health conditions: Having obesity and a history of a previous hernia increase your risk of developing a femoral hernia.
Diagnosing a femoral hernia involves a physical examination and imaging tests. During the physical exam, your healthcare provider will look for a bulge in your groin or upper thigh. They may gently palpate (touch) the area to assess for tenderness or pain. Imaging tests can also help confirm the presence of a femoral hernia. Your provider may order the following imaging scans:
Ultrasound: Uses sound waves to create images of the groin, abdomen, and pelvis, allowing healthcare providers to visualize the hernia and surrounding structures
Computed tomography (CT) scan: Utilizes X-rays to create detailed, cross-sectional images of the abdomen and groin, helping identify the hernia and its location
Magnetic resonance imaging (MRI): Involves the use of strong magnets and radio waves to create detailed pictures of the abdominal and groin area
The goals of treatment for a femoral hernia are to put the herniated tissue back in place and close and strengthen the weakened abdominal wall to prevent another hernia from developing.
Surgery is the only treatment for femoral hernias and is almost always recommended, even for reducible hernias (hernias you can manually push back into place). This is because there is a high risk of complications like strangulation (loss of blood supply) in femoral hernias compared to other hernia types.
Surgeons perform femoral hernia repair surgery in two ways: open and laparoscopic. Your healthcare provider will discuss which surgical option is best for you.
Open SurgeryAn open femoral hernia repair surgery involves a surgeon making an incision (cut) in your groin area to locate and separate the herniated tissues from the surrounding tissue and structures. The surgeon then places the herniated tissue back into the abdomen.
In some cases, some herniated tissue may require removal. The surgeon will use stitches to close the weakened abdominal muscles and may place a piece of mesh over the area to strengthen the abdominal wall and prevent hernias from recurring. They will then place stitches over the incision on your groin to help you heal.
Laparoscopic SurgeryA laparoscopic femoral hernia repair surgery is a minimally invasive procedure that involves the surgeon making several small incisions in your groin and lower abdomen. The surgeon inserts a laparoscope (a thin tube with a camera) into the groin area through one of the incisions.
Then, the surgeon will insert surgical tools into the incisions, which they use to help them place the herniated tissue back into place and place stitches and mesh on the abdominal wall to close and strengthen it. The surgeon will then remove the tools and use stitches to close the small incisions.
How to Prevent Femoral HerniaIt is not always possible to prevent a femoral hernia, but certain lifestyle habits may help lower your risk. Consider the following strategies:
Practice proper lifting techniques: Bend from your knees and keep your back straight to avoid straining your abdominal muscles when lifting heavy objects.
Prevent constipation: Stay hydrated by drinking enough water and eating plenty of fiber-rich foods (e.G., fruits, vegetables, whole grains) to prevent constipation and straining during bowel movements.
Manage a chronic cough: If you have a chronic cough, talk to a healthcare provider to address the underlying cause and prevent strain on your abdominal muscles.
If left untreated, a femoral hernia can lead to serious complications, such as:
Strangulation: Limited or blocked blood flow to the herniated tissue. Femoral hernias are at high risk of strangulation, which occurs in 15% to 20% of all cases. Strangulation is a medical emergency that requires immediate surgery to repair.
Tissue damage: Inadequate blood flow to the herniated tissue can lead to damage or necrosis (tissue death).
Intestinal obstruction: Occurs when part of the intestine bulges into the femoral canal. This prevents the passage of waste products and can make bowel movements and passing gas difficult or impossible. As a result, you may experience severe pain, vomiting, and constipation. This may sometimes require surgical removal of part of the intestine (known as a bowel resection).
A femoral hernia occurs when part of your intestine or abdominal tissue pushes through a weak spot in your lower abdominal wall. While some people with a femoral hernia may have no symptoms, others may notice a bulge in the groin or upper thigh and pain and discomfort during certain activities, such as standing up or lifting heavy objects. Women have a higher risk of developing this condition and the risk increases with age. Fortunately, surgery can help repair your abdominal wall and treat symptoms.
Frequently Asked QuestionsHow serious is a femoral hernia?
A femoral hernia can be serious if left untreated, potentially leading to complications like strangulation (loss of blood supply to the herniated tissue) and intestinal obstruction. Most femoral hernias require surgical repair to prevent complications and lower the risk of future hernias.
Can a femoral hernia heal without surgery?
No, a femoral hernia cannot heal without surgery. Surgery is the only effective treatment to repair the weakened abdominal wall and prevent the hernia from recurring.
Is it bad to walk with a femoral hernia?
Walking is generally safe with a femoral hernia, but avoiding strenuous physical activities is important. Talk to a healthcare provider for guidance on activity limitations and safe exercises with a femoral hernia and after a femoral hernia repair.
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The Race To Reinvent CPR
Greg Hayes, an emergency first responder in Chanhassen, Minn., was picking up takeout sushi when a 911 call came in: A 61-year-old had stopped breathing at home. Hayes and his team jumped in their ambulance and were soon pulling up in front of a suburban two-story house, where paramedics and other first responders were also arriving. All of them grabbed their equipment and raced through the open garage to find a man, gray and still, on the living-room floor with his wife and stepdaughter nearby.
Until that Thursday in August 2022, John Sauer's most pressing health concern had been his seasonal allergies. After a routine day — desk job in front of a computer, a three-mile walk with his wife, some yardwork — he was sitting on the couch in front of the television with his wife, Kristen Waters. But when a commercial came on, he didn't mute it as he usually did. Then, when his stepdaughter asked him a question about her car, he didn't answer — he rolled his eyes at her instead. And he kept rolling them.
Waters, a nurse, checked for his pulse. His heart had stopped beating. She told her daughter to call 911, and the two women struggled to get Sauer, who is very tall and rather bulky, onto the ground to start CPR. Waters pushed up his sweaty T-shirt to expose his chest and began briskly pushing on his breastbone. She had taught CPR classes, but she had never done it on a real person. Up and down, up and down, her fingers interlocked, hand over hand. Sauer's head bobbled limply around. Here I am doing chest compressions, she thought, and this CPR is never going to wake him up.
When Hayes arrived, he, too, didn't think there was anything that he or the medics — or even a hospital — could do to save Sauer. Not that he wouldn't give it, in his words, the "100 percent college try." But having been an emergency medical technician for more than three decades, he knew how sudden cardiac arrests usually end: Sauer would probably die.
As the clock ticked toward 30 minutes from when Sauer's heart stopped, the chance of his survival was dwindling rapidly to zero. Hayes began rehearsing in his head what he would say to Waters. He stared at a photo on the wall of Sauer white-water rafting with his family. "It was gut-wrenching," he says.
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