Keith W Roach, MD

11/14/2025

Dear Dr. Roach: What is known about Parsonage-Turner syndrome? One of my brothers has severe shoulder pain. He had an MRI done and was told that it may be Parsonage-Turner syndrome. Can this be related to COVID? He has been recommended to a neurologist, but they probably won't be able to help. He decided to do acupuncture and will be scheduling an appointment soon.

— L.A.

Dear L.A.: The nerve roots that come off the spinal cord in the lower neck and upper chest come together in the lower neck and the axilla (armpit) to form a complex neurological structure called the brachial plexus. Neuralgic amyotrophy — also called Parsonage-Turner syndrome, paralytic brachial neuritis, and other names — is an inflammation of the brachial plexus.

The classic symptom of neuralgic amyotrophy is the sudden onset of severe pain in the shoulder and outer upper arm. The pain can be excruciating and later associated with weakness, with a prominent "winged" scapula (shoulder blade) that is frequently present. An MRI does not make the diagnosis of neuralgic amyotrophy, but it is recommended to be sure that there isn't something else (like a tumor) causing damage to the brachial plexus. The diagnosis is supported by needle electromyography (EMG).

There are case reports of COVID-19 infections triggering neuralgic amyotrophy. Like so many conditions, it appears that there may be an autoimmune component, which can be triggered by an infection. Other infections, such as Lyme disease, can cause a similar-appearing syndrome of brachial plexus damage and should also be considered.

As you suggest, there isn't any specific treatment for neuralgic amyotrophy. Physical therapy will help people maintain or recover function, but it doesn't make the underlying problem get better any faster. The pain tends to get better over weeks, but the weakness can last for up to three years.

I found a single case report of a person with neuralgic amyotrophy who got better with acupuncture.

He decided to do acupuncture and will be scheduling an appointment soon.

11/14/2025

Dear Dr. Roach: I am 78 years old and 5 feet tall, and I weigh 90 pounds. My overall look is fine. However, in the past year, I have developed a huge stomach. My clothes are tight around the waist, and I'm very uncomfortable in them. I'm told by my doctors that I shouldn't lose any weight, but when I happen to lose a couple of pounds, it only shows in my face.

I exercise frequently and also do a lot of gardening. Is it possible for me to lose the stomach, and if so, how would I do it? My appetite has waned somewhat, so I eat smaller portions. Am I fighting a losing battle?

— E.S.

Dear E.S.: When I hear women say that they are developing swelling or enlargement in the abdomen despite not eating more than usual, I become very concerned about ovarian cancer and other less-common abdominal problems that can show up with excess abdominal fluid. Women with this issue should have a sonogram or a CT scan to see if there is fluid in the abdomen or any mass that doesn't belong there.

I sincerely hope I am wrong, but I have seen this diagnosis missed too many times. I'd recommend asking your doctor specifically about this possibility.

If this is not the issue, then I have to tell you that I don't know of any way to choose where the weight loss happens. I have had patients, friends and family who note that when they are able to lose weight, they lose weight in places that they didn't want to.

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11/13/2025

Dear Dr. Roach: My husband was diagnosed with secondary polycythemia in 2011. His hematocrit test (HCT) was 57%. He was referred to a hematologist. The hematologist would order a phlebotomy when his HCT was high. My husband decided to go to a Veterans Affairs health care center for his care to save money.

He saw a nurse practitioner at the VA. She said the new guidelines for treating secondary polycythemia that is not genetic is to go by symptoms, not numbers. She refused to order phlebotomies unless he was having dizzy spells or headaches. His HCT was 54.3%. He never had dizziness or headaches when his HCT was high.

He returned to his hematologist, who ordered him to have phlebotomies. His blood kept clotting during the phlebotomy. Are there new guidelines to go by the symptoms and not the numbers? Can this be dangerous?

— P.G.

Dear P.G.: Primary polycythemia, also called polycythemia vera or polycythemia rubra vera, is a type of blood cancer that causes the bone marrow to make too many red blood cells. Secondary polycythemia means that it isn't a blood cancer that's causing too many red cells; instead it's some other identifiable cause. Low blood oxygen is the most common one I see by far, which can be due to lung disease, sleep apnea, or high altitudes among other less-common causes.

Secondary polycythemia can also be caused by tumors that produce the growth factor erythropoietin. There are a handful of other causes like rare genetic mutations, endocrine tumors, and abnormal blood vessels in the brain. When the cause can be identified, it is treated as much as possible. Aspirin is often recommended to reduce the risk of blood clotting.

The nurse practitioner at the VA was correct that a phlebotomy (literally bloodletting; the removal of about half a unit of blood, up to a full unit) has not been shown to help people who do not have symptoms with secondary polycythemia.

Furthermore, if the HCT (the proportion of blood that is comprised of red blood cells) goes below 55%, many people with secondary polycythemia will get the sensation of shortness of breath or fatigue. For this reason, symptoms (which can also include itching all over especially after a bath or a shower, vision changes, and feeling full too early) are the main drivers for a phlebotomy.

Since the main risk at these high levels of HCT is abnormal blood clots (in the deep veins of the legs and pelvis or the veins to the lungs, for example), aspirin is a more important intervention than bloodletting.

He was referred to a hematologist.

11/13/2025

Dear Dr. Roach: Do omega-3 fatty acids thin your blood, and can you still take them while taking one low-dose aspirin a day?

— S.S.

Dear S.S.: Omega-3 fatty acids, EPA and DHA, are taken by many people, usually to help prevent heart disease. Although these were strongly recommended a few years ago by many, the most recent data have shown that they are effective at preventing heart attack and stroke in people with existing heart disease and those who also have diabetes and elevated triglyceride levels. For people in the general population, there is no consistent, significant benefit at preventing heart disease or stroke.

Omega-3 fatty acids do inhibit the action of platelets in a similar fashion to aspirin. However, this effect is small and does not lead to increased bleeding. For people who are prescribed aspirin, foods containing high amounts of omega-3 fatty acids (such as salmon or flaxseed) are safe, and omega-3 fatty acid supplements are not likely to be dangerous.

Still, it's probably best to discuss them with your doctor in case you have additional risks that I don't know about.

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11/11/2025

Dear Dr. Roach: Recently, I underwent breast cancer surgery at my local hospital. Imagine my surprise when I found several staff members who weren't wearing masks in the operating room. Later I learned the policy is that staff do not have to mask up until the field is sterile. In your opinion, is this good disease control management? It certainly made me feel unsafe as I went under general anesthesia.

— P.T.

Dear P.T.: The surgical team wears masks in the operating room to reduce the risk of the patient getting an infection. This is only part of the routine to reduce surgical infections, which also includes careful handwashing, clean garments that are only worn in the OR, and cleaning the skin with a surgical cleanser. Together, with careful surgical technique, surgical infection rates have dropped dramatically.

Certainly, the most important time to be wearing a mask is after the skin is prepped. I did read a study that didn't show a difference in surgical infections depending on mask use in the operating room. (One exception were surgeries that involved placing an implant.) Older patients are at a higher risk when the OR staff doesn't wear masks.

These studies largely came before the pandemic. Now that COVID is here to stay, it is reasonable for staff to be wearing masks around patients all the time, at least when there is COVID activity in the community. For operations with older patients and operations that involve implants, or when COVID or other respiratory viruses are active, it is particularly important for OR staff to wear masks around patients.

https://www.detroitnews.com/story/life/advice/2025/11/11/dr-roach-operation-room-staff-puts-on-masks-only-after-field-is-sterile/87085814007/ #

It certainly made me feel unsafe as I went under general anesthesia.

11/11/2025

Dear Dr. Roach: I am a 79-year-old male with two coronary artery stents that were placed in late 2021. I am on 20 mg of atorvastatin for cholesterol control. My last lipid panel showed an LDL level of 75 mg/dL. My clinical lab indicates that the desirable range is 0-99 mg/dL.

At my last cardiology visit, my cardiologist said he would like my LDL to be under 70 mg/dL. He told me to double the atorvastatin to 40 mg. However, taking two 20-mg pills of this prescription produced terrible gastric acidity. I get the impression that my body won't tolerate it.

Since 75 mg/dL is just about in the mid-range for the lab, I think I should continue to take 20 mg of atorvastatin once in the evening. Does this seem reasonable? Should I switch to another statin?

— W.W.

Dear W.W.: In my patients with known blockages in their arteries, I try to push down their LDL levels below 70 mg/dL — and, if my patients will tolerate it, below 40 mg/dL as recommended by European guidelines. Most people can achieve this with high-dose statins. Up to 80 mg of atorvastatin is tolerated well by most people.

Stomach acid is not a common side effect of statin use; in fact, some studies have shown that statins improve reflux symptoms. However, if you aren't tolerating it, there are at least three other options.

One is to live with your LDL at 75 mg/dL as it's pretty close to 70 mg/dL, like you suggest. Alternatively, you could try another statin. Rosuvastatin is even more potent than atorvastatin and is often tolerated well even in people who have side effects with atorvastatin.

Finally, you could try a second agent in addition to your 20 mg of atorvastatin, such as ezetimibe, which works in a different way from statins and is likely to bring your cholesterol down into the goal of less than 70 mg/dL. A PCSK9 inhibitor (such as alirocumab) would very likely get you below 40 mg/dL in combination with atorvastatin. Both of these medicines have different side effects from statins.A lower LDL means less risk of a heart attack.

11/10/2025

DEAR DR. ROACH: I am a 79-year-old female who is currently on biannual infusions for osteoporosis and high cholesterol. In 2018, I was diagnosed with Lynch syndrome with an MSH6 deviation. The genetic testing was done after I had breast cancer, endometrial cancer, and a colectomy for three years in a row. Yearly colonoscopies have been included in my preventive care.

In 2022, during my colonoscopy, I experienced excessive vagal tone and needed atropine to restore my heart beat. Since this time, I have been given Robinul prior to the procedure, which has prevented another incident of bradycardia. My gastroenterologist isn’t recommending any more colonoscopies due to this cardiac issue and my age.

I have always been told that colonoscopies are necessary to prevent cancerous polyps from occurring. Is the risk of a colonoscopy under these circumstances greater than the risk of my getting colon cancer due to Lynch syndrome? -- F.M.

ANSWER: People with Lynch syndrome are at an increased risk for a variety of cancers, especially of the colon but also other parts of the gastrointestinal tract (stomach, small intestine, pancreas and bile duct). People with Lynch syndrome are also at an increased risk for endometrial and ovarian cancer (in women), prostate cancer (in men), and others including skin and brain cancer. Gastroenterologists know that cancer of the colon can arise without a polyp.

For people with Lynch syndrome, a genetic analysis is recommended. The exact gene may help determine the optimal beginning time and frequency of a colonoscopy. The decision of when to discontinue screening via a colonoscopy is not agreed upon by experts, but clearly when the risk of performing a colonoscopy is greater than the expected benefit, it’s time to stop. This is less about reaching a certain age than it is about underlying medical conditions.

You have a slow heart rate during sedation for the colonoscopy, and it sounds as though your doctors have found a way to do the colonoscopy safely. Your lifetime risk of colon cancer, given your MSH carrier status, is estimated to be 20%, but at age 79, you have outlived much of your risk. Most cases of colon cancer in Lynch syndrome occur before age 80.

In my opinion, both the risks of a colonoscopy and the risk of developing colon cancer are low, which means that it is difficult to make a recommendation as to which way you should go. Stopping is reasonable, but if you feel strongly that you want to continue, this is also reasonable.

Should someone with Lynch syndrome avoid colonoscopies?

11/10/2025

DEAR DR. ROACH: I am an 80-year-old female who had shingles 30 years ago for six weeks. It subsequently came back permanently (herpetic neuralgia). I take 2,500 mg of gabapentin daily, which mostly controls the pain but does not help the tingling and numbness in the soles of my feet. Do you have any suggestions? -- P.S.V.

ANSWER: I am sorry that you had this complication, which is one of the most known painful conditions. Gabapentin is an effective treatment for many people with painful neuropathies of any kind. A dose of 2,500 mg is very high but is often needed to get control of the pain; however, many people cannot tolerate this dose due to the fatigue and sleepiness that it often causes.

In my experience, some people can get pain relief from gabapentin without getting relief from the numbness and tingling. It is possible that even higher doses might help (the maximum dose is 3,600 mg), but before trying this, your doctor might consider a second type of treatment for neuropathy, such as a tricyclic agent or an SNRI.

These drugs were developed for depression but can be used for neuropathy symptoms. Sometimes, multiple medicines allow for better symptom relief with less side effects than very high doses of just one medicine.

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11/06/2025

Dear Dr. Roach: I have hereditary hemochromatosis (HH) and atrial fibrillation. My AFib burden seems to vary with my iron levels. My AFib went from 58% to less than 2% in two weeks after I had a phlebotomy recently. I can't find anyone else who has had this experience. Am I the only one?

My last ferritin test from a few weeks ago was 96 ng/mL. About the same time, I stopped using my combined COPD inhaler because of side effects.

— P.M.

Dear P.M.: HH is a disease of iron absorption where the body cannot regulate how much iron it takes in. Normally, the body stops absorbing iron if it doesn't need it, but with HH, the body absorbs as much as possible all the time. The body has no normal way to get rid of iron, except when menstruating women lose some iron every month, but this isn't always enough to counteract the amount they get from their diets.

The resulting iron buildup after decades can cause damage to many tissues, including the heart. This can increase the rate of many kinds of arrythmias, not just AFib, and about 11% of people with HH will have an arrythmia.

Removing iron via phlebotomy (literally bloodletting; a person usually donates the equivalent of a unit of blood as often as necessary to get the iron level into the low-normal range, about where yours is) prevents most organ damage from iron overload. However, it doesn't do so quickly, and I don't think your recent phlebotomy was the cause of the sudden drop in your AFib.

Rather, I think it was the inhaler. One of the components of a combination inhaler is a beta agonist, such as albuterol (or a similar but longer-acting drug). These open up the airways, but they also tend to make the heart beat faster. They also predispose people to rhythm disturbances such as AFib. AFib in some people is permanent, but it comes and goes in other people. AFib is highly irregular and can be fast-paced or normal (and rarely slow).

Many people with AFib have an underlying risk, such as a genetic predisposition. When combined with damage to the conduction system by iron deposition in the heart, or by a medication that can induce AFib in susceptible people (or both), then AFib becomes much more likely.

In your case, I think the inhaler made AFib much more likely. Not everyone with AFib needs to stop using their inhalers (never do so without talking to your doctor), but some people are very sensitive to inhaled beta agonists that trigger AFib.

My AFib burden seems to vary with my iron levels.

11/06/2025

DEAR DR. ROACH: Is it possible to overdose on vitamin D through sun exposure? -- S.C.

ANSWER: Vitamin D toxicity is a very real thing, and it’s reasonable to be concerned about it. Since the skin can make large amounts of vitamin D, I understand why you are asking this question.

Fortunately, numerous studies have shown that even in people with very high amounts of sun exposure, the blood levels stay well below the toxic level. The body is smart and has mechanisms not to poison itself. (Hereditary hemochromatosis is one of the few examples where the body can poison itself by letting the gut absorb too much iron, as this is a failure of the regulatory system.)

Vitamin D toxicity almost only ever occurs in people who are taking high doses of supplemental vitamin D.

Sun damage to the skin is a much bigger concern than vitamin D with prolonged sun exposure.

How much sun would be "too much" sun?

11/05/2025

DEAR DR ROACH: I’m a 67-year-old male who recently had a calcium score test, and my results came in at 513. Needless to say, I was quite shocked at the results. I have always been an active individual and am not overweight. I have never had high cholesterol nor high blood pressure. I am, however, a diabetic.

I have an appointment with a cardiologist in the near future. I also understand that one cannot lower the score. Is there a possibility that these numbers could have been skewed or interpreted wrongly? Do you recommend a repeat test? Could you give some insight on this test? -- S.C.

ANSWER: A coronary calcium score uses a very fast CT scanner to take pictures of the blood vessels that supply the heart muscle with blood. There really isn’t room for misinterpretation, and unless they scanned someone else they thought was you, there isn’t room for error.

Many people who get a heart attack do not have traditional risk factors such as high cholesterol or high blood pressure. Unfortunately, diabetes is a risk factor, but the better the control of the diabetes, the less likely a person will develop complications.

A high calcium score is not a guarantee that you have or will get blockages in the heart arteries, but it does make blockages more likely. Using a decision analysis tool like the MESA calculator (MESA-NHLBI.org/researchers/tools/mesa-score-risk-calculator) can help you and your doctor decide whether a medication is worthwhile to reduce your risk of a heart attack or stroke.

I want to emphasize that medicines like statin drugs can still reduce the risk of a heart attack in people with normal cholesterol and blood pressure levels.

https://www.oregonlive.com/advice/2025/11/dear-doctor-how-accurate-is-a-coronary-calcium-score.html

An accurate estimate of 10-year CHD risk (MI, cardiac arrest, confirmed angina requiring revascularization, CHD death) can be obtained using traditional risk factors and coronary artery calcium (CAC). The MESA CHD Risk Score, which enables calculation of risk both before and after inclusion of an in...

11/05/2025

DEAR DR. ROACH: I am a 56-year-old male in relatively good health. Over the past few years, I’ve developed difficulty sleeping. I’ve tried all the tips, but nothing really helped until I tried legally available THC drinks. I sleep great after consuming one of these beverages with zero side effects. My question is: Are these drinks safe for long-term use, or should I be limiting my intake? -- Anon.

ANSWER: I really can’t answer the long-term safety of THC when used for sleep. There just aren’t reliable long-term data for me to answer with any certainty. There are data for long-term heavy users of recreational cannabis, and in them, the rate of psychiatric diagnoses (psychosis and cognitive impairment) is increased.

Long-term heavy users can also get cannabis use disorder, where people use cannabis more than the intended dosage, and it adversely affects various aspects of their life. Cannabis use disorder is similar in some ways to opioid use disorder and alcohol use disorder. I think that both serious psychiatric illness and cannabis use disorder are unlikely when taking a single dose at bedtime, especially one with a relatively small dose of THC.

Since you haven’t had side effects yet, it seems unlikely that you will develop them, but it depends on the dose. Some THC drinks contain 2-5 mg of THC, while others contain much more, as high as 100-200 mg. I would advise using the lowest dose that helps you sleep. I would also consider using THC every other day if you are concerned about dependence on THC.

Some cannabis products contain both THC and CBD. CBD has been found to lower anxiety. If what you are using now has CBD, consider changing to CBD only or a lower dose of THC to find the lowest effective dose. Be sure you know what you are getting; a third-party analysis is ideal.