Tingling & Numbness - Why Me?

In most cases, it comes on slowly, like tiny needles pushing against your skin. At first, it’s a tingle here or there, easily ignored. But over time, those imaginary needles feel as if they’re multiplying – pushing harder and longer into your skin. For a countless number of Americans, tingling in their hands and feet are part of daily life. These abnormal sensations can occur throughout the day, but for some, nighttime can be the most troublesome.

“This is not part of the normal process of aging”, says Lara Katzin, M.D., neurologist and specialist in neuromuscular disease at USF Health, “It’s not uncommon to wake up with tingling in your hand. If you cross your legs, you may also get tingling, but it should go away. That’s normal. But if you have persistent numbness or tingling in your hands, feet and toes, that should prompt you to see a doctor.”

Dr. Lara Katzin, USF Health Neurologist

Common Causes
Numbness and tingling can be symptoms of disease in the entire nervous system. The most common cause, known as peripheral neuropathy, usually occurs in people in their 50’s, 60’s or older and involves damage to the peripheral nervous system - the vast communications network that transmits information from the brain and spinal cord to every other part of the body. Symptoms can make the sensory nerves so sensitive that, in some cases, patients complain that the mere touch of bed sheets can "bother their toes.” According to the National Institute of Neurological Disorders and Stroke, more than 100 types of peripheral neuropathy have been identified, each with its own characteristic set of symptoms.

“The nerves are like insulated wires. You have the wires and the insulation around it. The axon is the part of the nerve that is similar to a wire. Myelin is the insulation”, explains the USF Health physician. “When neuropathies affect the axon, the nerves die off. It can be produced by metabolic causes, like diabetes or a vitamin B12 deficiency. It can also be caused by toxins like alcohol”, says Dr. Katzin, “We’re talking about chronic alcohol abuse, not your glass of wine every now and then.” Certain drugs used in chemo therapy, can also produce axonal neuropathies. Neuropathies which affect the myelin are usually caused by an autoimmune process in which the body’s immune system attacks itself.

“Neuromuscular medicine has undergone revolutionary changes. The flood gates of information have been opened because we have a much better understanding of the molecular basis for many diseases”, says Dr. Katzin.

Helping Doctors Help Patients
Dr. Katzin, a faculty member at the University of South Florida’s College of Medicine, teaches medical students and residents what key questions to ask patients who come in complaining of numbness and/or tingling. Among the queries: When did it start? How did it start? Did it start in your feet and slowly work its way up? Is it associated with weakness? How quickly are the symptoms progressing over time?

“I ask patients ‘What other medical problems do you have?’ so that I can see if the patient may have conditions that can be associated with neuropathies”, explains Dr. Katzin. The answers help to unravel the mystery of what’s happening in the nervous system. Diagnosing peripheral neuropathy, in particular, is often difficult. The reason: its highly variable symptoms. A thorough neurological examination is usually required for diagnosis and involves taking an extensive patient history. What Dr. Katzin teaches her residents can make a world of difference to the patient – sparing them years of pain without an accurate diagnosis and effective medications.

Fascinated by Neurology
“I guess I picked neurology because I find the nervous system so fascinating. I think it is the one field in medicine in which the patients have the most fascinating manifestations of their illnesses. I also like the fact that I can examine someone and trace back where the lesion is in the nervous system. That’s so interesting to me”, said Dr. Katzin.

The new arrival to the university’s neurology department is among the bay area specialists performing nerve conduction studies/ electromyography, better known as “EMG”. The technology is used to test the function of the peripheral nerves and muscles. By stimulating the nerves and testing their response, the doctor can determine whether the nerves are diseased and whether it is the axon or myelin that is affected. The EMG part of the exam examines the muscles by using a small needle. The electrical activity produced by the muscles are recorded by the needle and that data can be analyzed to determine whether the muscles are diseased.

Unsolved Mysteries
But in many cases of tingling and numbness a complete evaluation may not reveal the cause for the neuropathy. “It’s not that there is no cause, we just haven’t been able to figure out what it is”, admits Dr. Katzin. These cases are called idiopathic peripheral neuropathy. “This can be very frustrating for patients who want to know why this has happened to them. Even though we may not be able to identify a cause many times, we can still help our patients with medications to manage their symptoms.”

“I hope that within my generation, we will be able to identify more causes. Researchers are working hard to unravel the mystery of idiopathic peripheral neuropathy”, says Dr. Katzin.

About Dr. Lara Katzin:

• USF Health Neurology: (813) 974-4115 for appointments

Story by Lissette Campos, USF Health Communications

Afriyie Johnson MSN, ARNP-C
Instructor
University of South Florida College of Nursing

-What classes or program do you teach at USF's College of Nursing?

I teach in both the undergraduate and graduate nursing programs. I currently teach undergraduate Community Health Nursing and Community Health Nursing Clinical, I also teach graduate level Advanced Physical Assessment and Family Populations in Health Promotion. Other classes that I have taught include Undergraduate Physical Assessment, Primary Care of Young Adults and Women, Adult and Family Nurse Practitioner Practicum Seminar.

-How long have you been teaching at our nursing school?

I have taught at full time USF CON since August 1999 (8) years. I was a clinical preceptor with students from Michigan State University while working as a Family Nurse Practitioner for Ingham County Health Department for the Colleges of Human Medicine, Osteopathic Medicine and the College of Nursing for Family and Adult Nurse Practitioner students.

- What advice do you give students who may be apprehensive about traveling to distant places?

There are very few things more rewarding than facing your fears. When given the chance to see other countries and places, reflect on the fact that there are many more things that make the family of mankind alike than different. Fear usually springs forth from the unknown. Daily we are faced with the unknown so why not take the opportunity to enrich your life with the privilege of learning and growing via the opportunity of travel. Until you have seen other places you will never fully appreciate what it is to live in America. There is so much to learn and you have so much to teach, why rob yourself or others of the opportunity of sharing. My advice is to take your required shots, take the prophylaxis recommended for where you are going, find out as much as you can about the place and be open to new experiences and people. Expect the best, be prepared to be flexible, listen and follow the instructions of the native people, above all, leave your arrogance at home and be polite. Be careful to only drink safe water, dress appropriate to the climate and to the activity within culturally acceptable parameters, do not take unnecessary risks, and eat food that is identifiable, well cooked (hot) and expect the priceless experience of a great adventure.

- Where would you like to travel to for your next adventure?

I have had the privilege to travel extensively around the center of the globe: to Europe, Africa, the Middle East, Asia, Eastern Europe and continental North America. However, I have never traveled to the poles. I plan to go to Ghana and Nigeria next summer to do some faculty enrichment however I would love to go to South/Central America, the Caribbean, the South Sea Islands, and Australia and to Greenland in the future.

USF College of Nursing Instructor Afriyie Johnson, at right, in Ghana, Africa.

Over the summer, University of South Florida College of Nursing faculty member and Doctor of Nursing Practice (DNP) student, Afriyie Johnson traveled to Accra, Ghana in Africa as part of her evidence based project for her DNP degree. Her project took place at Valley View University in Oyibi, a suburb of Accra. Initially Johnson sought to develop a protocol to move diploma prepared registered nurses (RNs) to baccalaureate prepared nurses in a shorter time than current progression.

Johnson’s plans changed when she found that her visit coincided with Valley View University’s baccalaureate nursing program accreditation visit. The visit came just four days after her arrival and Johnson became very involved in the processes of assisting VVU in meeting the recommendations made by the National Accreditation Board of Ghana. Johnson felt that if there wasn’t a school of nursing in the area, there could not be a bridge program for diploma nurses to become bachelors-prepared nurses. This realization resulted in a priority shift and Johnson’s subsequent change in project focus.

During the next four weeks Johnson was instrumental in making revisions and fulfilling the recommendations of the accreditation board in order to bring Valley View University into compliance with the standards required to receive accreditation for a Bachelor of Science in Nursing program. Johnson helped prepare curriculum and accreditation documents as well as affiliation agreements for their clinical sites, one of which is in a remote mountainous location.

As part of the ongoing effort, Johnson and a few others from the United States, spearheaded by a nurse from New York and in collaboration with the head of the nursing school at Valley View University; are planning faculty development workshops for Summer 2008. The goal is to train nurses, physicians, and scientists as nursing faculty. They also plan to expose the local nurses to the expanding roles of nursing in the global market.

“Ghana is a beautiful country and the administration of Valley View University were wonderfully open, receptive and supportive of the assistance and expertise that we brought and plan to bring next Summer.” said Afriyie Johnson, a faculty member of the USF College of Nursing and also a graduate student in the Doctor of Nursing Practice (DNP) program.

Here in the United States we rely heavily on technology based education however nurses in Ghana rely on their exceptional nursing skills and educational techniques due to the lack of resources in the region. Area hospitals where students work see between five and six hundred outpatients every day, providing students a wealth of hands-on-experience in patient care.

“The nursing experience is so different and our practice realities are so different,” said Afriyie Johnson.

In Ghana, there are often long wait periods between certification and employment. Upon receiving a nursing degree and passing the certification examination nurses are placed in hospitals where there is a need, sometimes in locations far from their families. As a result, nurses in Ghana often seek employment in Europe, Canada and the United States. As in any discipline, people in search of a better lifestyle look for opportunities for better working conditions and rewards. Nurses in Ghana, are no exception.

It is Johnson’s hope that, in time, her dream of developing a bridge program for diploma nurses to become bachelors-prepared nurses in Ghana will come to fruition at Valley View University. The result would be to curb the nursing exodus that currently exists. In the mean time, VVU’s school of nursing received official accreditation two weeks after Johnson's departure and is currently educating its first cohort of students.

"This experience was very satisfying. It was a lot of work and it was not what I expected to do, but it was certainly rewarding and I hope to be involved in more such endeavors as it will hopefully further bring nursing education and care, all over the world to similar standards", said Johnson.

Photo Gallery Below:

From L to R: Mrs. Felicia Darkwah with Ms Johnson. Mrs. Darkwah is a nurse and midwife who spearheaded the nursing program at Valley View University and first approached the University with the idea of creating a Bachelors nursing program. She created the first draft of the proposed curriculum and has a long history working in Ghana to improve nursing and elevating nursing education.

Afriyie Johnson standing next to the FeyiasiHene (King of all of Feyiasi) and the Feyiasi villagers. During the mid 1960's, Ms. Johnson's own father built the structure seen in this photo. It was the village's first school and church building. The late queen mother of the village was Nana Afriyie after whom Johnson was named. The building is currently under renovation.

The whole village of Feyiasi turned out to welcome Ms Johnson back to the village where her father built the first church and school building several decades ago.

Valley View students being proctored while taking final exams in the hall above the cafeteria. This is the largest room on campus and also serves as the school's auditorium and chapel.

A Closer Look: Afriyie Johson

Story by Ashlea Hudak, USF College of Nursing
Photography by Afriyie Johnson

Carl Sagan Academy scholars play USF medical students for a day

View WUSF University Beat TV segment on Carl Sagan Academy students' hands-on lesson in medicine.

Listen to WUSF University Beat Radio broadcast.

View Fox-13 "What's Right With Tampa Bay" clip.

They touched hearts, brains and livers and shined pen lights in one another’s eyes to check reflexes. They debated the ethics of which patient should get a heart transplant, and rendered opinions about what to do for an overweight patient rushed to the emergency room with chest pain.

USF medical student Jessica Freilich, far left, discusses the brain with members of her CSA team. Back center is team co-leader H.B. White.

On Dec. 7, 68 students from Carl Sagan Academy (CSA) visited the campus of USF Health. The sixth, seventh and eighth-graders were hosted by the USF College of Medicine Class of 2010, which adopted the charter middle school last year as a community outreach project. The school is located near the University in one of the most economically depressed areas of Tampa.

The second-year medical students organized and ran the interactive health education sessions through which the CSA students rotated. The entire group started the day with a welcome from Steven Specter, PhD, associate dean for COM Student Affairs.

“You’ll have a chance today to get a first-hand glimpse of what medical students and other health professions do,” Dr. Specter said. “Our hope is that after seeing all this you may be motivated to seek a career in health. If you choose to do that, you’ll have to work very hard, but you have a wonderful opportunity to make a difference in people’s lives.”

The session creating the most buzz appeared to be the stations set up in the student pathology laboratory. There the CSA students, wearing purple gloves, could touch and hold preserved human organs -- including lungs, livers, kidneys, intestines and hearts -- as second-year medical students, teamed with pathology residents, explained the organs’ functions and pointed out the differences between healthy and diseased ones.

As a group of CSA students crowd around a table holding organs covered by sheets of white, medical student Ariel Lufkin launches into an explanation of the chambers and pumping action of the heart and what happens when blood flow is blocked. “What do you think causes the arteries to clog?” Lufkin says, pausing. “Who here has eaten fast food?” Several hands shoot up. “When we eat fast food, the cholesterol gets in the blood and is deposited in the artery wall.”

Medical student Ariel Lufkin uses a model while explaining the chambers of the heart.

He pulls the sheets off of the two hearts as students crowd around the cart holding them. “Everybody touch a heart – you have gloves on!” he says. “Oooooh, it’s hard…it’s nasty,” says one girl wrinkling her nose at the smell of formaldehyde permeating the room.

Lufkin points out the larger size of the diseased heart compared to the normal one. “This is what happens to a heart muscle when you overwork it… See that white stuff; it’s a scar from a heart attack.”

A "hands-on" look at the heart

Meanwhile, in an examination room of the Center for Advanced Clinical Learning, internal medicine chief resident Aliyah Baluch, MD, lets another group of students take turns flashing a pen light into her left eye and observe her pupil get smaller as she discusses reflexes. “As the light comes by, there’s too much light for the back of the eye, so the pupil gets smaller -- therefore not allowing so much light in,” she says. “What if it doesn’t get smaller?” one boy asks. “Then you have to do further testing,” Dr. Baluch replies, “because it means there’s something wrong with the sensors and nerves that make the pupil smaller.”

Medical students Thure Caire and Drew Carey were moderators for an ethics debate in which CSA students had to decide who gets a heart transplant.

In a Shimberg Library conference room, 14 CSA students have the chance to play doctors as they break into four groups to decide which of four “patients” will receive a heart transplant. Medical students Thure Caire and Drew Carey oversee the mock ethics debate in which each group is assigned to advocate for one patient – knowing that all badly need a heart and none will survive more than two months without a transplant. The CSA students express surprise and discomfort that they are forced to choose one patient – even if it’s just pretending. “Unfortunately, there’s just no way around it – there’s only one heart,” Caire tells them. “The dire need for a heart, whether the patient has a way to pay for the transplant and drugs they’ll need to take for the rest of their lives, their ability to recover and take good care of the heart -- these are all things you need to consider.”

CSA students engage in a spirited discussion about how to best advocate for their "patient."

Two CSA students – Nyla Davis and Jahnelle Tims – are named members of the hospital’s medical ethics board to help Caire and Carey make the decision. The board listens to each group’s arguments and assigns points to each patient case based on such variables as patient history, age, productivity, dependents and ability to pay. They decide to give the heart to Case #4 – a 28-year-old woman prisoner and former preschool teacher with heart failure caused by a virus. Serving time for white collar crime, she was the sole support for her brother with bipolar disorder. She beats out a 45-year-old father of three who has already rejected one heart, a 75-year-old grandmother caring for her four grandchildren, and a 35-year-old recovering alcoholic who is engaged and expecting his first child. Other groups who rotate through this ethics exercise make different choices.

At lunchtime, all the CSA students reconvene in a lecture hall to listen to two USF faculty members – Dr. Deanna Wathington and Dr. Jose Lezama – share their experiences as physicians. Before departing on the bus, they get another chance to role play as doctors, weighing in on patient tests and treatment, during an emergency room case presentation by Dr. Bryan Bognar, interim vice dean of medical education.

Dr. Deanna Wathington asked CSA students about the health experiences of their families.

“There are some very bright students at Carl Sagan who just need opportunities presented to them,” said Danish Ahmad, co-president of the Class of 2010. “This was an opportunity to get them excited and motivated about post-secondary education while exposing them to the health care field.”

“This day has just been amazing in so many ways for these kids,” said CSA Executive Director Kelly Browning, PhD. “It’s really helped them make the connection between the real world and why you need to learn about it.”

Kelly Browning, PhD, esecutive director of Carl Sagan Academy, with seventh-grade CSA scholar Talina Collins, who wants to be a pediatrician.

View podcast of Talina describing what it's like to touch a heart, liver and more...

Talina Collins, a CSA seventh-grade scholar who wants to be a pediatrician, said the activity she enjoyed most was handling and learning about the organs. “Wow, I could be doing all this stuff when I’m a medical student – I’m ready for college!” she said. “I think it’s good for the USF medical students to give back. They come to our school sometimes to tutor us, and we get to show them what we do. It’s good that we could come to their school so they could show us what they do.”

Forty volunteers from the USF College of Medicine's Class of 2010 hosted Carl Sagan Academy's visit to USF Health, doing everying from teaching the pathology of organs, moderating interactive sessions and preparing materials to leading the teams of students who circulated on the campus. The Executive Board who helped organize the event was Danish Ahmad and Nishit Patel, class co-presidents; and Maria Khambaty and Catherine Hough, co-community service chairs.

CSA student Antwoneisha Holmes gingerly touches a liver at first (above); but by the end of the pathology lab she's confidently showing off her gloves.

The College of Medicine Class of 2010 volunteers who hosted Carl Sagan Academy's visit to USF Health

-- Story by Anne DeLotto Baier/USF Health Communications
-- Photos by Eric Younghans/USF Health Media Center