8 Triggers That Make Restless Legs Worse

• Stress and anxiety. Rachel Salas, MD, an assistant professor of neurology at the Johns Hopkins University School of Medicine in Baltimore, says that stress and anxiety are big restless legs triggers. Stress reduction techniques like deep breathing or yoga may help.
• Nicotine. If you need another reason to stop smoking, calming your restless legs is a good one. Talk with your doctor if you think you need help quitting.
• Alcohol. Many people with RLS report that drinking can lead to more restless legs symptoms. Although alcohol can help people fall asleep quickly, it interferes with the quality of sleep and can make sleep apnea worse , says Alon Avidan, MD, MPH, an associate professor of neurology and director of the Sleep Disorders Clinic at UCLA. Try omitting alcohol to see whether your restless legs improve and whether you feel more rested in the morning.
• Vigorous exercise. Getting moderate exercise during the day can help ease restlessness at night. But vigorous exercise, especially close to bedtime, can have the opposite effect in some people.
• Medications. A number of medications can make RLS worse. In particular, anti-nausea drugs and sedating antihistamines (like Benadryl) block the brain’s dopamine receptors, causing restless legs symptoms. Antidepressants that increase serotonin and antipsychotic medications can also aggravate the condition. Let your doctor know if your restless legs symptoms worsen after you take a new medication. A change in dosage or to a different medication may do the trick.
• Caffeine. Because caffeine is a stimulant, it can interfere with sleep if it’s consumed too close to bedtime. It’s long been on the list of restless legs triggers, but Dr. Salas says recent research shows it may not be that big of a problem. In fact, she says, it may be beneficial in some people. Try cutting out coffee, tea, colas, sports drinks, and even chocolate to see if your symptoms improve or worsen.

Other Restless Legs Triggers

Other health conditions can also cause restless legs. This is what’s called secondary restless legs syndrome:

• Pregnancy. According to Dr. Avidan, about 20 percent of pregnant women report restless legs symptoms. This is more likely in the last three months of pregnancy, and iron deficiency is usually the culprit. If symptoms crop up when you’re expecting, your doctor will probably test the level of iron in your blood and prescribe iron supplements if it’s too low. The good news is that your restless legs symptoms will probably go away soon after you have your baby.
• Medical conditions. Restless legs symptoms are also seen in some people with kidney failure and diabetes. Treating these conditions will often calm the restless legs.

The Restless Legs Syndrome Foundation suggests using a sleep diary to pinpoint your personal triggers and gauge the severity of your symptoms. Always tell your doctor if your symptoms get noticeably worse.

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Triggers for Restless Legs Syndrome

Lack of a good night’s rest can really take a toll on quality of life. According to the National Sleep Foundation, one in ten American adults suffers from Willis-Ekbom Disease (WED) – more commonly known as Restless Legs Syndrome (RLS). This neurologic sensorimotor disorder creates the sensation or urge of having to constantly move one’s legs, and is marked by crawling, throbbing, itching, or aching sensations in these limbs.

RLS usually occurs in the evening hours. The sensations are worse at night, when lying down, or after long periods of sitting. Relief can be temporarily achieved by simply moving around, walking, or stretching.

Many physicians believe that there are also environmental factors – things we eat, drink, and do in everyday life – that can trigger or exacerbate the symptoms of RLS. By examining our actions, we can work toward reducing the occurrence of this bothersome malady.

Medicine and Restless Legs Syndrome

It may be a hard pill to swallow, but your medications could be causing your body’s restlessness. Certain antihistamines (such as Benadryl) block the brain’s dopamine receptors, which play a vital role in controlling movements. Antidepressants are also being examined as a possible culprit. They signal the release of serotonin, which can intensify that perpetual sense of “twitching.”

It’s all about finding the right balance with your medications; if you sense that your dosage is exacerbating your RLS, speak to your physician about an adjustment. A sleep medicine doctor may prescribe something called a dopamine agonist, which activates the receptors in the brain that regulate movement.

Iron Deficiency and RLS

Are you pumping iron? Ferritin, that is? Ask your physician about testing your serum ferritin levels for abnormalities. Unlike a regular iron measurement, this test records the proteins that store iron – in other words, the body’s reserves. If this reading is low, you are considered deficient.

Whether your iron shortage is related to anemia, or pregnancy (which causes a decrease in hemoglobin levels), a dearth of this vital nutrient can be problematic.  In many cases, iron supplementation is an easy solution to this. If you’re looking to increase your iron intake naturally, incorporating dark leafy greens and red meat are a great place to start.

RLS and Everyday Habits

Hazelnut, vanilla, or regular black – no matter what your preference is when it comes to your cup of joe, the hefty serving of caffeine could be one cause of RLS you hadn’t considered. Coffee, tea, soda, and chocolate can all be problematic for those who suffer from this syndrome (especially when they’re consumed too close to bedtime).

About 30-60 minutes of exercise a day can help you stretch, burn calories, and get those endorphins pumping. Cycling, yoga, and pilates are especially beneficial for quelling RLS symptoms. However, doing any strenuous activity right before turning in for the night is a recipe for restlessness. For this reason, exercise should be avoided in the hours before going to bed.

Sleep Medicine Specialist in Charlotte

If RLS is keeping you from getting much-needed sleep, pay a visit to a sleep medicine specialist. A diplomate of the American Board of Sleep Medicine and the American Board of Medical Specialties in sleep medicine, Dr. Jeannine Gingras has made helping her patients get better rest the primary focus of her career.

Founder and Medical Director at Gingras Sleep Medicine, and an internationally renowned expert on RLS, she lends a personalized approach to medical care – and she will work with you to discover a solution. Call our office today at (704) 944-0562 or fill out our appointment request form online, and start getting a good night’s sleep – every night.

Top 11 Treatments for Restless Leg Syndrome

Contents

Restless Leg Syndrome (RLS), also known as Willis-Ekbom disease, is a condition that causes discomfort, most commonly in the legs. These sensations are described as twitches, crawling, crawling sensations, and cause a strong desire to move the affected limb.

Symptoms of RLS usually occur while the person is sitting, resting, or sleeping, and often occur at night. Movements caused by RLS are called periodic limb movements during sleep (PLMS). Because of these movements, RLS can cause serious sleep problems.

Some people have primary RLS for which the cause is unknown. Others have secondary RLS, which is usually associated with nerve problems, pregnancy, iron deficiency, or chronic kidney failure.

Most people with RLS have mild symptoms. But if your symptoms are moderate to severe, RLS can have a big impact on your life. This can prevent you from getting enough sleep and thus create problems with daily attention and thinking, work and social activities.

As a result of these problems, RLS can lead to anxiety and depression. And the longer you have the condition, the worse it can get. It may spread to other parts of the body, such as the hands (1).

Because of the impact RLS can have on your life, treatment is important. The treatments are different because the underlying cause of RLS is really unknown. For example, some researchers suggest that RLS is caused by a problem with the chemical dopamine in the brain, while others believe it is due to poor circulation.

Here are the best treatments for RLS. Some of them you can try yourself. Other people you can talk to with your doctor who can help you put together a treatment plan that will ease your RLS symptoms.

Your first step in dealing with RLS should be to find out if it’s causing something. While RLS can be related to things that are largely out of your control, such as genetics or pregnancy, there are other possible factors to consider.

These factors could be daily habits, medications you take, your health condition, or other triggers.

Habits

Use of caffeine, alcohol and tobacco may worsen PD symptoms. Limiting these substances can help you reduce RLS symptoms (2).

Medicines

Some medicines can cause or worsen RLS symptoms. Examples include: (1, 2, 3).

• older antihistamines such as diphenhydramine (Benadryl)
• pain medications such as metoclopramide (Reglan) or prochlorperazine (Compro)
• neuroleptics such as haloperidol (Haldol) or olanzapine (Zyprexa)
• lithium
• selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac ), sertraline (Zoloft) or escitalopram (Lexapro)
• tricyclic antidepressants such as amitriptyline (Elavil) or amoxapine (Asendin)
• tramadol (ultra)
• levothyroxine (Levoxil)

Be sure to tell your doctor about any medicines you are taking, whether prescription or over-the-counter. Talk to your doctor about whether they may make your RLS worse, especially if you are taking any of the medications listed above.

Health conditions

Several medical conditions have been found to be associated with RLS. End stage renal disease (ESRD) and nerve damage in diabetes are associated with RLS. Iron deficiency anemia also has a strong association with RLS (see iron below) (4, 5, 6).

You should talk to your doctor about how your medical history may affect RLS, especially if you have any of these conditions.

Other triggers

Some people claim that eating too much sugar or wearing tight clothing makes RLS symptoms worse. While there isn’t much research to support these links, you may need to do some trial and error to see what works for your own symptoms.

Good sleep habits are recommended for everyone, but perhaps especially for those who have trouble sleeping, such as those with RLS.

While sleep may not help relieve the symptoms of RLS, it can help compensate for the loss of sleep caused by your condition. Try the following tips to sleep as soundly as possible and get more rest.

• Go to bed and wake up at the same time every day.
• Keep your sleeping area cool, quiet and dark.
• Minimally reduce the attention, like televisions and telephones, to your bedroom.
• Avoid electronic displays two to three hours before bed. The blue light from these screens can disrupt your circadian rhythm, helping you maintain your natural sleep cycle (7).

3. Iron and vitamin supplements

Iron deficiency is considered one of the main causes of RLS. Several studies have shown that iron supplements can improve the symptoms of RLS.1, 3).

A simple blood test can test for iron deficiency, so if you think this might be a problem for you, talk to your doctor.

If you test positive for iron deficiency, your doctor may recommend oral iron supplements, which you can find at your local pharmacy. In some cases, intravenous (IV) iron may be required.1, 8).

In addition, vitamin D deficiency may be associated with RLS. A 2014 study found that vitamin D supplements reduced symptoms of RLS in people with RLS and vitamin D deficiencies.9).

And for people on hemodialysis, vitamin C and E supplements can help relieve symptoms of RLS (4, 10).

Exercise can help you feel better if you have RLS.

The National Institutes of Health states that moderate exercise can help relieve mild symptoms of RLS.3).

A 2006 study of 23 people with RLS found that aerobic and lower body resistance training performed three times a week for 12 weeks significantly reduced RLS symptoms.11).

Other studies have also shown that exercise is very effective in RLS, especially in people with ESRD.4, 12).

Given these studies, as well as other studies showing that being active can improve sleep, exercise seems to come naturally to people with RLS.13).

One recommendation from the Restless Legs Foundation is moderate exercise. Don’t work until you’re in pain, as this can worsen RLS symptoms (14).

Like other forms of exercise, yoga and stretching have been shown to benefit people with RLS.12).

An 8-week 2013 study of 10 women found that yoga helped reduce symptoms of RLS. It also helped improve their mood and reduce their stress levels, which in turn may have improved their sleep. And a 2012 study found that yoga improved sleep in 20 women with RLS (15, 16).

Another study found that stretching significantly improved RLS symptoms in people on hemodialysis.17).

Researchers are not entirely sure why yoga and stretching work, and more research would be helpful. But given these results, maybe you should add some hamstrings and calf to your daily routine.

Massage of the leg muscles can relieve symptoms of RLS. Many health organizations, such as the National Institutes of Health and the National Sleep Foundation, offer this treatment at home.3, 18, 19).

Although there are not many other studies that support massage as a treatment for RLS, a 2007 case study showed its benefits.

A 35-year-old woman who received a 45-minute foot massage twice a week for three weeks improved her RLS symptoms over that period. Her massages included a range of techniques, including Swedish massage and direct pressure on the leg muscles (20).

Her RLS symptoms improved after two massage sessions, and she did not return until two weeks after the end of the massage regimen (20).

The author of this study suggested that the increased release of dopamine induced by massage may be responsible for the beneficial effect. In addition, massage has been shown to improve circulation, which may be responsible for its effect on RLS (20, 21, 22).

As an added bonus, massage can help you relax, which can improve your sleep.

7. Prescription drugs

Drugs are a key treatment for moderate to severe RLS. Dopaminergic drugs are usually given first. They are effective in relieving the symptoms of RLS, but can cause side effects and other problems.1).

Other types of medications can also help relieve symptoms of RLS without causing the same problems.

Dopaminergic drugs

Dopaminergic drugs increase the release of dopamine in the brain. Dopamine is a chemical that helps the body move normally (1).

Dopaminergic drugs are likely to help relieve symptoms of RLS, as this condition is associated with problems in the body producing dopamine.

The US Food and Drug Administration (FDA) has approved three dopaminergic drugs for the treatment of moderate to severe primary RLS:

• pramipexole (Mirapex)23)
• ropinirole (Requip) (24)
• rotigotine (Neupro) (25)

Although dopaminergic drugs have been shown to help improve RLS symptoms, their long-term use may actually exacerbate symptoms. This phenomenon is called augmentation. To delay this problem, doctors usually prescribe the lowest possible dose of these drugs (1, 26).

Also, these medicines may become less effective over time. To delay or prevent both of these problems, your doctor may prescribe a combination of dopaminergic drugs with other types of medications to treat RLS (1).

Gabapentin

The fourth drug approved by the FDA for the treatment of RLS is gabapentin (Horizant). It is an antiseptic preparation (27).

It is not entirely clear how gabapentin works to relieve symptoms of RLS, but studies show it is effective (28).

In one study, 24 people with RLS were treated with gabapentin or placebo for six weeks. Patients treated with gabapentin experienced improved sleep and reduced leg mobility due to RLS, while those treated with placebo did not.28).

Another study compared gabapentin with ropinirole (one of the drugs approved by the FDA for the treatment of RLS). Eight people with RLS took each medication for four weeks, and both groups achieved similar levels of RLS symptom relief.29).

Benzodiazepines

Benzodiazepines are medicines used to treat anxiety and sleep problems. Clonazepam (Klonopin) and other types of these drugs are often prescribed for people with RLS in combination with other medications (30).

Although these medications may not relieve symptoms of RLS, their benefit in improving sleep can be very beneficial for people with RLS.30).

Opioids

Opioids are commonly used to treat pain. In some cases, usually when other drugs fail or cause an increase, opioids can be used cautiously at low doses to treat RLS (26, 8).

Long-acting oxycotone/naloxone (Targinact) is an opioid that may help relieve symptoms of RLS and improve sleep (4). However, due to recent recommendations for the use of opioids, this should be the last resort.

As with all opioids, drug use must be carefully monitored by a physician due to the risk of abuse and dependence.

Leg hugs have been shown to help relieve symptoms of RLS.

Called restless, the bandage applies pressure to specific points on the bottom of the foot. The pressure sends messages to your brain, which responds by telling the RLS-affected muscles to relax. This helps relieve symptoms of RLS (31).

A 2013 study of 30 people who used a foot compress for eight weeks found a significant improvement in RLS symptoms and sleep quality.32).

The leg wrap is restlessly prescription only and costs about $200 on the company’s website. Your insurance may or may not be covered (31).

9. Pneumatic Compression

If you have ever stayed overnight in the hospital, you may have had pneumatic compression. This procedure uses a “sleeve” that crosses the leg, inflates and deflates it, gently squeezing and releasing the limb.

The hospital usually uses a pneumatic compression device (PCD) to improve circulation and prevent blood clots. Improved circulation may also be why pneumatic compression relieves RLS symptoms.33).

Some researchers believe that low oxygen levels in the extremities are the cause of RLS. They think that the body responds to this problem by increasing blood circulation through muscle contractions that occur when a person moves a limb (33).

Whatever the cause, some research has shown that pneumatic compression can help relieve symptoms of RLS.

A 2009 study of 35 people who used PCD for at least one hour a day every month significantly improved RLS symptoms, sleep quality, and activities of daily living. However, other studies have not shown the same effects (33, 34).

Some PCDs are available for rent, while others are available over-the-counter or with a prescription. PCD insurance may be easier to obtain for people who cannot tolerate RLS medications (33, 35).

A vibrating pillow called the Relaxis pillow may not relieve your RLS symptoms, but it will help you sleep better (4).

Use the vibration plate when you are resting or sleeping. Place the pad on the affected area, such as the feet, and set the desired vibration intensity. The pad vibrates for 30 minutes and then turns off (33).

The idea behind the cushion is that the vibrations create a “contrast”. That is, they overcome the discomfort caused by RLS, so that instead of symptoms, you feel vibrations (33).

Not many studies are available on Relaxis, and it has not been shown to improve symptoms of RLS. However, it has been shown to improve sleep (33).

In fact, one study found it to be as effective in improving sleep as four FDA-approved drugs for RLS: ropinirole, pramipexole, gabapentin, and rotigotine.36).

Relaxis Pad is available by prescription only. According to the company’s website, the device is not insured and costs just over $600 (37).

A non-invasive treatment that has not yet been used for this purpose and can significantly improve the symptoms of RLS.

This painless treatment is called Near Infrared Spectroscopy (NIR). NIRS uses long-wavelength light rays to penetrate the skin. Light causes blood vessels to dilate, increasing circulation (33).

One theory is that RLS is caused by low oxygen levels in the affected area. The increased circulation caused by NIRS is thought to increase this oxygen level, helping to relieve symptoms of RLS. 33).

Several studies have shown this treatment to be effective. In one study, 21 people with RLS were treated with NIRS three times a week for four weeks. Circulatory symptoms and RLS showed significant improvement (38).

Another showed that people who received twelve 30-minute NIRS treatments over four weeks also had a significant reduction in RLS symptoms. Symptoms improved within four weeks after the end of treatment (39).

NIRS devices can be purchased online for prices ranging from a few hundred dollars to over $1,000 (33).

These treatments have some research to support their use. Other treatments have less evidence but may work for some people with RLS.

Hot and cold treatments

Although there is not much research to support heat and cold for RLS symptoms, many health organizations recommend it. These include the National Sleep Foundation and the Restless Legs Syndrome Foundation.19, 40).

These organizations recommend taking a hot or cold bath before bed or applying hot or cold compresses to the feet (18).

The symptoms of RLS in some people are aggravated by cold, others have problems with heat. This may explain the benefits of these hot or cold treatments.

Repetitive Transcranial Magnetic Stimulation (rTMS)

A non-invasive procedure commonly used to treat depression can help relieve symptoms of RLS. So far, research has been limited and more research is needed, but the results are promising (4, 41, 42).

Repetitive transcranial magnetic stimulation (rTMS) sends magnetic pulses to specific areas of the brain.

It is not entirely clear why rTMS can help relieve symptoms of RLS. One theory is that impulses increase the release of dopamine in the brain. The second suggests that rTMS may help calm hyperosis in parts of the brain associated with RLS.43).

In one 2015 study, 14 people with RLS received 14 rTMS sessions over 18 days. The sessions significantly improved RLS symptoms and improved sleep. The results were maintained for at least two months after the end of treatment (44).

Transcutaneous Electrical Nerve Stimulation (TENS)

Using transcutaneous electrical nerve stimulation (TENS), the device sends small electrical currents to parts of your body to relieve pain.

There are not many studies on the use of TENS for the treatment of RLS, but they may be successful.

The idea is that, like the plate compactor, Relaxis also uses contrast. One study showed that regular use of TENS along with vibration treatment completely improved RLS symptoms in one man (33, 45).

Acupuncture

Acupuncture can be helpful in treating many conditions, and RLS can be one of them.

A 2015 study of 38 people with RLS who were treated with acupuncture for six weeks found that their abnormal leg activity due to RLS was significantly reduced.46).

However, more research is needed to confirm that acupuncture is a reliable treatment for RLS.

Varicose surgery

For people with certain circulatory problems, surgery may be the most effective treatment for RLS (12).

Varicose veins are dilated blood vessels, often in the legs, that are full of blood. This increased amount of blood can lead to superficial venous insufficiency (SVI), which means your body cannot properly circulate blood. As a result, blood accumulates in the legs.

In a 2008 study, 35 people with SVI and RLS underwent a procedure called endovenous laser ablation to treat varicose veins. Of 35 people, 84% of RLS symptoms improved significantly or completely resolved with surgery.47).

Again, more research is needed on this operation as a treatment for RLS.

RLS can cause significant discomfort, sleep problems, and problems with daily activities, so treatment should be a priority. Your first step should be to try out the options on this list at home. But if they don’t help you, be sure to talk to your doctor.

Your doctor can provide more information about each of these treatments and which one might be a good choice for you.

Be aware that what works for one person may not work for another, and you may need to try several different medications or treatments. Keep trying until you find a treatment plan that works for you (48).

Fever read online by Tess Gerritsen (Page 11)

Noah looked at the frog in his hand. She stared at him too, her eyes wide. He took the needle, then looked back at the frog. Those eyes seemed to implore him: “Don’t kill me! Do not kill me!” He put down the needle, feeling his nausea rise again, then looked hopefully at Amelia.

– Do you want to excel?

“I can’t,” she whispered. – Don’t make me, please.

One of the girls cried out. Noah turned around to see Lydia Lipman jump up from her chair and shy away from her partner, Taylor Darnell. There was a dull thud against the wood—boom, boom, boom—as Taylor stabbed the needle into the frog’s carcass. Blood splattered onto the desk.

— Taylor! Taylor, stop it now! exclaimed Madame Horatio.

But he continued to poke the needle. Boom Boom! The frog began to look like minced green.

“Two plus,” he muttered. I have been preparing for this test all week. You can’t give me two plus!

– Taylor, go to the director!

He stuck the needle even harder.

– You can’t give me a nasty two plus!

The teacher grabbed his wrist and tried to take the needle away.

– Now go to Miss Cornwallis!

Taylor withdrew his hand and pushed the dead frog to the floor. She flew right into Amelia’s lap. With a wild squeal, she jumped up from her chair, and a small corpse flopped onto the floor.

– Taylor! roared Madame Horatio. She grabbed the boy’s wrist again, this time forcing him to let go of the needle. “Get out of class immediately!”

– Fuck you!

— What did you say?

He got up from his desk and kicked a chair to the floor.

– Fuck you!

– From this moment you are excluded! All week you’ve been rude and defiant. Got it, buddy. You are no longer needed here!

He kicked the chair. He flew down the aisle and crashed into the desk. Grabbing Taylor by the shirt, the teacher tried to lead him out the door, but he deftly wriggled out and hit her on the back. She collapsed onto her desk, knocking over a jar of frogs. The jar shattered, the frogs jumped free and rushed across the floor in a waving green carpet.

Lady Horatio rose slowly to her feet, her eyes blazing with fury.

— I will get you expelled!

Taylor reached into his backpack.

Mrs. Horatio froze when she saw the gun in his hand.

“Put it down,” she ordered. “Taylor, put the gun down!”

The flash seemed to hit her in the stomach. The teacher staggered, put her hands on her stomach and collapsed to the floor. There was amazement in her eyes. Time seemed to stand still, frozen for that endless moment, while Noah watched in horror as a stream of bright blood ran towards his sneakers. And then the silence was broken by a frightened girl’s cry. The next moment, chaos reigned around him. Noah heard the falling chairs rumble, saw the running girl stumble and fall on her knees on the broken glass. The air seemed to be saturated with blood and panic.

Another shot rang out.

Noah’s gaze, like a camera in slow motion, slid over the fleeing figures; he saw Vernon Hobbs lumbering forward and crashing into the desk. The classroom was a blur, with flowing hair and running legs. But Noah himself could not move. He seemed to be stuck in this nightmare, the body refused to follow the command of the brain: “Run! Run!”

His gaze snatched Taylor Darnell out of the chaos, and to his horror Noah noticed that the muzzle of a gun was aimed at Amelia’s head.

No, he thought. – No!”

Taylor fired.

Suddenly, out of nowhere, a trickle of blood flowed down Amelia’s temple, then a trickle appeared on her cheek, but the girl did not fall – with her eyes wide open, like a hunted animal, she looked at the muzzle of a pistol.

“Please, Taylor,” she whispered. “Please don’t—”

Taylor raised his gun again.

At that moment, Noah got rid of the paralyzing nightmare, his legs moved again, and his body began to obey. The brain immediately noted a lot of details. Noah saw Taylor raise his head and turn to him. The gun, having described an arc, also turned out to be directed at him. Rushing at Taylor, Noah saw surprise in his eyes.

Another bullet fired from the muzzle.

– I just found out that my patient was put here. Why didn’t anyone call me?

The nurse on duty looked up from her desk and seemed to cringe when she saw that the question was coming from Claire.

— Um… which patient, Dr. Elliot?

– Katie Youmans. I saw her name on the door of one of the wards, but she is not in the ward. I didn’t find her card either.

– She was brought just a few hours ago by ambulance. She’s in the x-ray room right now.

– But for some reason no one informed me.

The nurse looked down:

— Dr. Delray became her doctor.

Claire silently accepted this unpleasant news. In general, there is nothing unusual in the fact that patients change doctors, sometimes for the most banal reasons. Two patients moved from Adam Delray to Claire. But the fact that this particular patient chose a different doctor surprised Claire.

When she first came to see Claire for a bladder infection, sixteen-year-old Katie Youmans, slightly retarded, was living with her father. Claire immediately noticed the bruises around the circumference of the girl’s wrists. Forty-five minutes of sensitive questioning and a pelvic exam confirmed Claire’s suspicions. Katie was taken from the custody of her abusive father and placed in an orphanage.

Since then, the girl has blossomed. Her injuries, both physical and mental, were gone. Claire considered Katie her victory. Why would a girl change doctors all of a sudden?

She found Katie in the x-ray room. Through the viewing window, Claire saw that the girl was lying on the table, and an X-ray tube was hanging over her foot.

— May I ask what diagnosis she was hospitalized with? Claire asked the radiology technologist.

– They told me it was panniculitis of the right foot. There is her card; you can take a look if you want.

Claire took a card from the table and read the entry made in the reception area. It was dictated by Dr. Adam Delray at seven o’clock in the morning.

“White woman, sixteen years old, stepped on a nail two days ago. This morning I woke up with a high fever, chills, swollen feet…”

Claire skimmed through the description of the patient’s physical condition, turned the page, and read the prescribed treatment.

Then immediately grabbed the phone to send a message to Adam Delray’s pager.

A moment later he entered the x-ray room, as always, in his white long coat, pressed and starched. Despite Delray’s unfailing affability, there was no genuine warmth in their relationship, and Claire suspected that behind the northerner’s outward restraint was a typically male competitive spirit, perhaps even a sense of resentment for having taken two of his patients away from him.

And now that he had selected her patient, Claire had to suppress her competitive spirit. Right now, her only concern was the well-being of Katie Youmans.

“I saw Katie as an outpatient,” she explained. — I know her well enough, and…

— Claire, it’s a common story. Adam put a hand on her shoulder as if comforting her. I hope you don’t take this to heart.

– I didn’t call you on your pager about this.

– It was just easier for me to accept it. I was on emergency duty when she arrived. And her caretaker said that Katie needed a therapist.

— I am quite capable of curing panniculitis, Adam.

— What if it develops into osteomyelitis? It’s much more difficult.

Are you saying that the family doctor is not qualified enough to help his patient?

– The decision was made by the girl’s guardian. It so happened that I was the doctor on duty.

Claire was already so angry that she chose not to answer. Turning away from Dr. Delray, she looked out the window at her patient. Former patient. Her attention was suddenly drawn to the drip the girl was connected to, and the handwritten sign attached to the bag of dextrose and water.