Denver Doc Online

What causes panic attacks?

2011-03-20T14:34:00.010-06:00

If you've not had a panic attack, you can scarcely imagine what they are like. When I diagnose patients with this condition, they all nod when I describe panic as not so much a feeling of "I'm so anxious" but a frightening conviction that "I will pass out" or “I will die.” As opposed to anxiety, panic attacks are intense and episodic, occurring abruptly with or without a particular trigger. They cannot be banished with rational override. If they are not recognized as panic, they often result in expensive overuse of medical services through visits to ERs, cardiologists, or pulmonologists. Theories abound on the biological underpinnings of these show-stopping events.

Panic attacks often include a subjective feeling of not being able to get a deep breath accompanied by the need to yawn or sigh in order to improve the situation. Conscious attention to breathing overrides the automatic regularity of inhalation and exhalation, a state I've dubbed "too much minding the matter.".As a result of disordered breathing, panic victims suffer disturbances in body levels of carbon dioxide, either hypercapnia (too high) from shallow breathing or hypocapnia (too low) as a result of hyperventiliation.

Oddly, variances in either direction have been linked to the onset of panic attacks. Shallow breathing or hypoventilation produces hypercapnia which in turn induces a fear of suffocation--think buried alive or stuck in a mineshaft rebreathing air increasingly devoid of oxygen. Some researchers believe that panic patients have an overly sensitive internal suffocation alarm--any rise in carbon dioxide levels sets off a frantic 'gotta’ get outta here now' reaction. Conversely, hyperventilation produces hypocapnia which causes a constriction of airways and an unpleasant awareness that each inhaled breath is insufficient. Either way spells panic for susceptible souls. Many people with panic complaints often lose that frantic focus on breathing while exercising as aerobic activity drives a deep and regular breathing pattern.

Newer research suggests that a hormone that plays a role in wakefulness may contribute to panic attacks. Before considering how high levels of orexin (orx) turn ordinary citizens into panicky wrecks, here’s some interesting background on this hormone also known as hypocretin. Brain cells that release orexin are found in the hypothalamus and are active during waking hours and inactive during sleep. Orx receptors exist throughout the brain and are activated by orx release. A lack of orx-producing neurons causes narcolepsy—a condition associated with unpredictable and sudden attacks of sleep. Researchers have used orx-antagonists which block the effects of orx to induce sleep in lab animals and humans.

Pharmacologists at Wake Forest University administered orx as a nasal spray to a slew of sleepy monkeys to see if they could rouse sufficiently to perform complex mental tasks(1). The monkeys, like your average teenager, were kept awake with videos, music, treats, and interacting with humans ‘til all hours of the night. As you can see from the PET scans above, snorting orx changed great scads of sleepy blue brain material into red, glucose-metabolizing neurons hard at work on image-matching tasks, and the orx-treated group performed circles around their sleepy colleagues. Imagine squirting your comatose teen with orx on a school morning!

So what’s orx got to do with panic? Psychiatrists at Indiana University found that panic-prone rats were over orx-ed(2). Not hard to imagine if a little orx is good for alertness, too much orx would result in a tightly wound rat—or human—jumpy, easily startled, and prone to freak out. And the more active the orx neurons in the rats, the more their paniclike behavior increased.

Not satisfied with rat data alone, the investigators somehow persuaded humans with panic disorder to undergo spinal taps, checking for levels of orexin bathing their beleaguered brains compared to others free from fear. Sure enough, orx levels were much higher in the panic-prone. Someday, orx-antagonists that block orx receptors may be a non-sedating, non-addictive approach to panic control.

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1. Deadwyler, SA et al. Systemic and nasal Delivery of Orexin-A Reduces the Effects of Sleep Deprivation on Cognitive Performance in Nonhuman Primates. Journal of Neuroscience. 26 December, 2007, 27(52): 14239-14247.

2. Johnson, PL et al. A Key Role for Orexin in Panic Anxiety. Nat Med. 2009;16[1]:111-115.

Radiation from medical imaging

2011-03-08T11:05:00.012-07:00

Plagued by shoulder pain, especially at night, Jack was not happy with his orthopedist nor improved by physical therapy. Being a tightly wound sort, he'd come to the conclusion that the pain must be from cancer. I was happy to reassure him, as I'd done many times in the past, that he did NOT have cancer. Soothing the worried well (there's actually an ICD-9 diagnostic code for 'worried well') is one of the easiest parts of my day.

But Jack came back the following week, yet again shouldering grave doubts. A second opinion from another orthopedist confirmed the original diagnosis of a torn rotator cuff. So what was on Jack's mind? He was agonizing over the fact that Dr. Two took a repeat set of shoulder films. Not the unwarranted expense that now worried Jack, however, he was near tears over the possibility that this extra radiation would significantly increase his future risk of cancer.

So what's the scoop on medical imaging and cancer risk? Radiation from any source is not only a cancer inducer, turning healthy cells into pre-malignant ones, but also a cancer promoter which can push these compromised cells into a more abnormal state. Radiation danger is compounded through a lifetime of ionizing destruction; years of exposure compounding today's CT with yesterday's tan. If you'd like an estimate on your annual irradiation, check out the interactive quiz at American Nuclear Society's website.

If you're not an internet quiz type, let me inform you that a single CT scan can deliver a radiation dose equal to dozens of shoulder films. And there's no particular standardization here; radiologists can adjust their sets to enhance detail, and the higher the dose, the crisper the image. As a result, concerned specialists have banded together in various self-policing initiatives to rein in the rads, among them Image Gently setting guidelines for testing children and Image Wisely for adults. Nevertheless, the estimated annual number of CT scans in the US rose from 3 million in 1980 to 67 million in 2006 and the numbers continue to climb. Scarcely an ER visit goes by for one of my patients without an accompanying CT procedure. And one CT begets another when "incidentalomas" are found (unexpected abnormal findings of unclear significance) that require future scans to clarify their nature.

Based on data from survivors of the atomic bombings in war-time Japan, biophysicist David Brenner estimated the lifetime risk of cancer for a child undergoing a single abdominal CT as one in 1000. While other experts take issue with both his calculations and his conclusions, all agree that rads must be reduced.

One of the most innovative approaches comes from Mass General Hospital. Docs there created a rather complex program that scores the appropriateness of the choice of a diagnostic CT as compared to other imaging techniques for any particular clinical situation. The software shares this info with the ordering physician who is then offered the opportunity to change their minds and their orders. This software replaces the aggravating insurance pre-authorization procedures that Dr. James Thrall has dubbed "1- 800- may- I- do- a scan." Once this process was in place, CT use at MGH dropped considerably.

There is no doubt that CT technology has been critical to the accuracy of diagnosis since its inception. Pre-CT scanning (back when I was a doc-lette in training), diagnosing brain tumors involved a horrendous procedure wherein air was introduced into the spaces around the brain (as demoed graphically in "The Exorcist"). CT scans are perfectly appropriate even while over-ordered. Ask your doctor, however, what your other choices might be when offered such tests.

Alpha brain waves and sleep disturbances

2011-03-05T09:46:00.008-07:00

I stay in touch with the world in the course of a night as things that go bump in the night make me jump. Ringing phones send me into a hot flash of anxiety and insomnia even if it's just the gentle whir of a cellphone on vibrate! Last night, my husband's cell went off at 3:30 a.m. one floor and half the house away. He snoozed on while I tossed and turned.

No doubt that many--e.g. mothers, doctors, and plumbers--all need a heightened nighttime awareness of the world, but this sleep-searing sensitivity can get out of hand. "Resistance to acoustic disturbance" is a measure of sleep soundness and is known to vary during the course of a night's sleep and also from sleeper to sleeper. Scientists are hot on the trail of why.

Nocturnal observations of 13 sleepers sleeping in a Massachusetts General sleep study lab revealed certain brain wave characteristics that predicted whether or not an individual would rouse to the noise of traffic or phones(1). As we transition from wakefulness to sleep, certain patterns emerge in our brain wave patterns signaling a shutting down of external awareness and a growing hubbub of internal brain activity. Alpha waves that flow from the back of our brain decline in amplitude as we drift into sleep. However, this wakeful wave does not disappear entirely, and, in fact, the more powerful these alpha signals, the more fragile our sleep.

The scientists confirmed that increased alpha activity as seen on EEG prior to the delivery of an external sound increased the likelihood that the subject would rouse unto wakefulness in response to the noise. Thus, alpha activity in the brain not only correlates with mental alertness by day but easily disturbed snoozing by night. The researchers concluded that this information may someday allow for the over-alpha'd amongst us to be variably medicated based on read outs from sleep monitoring devices rather than bluntly sedated for hours by currently available meds.

Sounds kind of "Brave New World"ish to me. And who then will lie awake waiting for teens?
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(1) McKinney SM, Dang-Vu TT, Buxton OM, Solet JM, Ellenbogen JM (2011) Covert Waking Brain Activity Reveals Instantaneous Sleep Depth. PLoS ONE 6(3): e17351. doi:10.1371/journal.pone.0017351.

What's up with flu this season?

2011-02-19T17:41:00.004-07:00

I've just started seeing patients with influenza this month. No lack of people coming in for "flu" since winter began, but most of these visits are for any number of other circulating viruses. The miserable souls dragging their sorry selves into my exam room here lately have been hit hard and fast with fever, chills, bone-deep aching, headache, and a cough that generates from the depth of their being. All save one passed on flu shots, and the latter had a mild version of all of the above, puzzling until I realized she'd gotten vaccinated earlier which softened the blow.

Good news here is that this year's shot, for those of you who got it, is a good match for the strains currently flying through the air in projectile spittle. The CDC's latest update confirms my observations that true influenza is here, and the predominate strain is A/H3N2 which is not that scary H1N1 "swine" flu that showed up last year (although that one's going around as well). The H3N2 virus hits hardest amongst young children and older adults. And I'm here to tell you that the in-betweeners are pretty darn miserable too.

If you have an underlying illness such as asthma or COPD, beat feet to your doc's at the first sign of true flu. This year's strains are still sensitive to Tamiflu, but official recommendations are that this drug only be given to those who either are at risk for or suffering from progressive disease.

"Turn your DNA into art"

2010-11-21T13:25:00.005-07:00

The perfect personalized gift this holiday season--a work of art based on the recipient's unique genetic sequence. If you can only figure out some sneaky way to swab their inner cheek without raising suspicions, you then mail off the sample to Yonder Biology who will turn it into a "beautiful genetic image" on photographic paper, stretched canvas, or acrylic face mount at prices ranging from $99-$1,199. Add a "Me" t-shirt for an extra $34!

Whether or not you choose this route to self-expression, it's a fun web-site. Check-out:
Yonder Biology.

Rose Kelly

2010-08-01T13:14:00.009-06:00

Rosellen Kelly, 8/20/52-7/31/10

I lost my dear friend Rose yesterday to cancer. Mom, wife, friend extraordinaire, writer, artist, and Assistant Head of School at St. Anne's Episcopal here in Denver, she was a treasure to all who knew her. She collected friends like an endless strand of pearls--like the ones she wore at a time when our generation was mostly through with such traditional adornment.

Gracious, hilarious, and soothing, she told me that she viewed death as "just showing up for my next assignment. An angel in life, she has ample experience for her upcoming gig.

Duke wants picky eater info

2010-07-25T13:19:00.006-06:00

Well, I've heard it all. The patient who ate her way past the benefits of gastric bypass surgery by eating a bag of Hot Tamales candy each day. A man who has eaten the exact same meal three times daily over the five years that I've known him. Another who drank 18 colas a day supplemented by cereal in the a.m. and a hamburger in the p.m. My daughter who scraped anything larger than a grain of rice off her tongue for the first 2 and 1/2 years of her life.

Researchers want to hear from you if you are an adult picky eater. Apparently, experts now classify this as an eating disorder, and they are seeking data on the effects of finickiness on health and social situations. Per Marsha Marcus, a psychologist involved with the study, "We want to define the boundary between normal weird eating and real problems."

Would you like to participate in the quest to find the cutting edge of 'normal weird' as it extends into 'real problems'? Log onto The Food F.A.D. Study and contribute to medical science.

Of Busyness and Chocolate

2010-07-24T14:59:00.003-06:00

"We show in two experiments that without a justification, people choose to be idle; that even a specious justification can motivate people to be busy; and that people who are busy are happier than people who are idle.”(1)

The past few days have been stressful, so last evening I set to work on my kitchen, wiped down cabinets, sudsed up countertops, and then got down on my knees to hand scrub the floor. This was a Friday night, mind you, but I was content if more than a little sweaty, completely calmed by my whirlwind of activity. As a result, I've been thinking about busyness, and, my conclusion-- based on encounters with people both happy and un--is that humans enjoy being busy. Researchers from the University of Chicago’s Booth School of Business concur that busyness is a source of happiness.

As you know from this blog, scientists will study just about anything, and their most willing and available subjects are college students. Researchers at the University of Chicago theorized that "People dread idleness, yet they need a reason to be busy." So they grabbed a group of undergrads, hooked them up with a bogus survey, and here's what they found about idleness, chocolate, motivation, and happiness.

The students were asked to complete the survey then offered various strategies for turning it in. All involved the choice between a 15 minute sit-around-and-wait versus a 15 minute walk to another location. Without a chocolate inducement, the majority of subjects chose to wait. If offered a choice of milk chocolate on site vs. walking for dark, however, significantly more subjects opted to ambulate. The final test group was forced to walk or wait as a condition of the experiment. In every case, those who walked judged themselves happier than their lazy-bone colleagues. The researchers concluded, as stated above, that while people might choose to be idle, they’re willing to get moving for rewards as ‘specious’ as chocolate, and they’re always glad to be busy.

I talked this all over with a psychologist friend, and we agreed that this research is adrift in specious reasoning. Did the walkers, in fact, become happy due to walking or did they walk because they were happy? Or did they become happy while walking because it was such a nice break from their busy schedules to slow down and walk through the beautiful campus (if indeed the U. of Chicago campus is beautiful). Or is this the healthy person bias, meaning are people who choose to walk for chocolate on average people who are optimistic about the future and happily seeking healthy choices?

Other research confirms another obvious fact, namely that active people derive satisfaction not necessarily from busyness so much as from being valued and needed as a result of that which they accomplish in their work. And too busy, frantically busy, is a known detriment to health. Stay tuned for more busy research in upcoming posts.
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(1) Hsee, CK, et al. "Idleness aversion and the need for justifiable busyness." Psychol Sci. 2010 Jul;21(7):926-30.

Don't cool your jets!

2010-05-05T19:46:00.002-06:00

I get daily discount deals by e-mail. Nothing wrong with these bargains, but who on earth writes their ad copy? This one was too rich to keep to myself:

When pilot lights go out, it is because they lack ample
core strength, a failure that results in uncooked pilots.
Keep your pilot light burning bright with today's deal
at "X" pilates studio.

Caffeine plus exercise

2010-04-21T07:25:00.004-06:00

I am preparing a talk on exercise, and I figure I can't just say "You should," thank the audience, and head for the gym. On perusing articles on exercise and breast cancer (you should do the former to decrease risk of the latter!), I followed one of those delightful internet link trails and came across this interesting study on New Jersey mice (1).

Imagine being offered three choices: two weeks of daily Starbucks plus an obligatory work-up with a personal trainer (both free of course!) that same Starbucks sans gym work-out, or a caffeine-free opportunity to exercise only if you care to but never mind if you don't. These Jersey rodents were assigned the mousy equivalent of these choices, then all underwent tanning sessions under UV lights. Oh yeah, and then followed by skin biopsies...

All lost some of the fat lurking just beneath their furry hides, but the exercise plus caffeine group lost twice as much as the indolent coffee drinkers. Better yet for those buff little fellows that enhanced their exercise-enhanced physique with tans, those who drank caffeine-laced water AND exercised exhibited apoptosis of sun-damaged skin cells. In other words, caffeine inhibited DNA damage from UV light--and therefore tumor formation-- by promoting the destruction of UV-damaged cells.

If we're at all like mice, which we more or less are, caffeine plus exercise may equal some sort of cancer protection.
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Yao-Ping, L et al. Voluntary exercise together with oral caffeine markedly stimulates UVB light-induced apoptosis and decreases tissue fat in SKH-1 mice. PNAS July 31, 2007 vol. 104 no. 31 12936-1294.

The changing face of primary care

2010-04-09T14:39:00.004-06:00

I ran into one of my patients today at the grocery. We chatted in the bread dept. about footwear and fiber, then met again in books. I was there considering whether or not I could justify adding yet another book to my 'to read' pile, she was just browsing on her way up one aisle and down the other. By the time we parted, I'd learned that her older son, once my patient, had moved home again and was struggling with depression. Her younger was now in his 7th year battling an HIV infection. Who knew I could learn more about her personal life at King Sooper's then ever I knew from our not infrequent exam room encounters?

This small town sort of intimacy in the middle of a moderately big city represents all that I love about my practice of medicine. Alas, it looks like things will change mightily in the coming year as my partner and I strike out in new directions in order to continue practicing medicine at all.

Strange how primary care is front and center in the middle of health care reform, yet remains undervalued and underfunded in ways that will soon completely preclude the sort of Mom and Mom shop that she and I run. In the face of falling reimbursements and rising expenses, here's what we view as our two choices:

The first is to become employees of a large hospital corporation. Economy of scale and deep pockets will remove the agony of the overhead--buying medical supplies and injectibles in quantities and at per unit prices of which we can only dream in our current situation. Being able to negotiate with insurance companies for contracts that two docs in a 1950's style little medical box could not begin to command. But...no more funky offices adorned with antiques and artwork (and leaky basements!), no more elevator-free hop, skip, and jump from parking lot to office door, January 2011 would find us working out of a medical building reeking of disinfectants and cleaning products instead of coffee and popcorn.

The other option is a gradual shift to a membership practice. Many dollars short of a concierge version which requires an annual fee of $1,000 or more, this concept involves a much smaller cost, say $25/month, which not only brings in the sort of yearly revenue that covers property taxes and hazardous waste disposal, but also benefits members with 24/7 ask-a-nurse access, wellness and nutritional counseling, as well as e-mail access and same-day appts. While there is no requirement to join in order to remain our patients, this nominal-ish sort of fee would be each patient's affirmative vote that small practices reap big satisfaction for all.

Obviously, my language screams of my preference, but we worry, rightly, about 'willingness to pay.' Particularly in light of the new health care legislation, there is increasing belief that health care is a right for which one should not have to pay much at all. Our time frame here is short in terms of decision-making; I'd love to get your opinion--especially from my patients but honestly, from anyone who'd like to chime in--about what you'd like your future relationship to be with us or whomever your PCP may be. Feel free to use my e-mail address or to leave anonymous observations.

Other people's motives--How do we judge?

2010-04-04T19:55:00.006-06:00

As soon as I learned to drive, my parents instructed me to 'lock your doors' when driving at night or through 'certain neighborhoods.' When I moved to Cleveland for internship, my uncle advised me to forget locking my doors in those riskier parts of that city but rather DO NOT drive through them under any circumstance, night or day.

With such precautions drummed into me at an impressionable age, I remain ever alert to shady pedestrians at downtown intersections. To my son's dismay, I'll lock the doors if I judge a sketchy passerby likely to open the door and grab my purse or, worse yet, to hop in the passenger seat and abscond with me and/or my car (Oh like that would ever really happen Mo-om!).

Call me paranoid or over-sensitive, but never deny that I have a highly trained right temporoparietal lobe aka the temporoparietal junction (TPJ). Scientists now know that this section of our brain, seated just above the right ear, is vice president in charge of judging other people's motives. Here's how they figured this out.

Patients with brain damage to the TPJ are known to have trouble inferring moral intentions. Social scientist Liane Young and colleagues at MIT decided to test normal subjects with their TPJs intact and turned off. Now who on earth would volunteer for an experiment that involves turning off a section of their brain? Perhaps MIT undergrads feel they have neurons to spare.

Anyway, Young and company used "transcranial magnetic stimulation (TMS), a technology that uses a tightly focused magnetic field to temporarily disable individual regions of the brain." Before and after a magnetic zap to their TPJ, the volunteers read scenarios in which subject A accidentally kills subject B or narrowly misses killing the hapless B on purpose. As opposed to their righteous pre-TMS states of mind, the group post-TMS were much more forgiving of attempted murder.

So what? Well, we know that the TPJ continues to mature through adolescence and beyond, so someday my son will 1) be more forgiving of my heightened sense of other people's malevolent motives, 2) will lock his own darn doors, and 3) will make better choices in general (I hope). In addition, the MIT social scientists are now turning their attention to the TPJs of persons with autism spectrum disorders, conditions in which the ability to 'read' other people is seriously impaired.

Pain perception

2010-03-24T20:44:00.013-06:00

Some people are stoic and some aren't. … Maybe there's a plausible biological reason for that difference.
---Dr. Geoffrey Woods, Medical geneticist, Cambridge University

My patient's face was all pinchy with pain, an expression not generally seen in a 20-something year old lady. She'd visited Walmart the previous day (an outing that always makes me pinchy with impatience as my husband meanders through every last aisle). While there, she bent over to examine some wonderful find and skewered her forehead on a metal hook.

"Ew," you're thinking, which is what I would've thought if there had been a ragged tear in her face, or any kind of mark whatsoever. Her forehead, however, was completely smooth and unblemished.

"So," I said, "where did it snag you?" And I touched the indicated spot, sending her recoiling in pain, pinchier than ever. The area wasn't red, abraded, swollen, or bruised. I told her that while I appreciated she was in a lot of pain, my examination indicated no serious injury. I then assured her that her pain should diminish greatly in the following days.

As usual, when confronted with pain reports that seem to far outstrip apparent injury, I wished I could walk a mile in her forehead. What was she really feeling in there? Real pain, real drama, a need for sympathy, worried sick, or what?

Dr. Woods and company also wondered why humans demonstrate such a wide spectrum of pain perception. They already knew from previous research that three rare mutations in the SCN9A gene are a serious problem insofar as such genetic changes can cause persons to be either too sensitive or completely oblivious to painful stimuli. In the first case, the faulty SCN9A gene allows sodium ions to flood through channels in the surface membranes of cells in the central nervous system. As a result, these neurons painfully overfire in response to minor daily occurrences such as bumping a shoulder against a wall when taking a corner too close. At the opposite extreme, SCN9A gone haywire in a different way prevents the perception of pain altogether. Affected persons, consequently, receive no signals say from a fracture or sprain and, therefore, have no cue to stop moving and get off the injured joint.

The Cambridge team went looking for subtle, more common mutations in the SCN9A gene, namely substitutions of a single nucleic protein (SNP) in the gene's sequence(1). They studied a group of subjects with osteoarthritis of comparable severity to see if these SNP variations correlated with differing levels of pain perception. One variation present in a small subset of the group was indeed associated with the highest pain perception in those who carried it. The scientists then looked in other people with other common pain syndromes such as sciatica and lumbar disk disease, again finding that "the statistical link between having the rare SNP and feeling more pain was impressively strong." In other words, those persons with lower pain thresholds were significantly more likely to have this particular SNP variant.

The researchers found that just under 20% of their subjects carried one copy of this particular SCN9A mutation, but only 2-3% had two defective copies, and these were the people most likely to react strongly to their painful conditions. Further testing suggested that this mutation renders them incapable of squeezing their sodium channels shut so wave after wave of pain news just keeps rolling in.

Obviously, this genetic test is not available for clinical use, and there's nothing to be done about it anyway. Those of us in the medical business and everyone involved in the sympathy business can now appreciate, however, that some persons are hard-wired for more pain than others; for such persons, that 'stiff upper lip' advice may be harder to follow. And my hapless Walmart shopper was back two days later, her forehead no longer tender but her head now clamped in the vise of a secondary tension type headache brought on by scrunching her brow over the original hooking.
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1) Woods, GC, et al. "Pain perception is altered by a nucleotide polymorphism in SCN9A," Proceedings of the National Academy of Sciences.

Probiotics and clostridia difficile

2010-03-21T18:51:00.007-06:00

I noticed a disturbing item in this a.m.'s paper--diarrheal illnesses caused by clostridia difficile are increasing in number and virulence. This serious intestinal condition is now more common than disease caused by methicillin resistant staph aureus aka MRSA as a cause of serious hospital-acquired infections.

C. diff tends to be a nosocomial infection, i.e. one that results from medical treatment, specifically, in this case, from the use of potent antibiotics. C. diff is not normally present in the gastrointestinal tract but moves into the territory after antibiotics kill off the good little bacteria who normally call our colons home. Increasingly virulent strains of c. diff can cause life-threatening colitis which occasionally requires emergency surgery, sepsis (overwhelming infection), and death.

While community-acquired C. diff rarely causes serious illness, it can run on and on in unpleasant and debilitating ways. Research suggests that the use of probiotics --preparations available over-the-counter that contain live bacteria of the intestinal-friendly variety-- can decrease the risk of antibiotic-related diarrhea including C. diff. While the use of these supplements is not recommended as the sole treatment of the condition, they may in fact promote a healthier micro-environment in the colon which increases resistance to a C. diff invasion.

I often recommend probiotics to my patients starting antibiotics for acute bacterial illness. I was interested, therefore, in a recent review by Consumer Lab of the various products on the market. Consumer Lab conducts testing on various over-the-counter nutritional supplements, including a review of the scientific literature for supporting information on their legitimate uses as well as a summary of testing results for purity and truth-in-labeling. Their nominal annual fee is well worth the price for consumers interested in using such products.

In the "you can't always get what you think you do" world of label-reading, I discovered that two of the probiotic products I recommend by name--Culturelle and Align--did not deliver the promised organisms per capsule. There is quite an in-depth discussion of probiotics on this site, and I recommend it to you as vital information concerning the increasingly perilous world of microbes, anti-microbes, and the pro-microbes that defeat them.

Cigarettes and cognition

2010-03-14T14:09:00.006-06:00

I was just visiting Mauigirl's blog; she's been struggling with the declining health of her aging mom. Between a hospital stay followed by a move to a nursing home, MG's mom has been one month without a cigarette. MG notes that research suggests that nicotine has favorable effects on cognition and wonders if the notable change she's seen in her mom's mental functioning might be, in part, due to the lack of nicotine. I've often told my patients that people like to smoke for good reason, that, in fact, cigarettes are not only calming but wonderful for concentration and focus.

Cigarettes--or rather the nicotine within--may be neuroprotective. While I'm all in favor of saving the brain, I won't be prescribing cigarettes to anyone wishing to keep their marbles. But there's interesting evidence suggesting that nicotine is not without its benefits to brain.

Scientists have noted that persons who smoke have lower rates of neurodegenerative diseases such as Parkinson's and Alzheimer's. Korean rats were encouraged to smoke via an automatic smoking machine. After four weeks of 'automatic smoking' for ten minutes per day, the rodents were significantly protected against the seizure-inducing effects kainic acid. Apparently, if you want to dip your head in kainic acid (whatever that is), you might consider smoking too.

Kainic acid exposure aside, researchers have other theories why nicotine is good for the brain. The brain is full of nicotinic acetylcholine receptors; activation of these cellular switches has a number of beneficial actions. This effect of nicotine has been compared to "turning up the volume of a radio signal." As acetylcholinergic brain cells are in charge of memory and executive functioning--i.e. planning and carrying out complex tasks--turning up the volume is a good thing. No wonder people enjoy the clarity and focus of a Marlboro.

Neuroscientists at the University of Florida have discovered still another mechanism as to why nicotine might promote brain health. They found that nicotine prevents overactivation of little neuron-supporting cells called microglia. When the microglia get all hot and bothered with overactivation, they can set off events toxic to their neuronal buddies unto death. Well who wants that? Check out what Florida's Dr. Douglas Shytle has to say about that:

Microglia can be your best friend or your worst enemy depending on the signals they receive. The analogy is that you keep talking to them they will take care of you, but if you stop talking they are more likely to get aggressive and have a toxic effect on the brain.

If all this makes you want to take up smoking again, hang on. The Southern investigators realize that they must "now develop drugs that mimic the beneficial action of nicotine without its unwanted side effects."

Occipital neuralgia and Lyrica

2010-02-28T12:49:00.006-07:00

Maureen periodically flinched while we talked as searing pain shot up the back of her head. Short but severe, these jolts of pain were diagnostic of neuralgia, a condition wherein a single nerve-- the greater occipital in this case-- seizes with pain. As a result, my patient was experiencing show-stopping discomfort from the base of her skull over the back of her head, sometimes on the left and other times on the right.

She spent her days hunched, like so many of us, over a computer and desk. On standing, she carried her head forward and her shoulders rounded reflecting the anterior thrust of her daily activities. All this was aggravated by breasts so large that her bra straps had dug permanent grooves in the top of her shoulders.

No easy fix for Maureen. I assumed that she, like many people, would not embrace the idea of medication, particularly over the long haul. I told her my plan--a short term fix to improve things quickly with a medication called Lyrica coupled with a larger plan to improve her posture, strengthen her supporting abdominal and back muscles, and perhaps consideration of breast reduction surgery.

Lyrica (pregabalin) is indicated for the treatment of seizures, diabetic neuropathy, nerve pain following seizures, and was recently approved for the treatment of fibromyalgia. Its use for occipital neuralgia, therefore, is 'off-label' but experience confirms that it soothes hypersensitive nerves no matter their location. Unfortunately, it's not without side effects, causing sedation, dizziness, and dysequilibrium, but its analgesic benefits can far outweigh these problems in patients whose daily lives are completely turned upside down by pain.

Maureen headed out with samples plus referrals to a physical therapist and a plastic surgeon and a written copy of the plan. Here's the phone message I received the next day:

Patient doesn't want to take Lyrica over a long period of time, was looking for a quicker working solution to pain. Advise.

Argh. Message back to patient:

Lyrica is a quicker working solution. Physical therapy, posture work, and possible surgery is the longer term answer.

The next message from Maureen sent the following day:

Pain free for the first time in weeks!

Fear Factor

2010-02-26T12:06:00.005-07:00

"Get over it!"

Those who fear not are fond of telling the overwrought amongst us to face our fears and move on. If you're a hot reactor who barely copes with scary movies or prefers to watch TV's "24" through slits between your fingers, here's some interesting news. You may, in fact, be genetically wired to startle and gasp and burst into tears.

Anxiety is a good thing, an unpleasant emotion that warns us against potential danger. Anxiety run amok can be a show-stopper--ask anyone who suffers from phobias and struggles with fear of crowds, riding in cars, flying in airplanes, visiting the doctor, or other situations that most people plunge through with nary a second thought. Neuroscientists are hot on the trail of the biological bases for various behaviors and the genetic codes that determine why we act the way we do.

Investigators at Weill School of Medicine in New York noted that mice with a small change in the gene sequence for a brain chemical called brain-derived neurotrophic factor (BDNF) are wimpy little things. BDNF is an important protein in mice and humans alike that supports brain cells to thrive and multiply especially in the brain regions responsible for learning and memory. These scaredy mice have DNA coding for BDNF that is just one molecule different from that of their intrepid colleagues. The cringing rodents with genetically skewed BDNF are not only anxious but known to have difficulty overcoming their fears and are resistant to treatments such as Prozac that decrease anxiety.

Dr. Fatima Solimon and her fellow psychobiologists at Cornell brought human and mouse volunteers with both normal and variant BDNF down to their lab for a psychological workout. Fear responses are prone to 'extinction' when subjects are repeatedly exposed to the threatening stimuli without any consequences. Psychologists use such exposure therapy to help people overcome phobias. Mice freeze and humans sweat when fearful, and the researchers checked how long it took subjects to quit freezing and sweating as correlated with their genetic type. In addition, the humans underwent functional MRI scans looking for high activity in brain regions known to be associated with both fear as well as the ability to master emotions through conditioning.

Their experiments confirmed that humans with variant BDNF coding have no problem learning that which is threatening but have a terrible time unlearning the cues that first signified danger. The people kept sweating and the mice kept freezing in their tracks long after the fearless subjects with the hardy BDNF were dry, calm, or scampering about their cages. And MRI scanning confirmed that those with the anxious variety of BDNF had trouble turning off their fear centers and turning on their learning centers.

Solimon and company whose findings appeared in a January, 2010 issue of Science Magazine are hopeful that their findings may ultimately translate into better understanding and treatment of persons with anxiety disorders, phobias, and PTSD. Those who suffer so are indeed eager to get over it.

Back away from the computer, ma'am!

2009-12-11T17:32:00.002-07:00

Received from a patient today:

"I am still having a very upset stomach and some episodes of diarrhea (3 to 4 a day now). They are happening after each email now instead of just in the evening."

Elderberry juice and H1N1 flu

2009-11-29T18:16:00.005-07:00

I posted some time ago about a potential influenza complication known as a cytokine storm. While this violent immunological over-reaction is known to occur with H5N1 or 'bird flu,' it has not proven to be a problem thus far with this current epidemic. In fact, the adults (I see few teens and no children) in my practice, while not enjoying their bouts of 2009 A(H1N1) flu, are finding the one week course more a matter of misery than serious disease.

I only just got my H1N1 shot last week--the Denver Public Health Dept. did not feel that internists were a high risk group! As I've been seeing cases of this flu for months, I started taking elderberry juice concentrate about a month ago. An article published in July of this year(1) used spectrometry to determine which elderberry molecules bound to the influenza particles thus inhibiting their ability to penetrate and infect host cells. Two compounds were identified that, in fairly low concentrations, stopped the little flu buggers dead in their tracks. In fact, their ability to inhibit H1N1 infections in lab conditions compared favorably to that of Tamiflu.

I ordered my elderberry concentrate from wyldewoodcellars.com. Per my favorite naturopath Dr. Jacob Schor, I take 1 tablespoonful in water each morning. I won't kid you, I don't love it, but it's palatable and better mixed with OJ.
_____
1. Roschek, B. et al. Elderberry flavonoids bind to and prevent H1N1 infection in vitro. Phytochemistry 2009 Jul;70(10):1255-61. Epub 2009 Aug 12.

Oil pulling testimonial

2009-11-28T10:49:00.006-07:00

I've written before about oil pulling, an ayurvedic practice that involves swishing a mouthful of oil around in the mouth for 10-20 minutes first thing in the a.m. One web-site proclaims that "regular application of this treatment by reversing [this natural bodily intrusive element evinced by the microflora] so that wellness is the dominant state of the human body is likely to increase the average human lifespan to approximately 150 years, double the present life expectancy."

Well I don't know about that, I don't even get what this authority is talking about. A small study from India(1) concluded, however, that oil-pulling daily for 10 minutes caused a significant decrease in oral Streptococcus mutans (the bacteria that promotes tooth decay) within 1 week of starting the practice.

I recently visited my dental hygienist for a check-up and cleaning. I have practiced daily oil pulling with sesame oil for 5 of the 7 months since my last visit with her. The conclusion? Less stain despite daily coffee, no difference in plaque, very healthy gums, and--best-of-all for me--no sensitivity in the lower teeth to her merciless probing. She was so impressed by the sparkle of my front teeth (so shiny, per her, "they look like glass") that she plans to recommend the practice to others.
_____
1. Asokan, S et al. Effect of oil pulling on Streptococcus mutans count in plaque and saliva using Dentocult SM Strip mutans test: A randomized, controlled, triple-blind study. J Indian Society of Pedodontics and Preventive Dentistry 2008. Vol 26, Issue 1, pgs 12-17.

Hydrosal, Drysol, and hyperhidrosis

2009-11-21T09:45:00.008-07:00

I can now wear tops TWICE and can wear regular shoes. DrySol, you're the best!
--Comment from satisfied user on drugs.com

I had the mixed pleasure of dining at Red Robin recently. Always a pleasure to not cook dinner and not clean up afterwards, but the burger was just so-so. I was briefly alarmed to note as the host seated us that he had enormous sweat rings below his armpits, but then I realized that some misguided RR fashion designer had put darker panels of red material down the sides of the staff's red t-shirts.

Some people, of course, do suffer from axillary hyperhidrosis or excessively sweaty pits. And they suffer terribly, choosing clothing colors less likely to broadcast their problem, keeping their arms close to their bodies. Never raising their hands because they're sure it would be an embarrassing mistake.

Enter Drysol, one of medicine's best kept secrets. Part of the problem, my problem anyway, is the don't ask/don't tell mentality of hyperhidrosis. If I don't ask, patients mostly don't tell me that they suffer from sweaty pits, hair, hands, or feet. Last month, however, I had a patient ask for Drysol by name--he'd heard about it from his nephew. And now he says "It's changed my life."

Those are strong words indeed, praise I most often hear applied to antidepressants, anti-anxiety, and anti-acne medication. Drysol or aluminum chloride hexahydrate is strong stuff. It doesn't always work, and it stings like crazy if applied to wet or newly shaved skin, but when applied with care according to the directions, many hyperhidrotics lose their drip.

Hyperhidrosis is a disorder of sudomotor nerves or those nerves that hook up to and activate sweat glands in response to heat or emotion. While thermoregulation (keeping body temperature in a healthy range) is controlled by the hypothalamus deep and central in the brain, sweaty response to emotion is under the control of the anterior cingulate cortex behind the rational frontal brain and heavily connected to our fear-directing amygdala.

A new preparation of aluminum chloride hexahydrate has been released called Hydrasal which is in a salicyclic acid gel formulation rather than pure alcohol. Small studies recently released at the March meeting of the American Academy of Dermatologists show this product is better tolerated than the Drysol preparation and is also useful in patients who are undergoing Botox injections for hyperhidrosis with incomplete relief of excessive sweating.

Bacterial contamination from toilet flushing

2009-10-28T11:22:00.004-06:00

I recently completed a long car trip, and thus spent more than a moment in public restrooms. Once in the stall, purse and road atlas in hand, I faced each time the dilemma of where to stow my gear whilst completing my business. Some facilities have elegant shelves to hold these items, others a hook on the door, some no place at all but the more or less unsavory floor. Imagine then how floored I was to read this item in the latest issue of Health Magazine(1):

"Don't put your purse on the bathroom floor; E coli in spray droplets following a flush may land on it. Hang it in the stall, and clean it inside and out weekly with a disinfecting spray or wipe."

Flushed with doubt, I wondered if this was all some sensationalist piece of journalistic nonsense designed to sell magazines and Wireless Wipes. But alas, check this out and think it over the next time you set your bag on the only dry spot on the tiled floor of a public can:

Microbiologists in the UK (2) contaminated "the sidewalls and bowl water of a domestic toilet to mimic the effects of soiling after an episode of acute diarrhoea." In other words, they dumped a gelatinous turdoid sort of matter containing fecal pathogens into the toilet bowl. Cultures of the bowl water and porcelain surfaces confirmed that significant colonies of the little darlings were clinging for dear life therein. They then flushed, and subsequent testing of the toilet AND the surrounding air confirmed that the bacteria had diminished in numbers in the actual toilet (thank heavens) but that a significant number of them had been jettisoned into the air on aerosol droplets of toilet water.

Dr. Barker and company concluded: "Many individuals may be unaware of the risk of air-borne dissemination of microbes when flushing the toilet and the consequent surface contamination that may spread infection within the household, via direct surface-to-hand-to mouth contact. Some enteric viruses could persist in the air after toilet flushing and infection may be acquired after inhalation and swallowing."

Think about it. Your toothbrushes sit how far from your toilet? My bathroom cup is inches away from mine. Do you close the cover before flushing? All this dainty hand washing, was it before or after you picked up your purse from the bathroom floor?

Yech.
_____
1) Health. November, 2009. p. 20.
2) Barker, J, Jones, MV. The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet. J Appl Microbiol. 2005;99(2):339-47.

Diagnoses at Denny's

2009-10-27T11:34:00.005-06:00

I've mentioned before that I tend to diagnose the passers-by that I see around town and on the road. I was eating breakfast at the Denny's in Moab, Utah this past week when a middle-aged couple lumbered to their seats.

They were both quite wide in the middle, carrying way too much visceral fat packed around their waistlines. Doubtless two cases of metabolic syndrome, a high risk constellation of central obesity plus two of the following: high blood pressure, low HDL cholesterol, diabetes or elevated fasting blood sugar, and elevated triglycerides. Of course, I have no idea about their lab findings, but he no sooner sat down but he pulled out a ziplock baggy jammed with pill bottles.

He was unnaturally red in the face contrasting with his pale arms and legs sticking out from t-shirt and shorts. Sunburn? Shoot, that's a med. student's diagnosis. Idiopathic erythema? Rosacea? Polycythemia vera? His legs, however, had none of the swelling or skin changes associated with venous insufficiency which is a good sign, but his calves and thighs were scrawny which may be a bad sign per a recent report that a low thigh circumference is associated with a higher risk for heart disease!

As they sat, unaware of my clinical musings, she leaned forward, grinning, and said something to him in a low voice. His face immediately crinkled with amusement and softened with affection.

My final diagnosis? They were in love!

Fun with the flu

2009-10-19T19:23:00.002-06:00

My patient no sooner sat down when she grabbed a Kleenex, said "Hold on!" and quickly turned away, coughing wetly into the tissue.

"Oh gad," I thought unhappily, "She's going to show it to me."

At that moment, my patient dabbed delicately at her lips, looked over her shoulder, and said, "Don't worry, I'm not going to show it to you."

We both burst out laughing.

C. difficile and diarrhea

2009-10-17T08:35:00.007-06:00

Clostridium difficile (C. diff) is one of many reasons to stay out of the hospital. This bacteria is not a normal inhabitant of the human gut, but once it gets a toe-hold therein, it invades the colon wall, produces toxins, and causes serious illness with bloody diarrhea. Long classified as a nosocomial infection (acquired as a result of being under hospital care for another medical problem), C. diff is now showing up as a community-acquired infection.

The classic patient profile for C. diff sufferers is someone who is old, rather ill, and receiving heavy duty antibiotics such as clindamycin, cephalosporins (which are routinely given before surgical procedures), and fluoroquinolones such as Cipro and Levaquin. Several times a year, I see a patient who has none of those characteristics but has big-time diarrhea due to C. diff. Here's disconcerting news about possible sources of community acquired C. diff.

Meat in Tucson: Researchers there sampled both raw and "ready-to-eat" meat from supermarkets. 42% of the product tested was positive for toxigenic c. diff.(1)
Ready-to-eat salads in Scotland: 7.5% of these "healthy choices" harbored virulent c. diff.(2)
Meat in Canada: 20% prevalence, and more common in winter.(3)

Denver infectious disease specialist Dr. Mary Bessesen theorizes: "I suspect that animals carry it in their gut and on their skin when they arrive at the packing house." She goes on to note that no one knows for sure whether C. diff in the commercial meat supply causes human disease but "what we have thus far is suggestive only--not proof--but it is concerning."

Yuck.
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1) Songer, JG et al. Emerg Infect Dis. 2009 May;15(5):819-21.
2) Bakri, MM et al. Emerg Infect Dis. 2009 May;15(5):817-8.
3) Rodriquez-Palacios A. et al. Emerg Infect Dis. 2009 May;15(5):802-5.
4) Vujia, DJ et al. Emerg Infect Dis. 2009 Jan;15(1):69-71.

"Using the daylight"

2009-10-11T19:37:00.007-06:00

Wise words from a century ago(1):

When illumination was poor, people went to bed shortly after nightfall and arose at daybreak. As illumination has become better, they have gone to bed later and later, especially in the cities; and the hour of rising has grown later until, in the summer at least, many persons sleep as much during daylight as in the dark.

This is of course unfortunate. Sleep is never so restful--at least for most persons--during the hours of light as when it is dark. Everyone knows this from personal experience. The old saw was that two hours of sleep before midnight were worth twice that amount afterward; and while this might not be literally true, the truth in it is that if sufficient sleep is to be obtained after midnight, then much of it must be secured after darkness has ceased. Everywhere one hears the complaint that people are becoming more nervous and are losing the power to rest thoroughly. Undoubtedly, some of this--probably much more than we suspect--is due to the fact that so much of sleep in city life where the increase in nervousness is particularly noticeable must under present conditions be obtained during hours of daylight.

The article goes on to make a case for the establishment of daylight savings time. So now we have daylight savings time, and people are still going to bed too late but now they're also getting up too early, getting insufficient sleep whether it's dark or light. And ever more, they're also becoming more nervous and are losing the power to rest thoroughly.

You cannot flick off bright lights, computers, or TVs and just pop into bed expecting to fall directly to sleep. A case could be made for turning down the wattage in preparation for bed, perhaps reading with just an Itty Bitty Book Light turned onto the page instead of a table lamp flashing our brains. Less Ambien and more common sense.
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1)The Journal A.M.A., July 31, 1909, liii, 383, 387.

Influenza, antibiotics, and procalcitonin

2009-10-10T12:23:00.009-06:00

Sure, I know what procalcitonin is, namely that which is not yet but will be calcitonin or the hormone produced by the thyroid which shuts off bone breakdown. Salmon calcitonin (Miacalcin) nasal spray used to be the only drug available for treatment of osteoporosis before Sally Field and other aging baby boomers elevated this condition to a status worthy of new and better compounds.

So what's this got to do with antibiotics? Nothing that we knew about back when I was in med school, I can assure you of that. An article and editorial in a September issue of JAMA(1), therefore, was quite an eye-opener on just how important it is to continue on with continuing medical education.

First, a word or two about lower respiratory tract infections (LTRI) and antibiotic use, a subject that impacts my patients and my decision-making processes every day, especially as swinish flu slams the Denver area. Why do I closet myself several times an hour with some miserable coughing wretch at great personal risk to my own lower respiratory tract? To distinguish ordinary, show-stopping/week-ruining influenza from its many complications, particularly secondary bacterial bronchitis and pneumonia. Often it's me (don't want to overprescribe antibiotics to avoid complications to the patient and antibiotic resistance to the public) vs. them (No time for this! Need antibiotics! Big test/presentation/trip/wedding coming up! Need antibiotics!).

I check out: how sick are they, how long have they been sick, are they having trouble breathing, is their O2 level low, how do their lungs sound, what color are their secretions. Knowing all the while that they feel miserably sick, any days with flu are too many days, their airways are swollen so of course they feel short of breath, and, of course, their secretions are doubtless gross because flu-sloughed cells in the airway plus gobs of white cells will make that which they hack out green.

Surely there must be a better formula other than my experience + intuition + observations. Enter procalcitonin(PCT), and it's not just for regulating calcium anymore. While the thyroid C-cells make PCT and turn it into calcitonin depending on the biochemical need to drop calcium levels in the blood, all sorts of other tissues release PCT when the body is fighting bacterial attack. Under normal conditions, PCT is barely detectable in the blood but levels can soar 100,000-fold with widespread sepsis as bacteria invade the bloodstream.

So here we have a wonderful demonstration of theragnostics (another concept that's new to me) wherein a diagnostic test--say PCT levels--identifies patients likely to be helped by a certain therapy, and then targeted drug therapy is given--e.g.antibiotics--based on those results. And I, with my expensive cognitive skills, am cut out of the equation thus making therapy not only more scientific and less intuitive, but also more accessible and affordable!

Now of course this is not yet anything you'll find in a Walgreen's TakeCare Clinic (until perhaps a handheld PCT-O-Meter is developed) but the possibilities are exciting. Not only could we know just when to treat acute bronchitis or pneumonia with antibiotics because PCT levels indicate a bacterial source, we could use this test in other puzzling situations such as whether or not artificial joints are infected or a patient with worsening chronic lung disease has an infectious complication.
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1) Schuetz, P et al. Effect of Procalcitonin-Based Guidelines vs Standard Guidelines on Antibiotic Use in Lower Respiratory Tract Infections. JAMA Sept. 9, 2009 Vol 302, No. 10 1059-1066.

Emotion and Memory

2009-10-04T13:06:00.007-06:00

My friend got lost years ago while on a cross-country skiing trip. The morning paper and the evening news reported search efforts in daily, discouraging detail. Time passed, and the possibility that my friend and her skiing partners lived on became less and less likely. One day, however, while driving home with the car radio on, a breaking-news bulletin announced that they had been found, alive and well if a bit frost-nipped on fingers and toes. I had to pull over and get a grip on my teary emotions.

I can tell you the exact spot I pulled over, the weather, and where I had been. This all quite remarkable as, on average, I've a big picture sort of mind while the details leak before storage in long-term brain files (no surprise this to my husband). My friend later told me that everyone invariably related the minutiae of the moment in which they'd heard of her rescue--this after I'd supplied her with my experience as if it were the most fascinating tale.

So what's with this emotional boost to memory? If you were alive at the time, you can doubtless remember where you were when Kennedy was shot or the moon landing occurred. Likewise for the World Trade Center tragedy and perhaps Princess Diana's death.

Japanese neuroscientists studied emotion and memory in patients with Alzheimer's Disease (AD) following the devastating Kobe earthquake of 1995.(1) They performed brain MRIs on all the subjects, then checked out who remembered the earthquake and who remembered the MRI. The patients were much more likely to remember the quake, suggesting that intense emotions reinforced the memory.

The researchers went on to correlate the ability to remember the temblor with the residual size of the subjects' hippocampus (the brain's memory center) and amygdala (emotional center). Victims of AD are known to suffer from brain shrinkage. Those who retained the emotional memory of waking up to a significant earthquake were much more likely to have a normal-sized amygdala no matter the size of their hippocampus, and, likewise, those with impaired emotional event memory had more intense amygdalar damage.
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1)Kazui, H. Emotion and memory. Four studies of the emotional memory in Alzheimer's disease. Japanese Journal of Neuropsychology. VOL.18;NO.3;PAGE.150-156(2002).

Can Prednisone make me feel crazy?

2009-09-30T18:13:00.004-06:00

If you've ever taken it, you already know the answer is an emphatic YES!! Here's a visual from my friend and artist Rose Kelly about her trip to the "Prednizone" while undergoing chemo.

Advanced glycation end products

2009-09-27T16:05:00.004-06:00

That which is truly tasty, like make the hair stand up on your neck and shiver over the full delicious tastiness of it all, may prematurely age your blood vessels, your nerves, your kidneys, and your joints.

These advanced glycation end products or AGE are the end-products of reactions that bond sugar to protein in the absence of water. Think sugar steaks (too bad you won't want to try one at Bastien's Steak House on Colfax after reading this), the brown sugar/Jack Daniels crust on baked ham, browned cookies, the caramelized surface of creme brulee. So let's just say you avoid AGE in foods, and I'm not necessarily saying you should because, after all, life is meant to be enjoyed, well turns out you can glycate your own darn sugar once its ingested or produced. And fructose (that which sweetens your bottled drinks) is very prone to glycation.

So AGE along with ALE (that would be advanced lipoperoxidation end products or metabolized fat) are very proinflammatory molecules. AGE hooks up with specific cellular receptors called RAGE and the combo acts as a 'master switch' that activates nuclear factor kappaB(1) and creates high levels of dysfuntional proteins among other things. The sort of dysfunctional proteins that gum up your brain, your peripheral nerves, and your arteries.

Well we're all going to rust and glycate and peroxidate eventually, and we may as well do it with the satisfied smile of the occasional gourmand. But, as in all things, a little is good but a lot is not, and if you want to keep your cells functional, some things are best done in moderation or not at all.
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1) NF-kB is a good thing if you happen to be injured or infected as it amplifies the immune response but a bad thing if you happen to drink Coke and eat browned chocolate chip cookies on a regular basis.

New Diagnoses, New Behavior

2009-09-22T09:22:00.004-06:00

Can't look for what you might find
Once more you're running around in circles just to prove
You knew the answers all the while
Can't figure why no matter what you say or do
Things stay the same you will remain
Day late a dollar short
Day late a dollar short
--The Acro-Brats(1)

There's nothing like a new diagnosis of diabetes to get a patient's attention. Suddenly, all those discussions about diet, exercise, weight loss, soda consumption, etc. make sense. Well better late than never (perhaps The A-B's have a song about that too) but there's also the day late dollar short thing too because this is a condition that you are far better off without.

Yale scientists actually set out to prove what I already knew from years of consultations with the newly diagnosed. They checked out data from the Health and Retirement Study panel on over 20,000 people who were overweight or smokers.(2) The odds of weight loss or smoking cessation were hugely increased among individuals newly diagnosed with serious illnesses such as diabetes, smoking, heart disease, or COPD. Those who'd just learned they had heart disease were 5 times more likely to throw away the smokes than persons just counseled to do so just because it was the right thing to do, and new diabetics sent their BMI's plunging compared to the merely overweight.

Can't figure why no matter what I say or do
Things stay the same patients will remain
Day late a dollar short
Day late a dollar short

_____
(1) I actually listened to this song on You-Tube. Definitely not my thing--the metallic thrum made my amygdala cringe-- but I appreciate the edgy frustration expressed by the Acro-Brats. I feel it myself, everyday, in exam room encounters.
(2) Keenan, PS. Smoking and weight change after new health diagnoses in older adults. Arch Intern Med. 2009 Feb 9;169(3):237-42.

Too close for comfort?

2009-09-20T09:14:00.005-06:00

I recently attended my 40th high school reunion. I talked for awhile with one old friend I hadn't seen in years. But I was distracted during the entire conversation by her preferred conversational distance which was close, darned close! Not a breath problem--hers was fine and apparently mine was too--just my problem with her 'in my face' proximity. A new study may indicate why, and it implicates my overactive amygdala.

I've mentioned before that the amygdala, an almond-sized region at the base of the brain, is nerve cell center for coordinating response to threat. If yours is on overdrive like mine, you may over-respond to horror movies, scary books, and phones ringing in the night.

Neuroscientists had the opportunity to study the biological underpinnings of personal space in a patient known as SM. She had a genetic disorder that took out her amygdala, and as a result, she could not recognize fearful facial expressions in others, and was very outgoing and far more trusting than average. And she cozied up in conversational situations such that she--Ms. Red above--let an experimenter get twice as close to her as the other Ms. Blues did without expressing any discomfort in the situation. (1)

Scientists went on to study preferred conversational distance with functional MRI scanning.(2) They socked away average persons with intact amygdalae in the machine, then got closer and closer to the subjects, measuring their brains for activity. When they invaded that person's comfort zone, the amygdala lit up with activity.

"Our findings support the idea that the amygdala functions as the brakes in social interactions, If you take away the amygdala, it seems like you are less tuned to ... social [behaviors] that can cause discomfort," says neuroscientist Richard Davidson of the University of Wisconsin.(1)
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1) ScienceNOW Daily News, August 31, 2009
2) Kennedy DP et al. Personal Space Regulation by the Human Amygdala. Nat Neurosci 2009 Aug 30.

Antibiotic resistance and beyond

2009-09-17T06:50:00.001-06:00

Almost all the drugs that we consider as our mainline defense against bacterial infection are at risk from bacteria that not only resist the drugs but eat them for breakfast.
--George Church, geneticist, Harvard Medical School

What's eating you may eat drugs too! Church and company dug up this unhappy piece of news while digging in a cornfield fertilized with manure from antibiotic-fed cows. They compared the locals (soil microbes) in the corn patch to their bacterial colleagues from the dirt of a pristine forest and several other locales more or less contaminated with druggish waste.

So you'd expect those bugs inured to manure to be antibiotic resistant and the au naturel bunch to die when cultured with drugs, right? Unfortunately, wrong. Bacteria from every sampling included strains that could survive "with nothing to eat but antibiotics." Not only did these little hummers not die from the drugs, they devoured them.

For those of us who think antibiotic resistance is not a huge and looming danger, Gerry Wright, a chemical biologist from McMaster University, sums it up in words that can't be ignored: "Soil bacteria pass around resistance-conferring genes like teenagers swap downloaded music files, and pathogenic [disease-causing] bacteria could likewise pick up antibiotic-digesting genes, particularly from a closely related microbe.

Great.

Health care debate

2009-09-15T19:04:00.004-06:00

If you live in the Denver area, consider attending the Great Debate on Health Care this Thursday, Sept. 17th at South High School. Conservative talk show host Hugh Hewitt and C.U. law professor Paul Campos, both articulate proponents for their respective sides, will debate current proposals for health care reform. You can order tickets online at 710knus.com or purchase tickets at King Soopers.

Denver Doc now on Twitter

2009-09-15T12:13:00.003-06:00

I've made the technological leap to Twitter for those medical pearls of wisdom from me to you that fit in 140 characters or less. No updates on my dentist appt. or the weather here in Denver, just good health-related information from reliable sources. This blog will continue to be published on a regular basis as well.

If you're interested in Twitter updates from Denver Doc Online, you can sign-up at
www.twitter.com/docofages. Thanks!

The amygdala and PTSD

2009-09-14T20:13:00.009-06:00

I can hardly bear to watch violent or scary movies. I walked out on The Ring the moment the dried-up little girl was found in the closet (thankfully, the movie was 'showing' at the time in our living room). And the opening scene of The Exorcist in which Father Merrin finds the creepy little statue, the wind blows, and a couple of dogs fight still can interfere with a good night's sleep for me.

Research suggests that an overactive amygdala (the brain's VP in charge of processing emotional experiences and fear) may predict how an individual handles stress, be it in pictures or for real. Israeli scientists used functional magnetic resonance imaging (fMRI) to scan the brains of 18 year old subjects undertaking training as paramedics(1). They scanned the trainee's brains while showing them photographs of graphic medical scenes specifically looking for activation in the amygdala region. They also screened the recruits for stress symptoms including anxiety and insomnia.

After 18 months and a grisly load of combat experience, the researchers found that those paramedics with the largest increases in stress symptoms were the ones with the greatest amygdaloid activity on the initial scan. Study co-author Talma Hendler says that the amygdala may be an "a priori biological marker" for individual susceptibility to post-traumatic stress disorder.

Rather than use a fancy, expensive fMRI as a screening test for fitness under fire, I suggest a less expensive showing of Inglorious Basterds. Check the subjects' heart rate and blood pressure by the movie's end, and you'll know who's ready for the field and who should stick to the office.
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1. Proc Natl Acad Sci USA. 2009 Aug 18;106(33):14120-5.

H1N1 vaccine--one dose will do!

2009-09-10T18:21:00.003-06:00

This just released today on the New England Journal of Medicine web-site. Results from the H1N1 vaccine trials indicate that one dose of the soon-to-be-released shot results in a good response from most adult subjects. Furthermore, no serious adverse effects occurred--just the usual sore arm and the vague flu-ish sort of feeling that is commonly occurs as a result of the immune reaction to the shot.

Vaccine demand is expected to exceed supply through the fall, so this one shot news is good news indeed.

Who should get Tamiflu for H1N1 flu?

2009-09-07T16:22:00.006-06:00

If this past weekend is any indication of phone calls to come, I will be busy fielding requests for Tamiflu for suspected 2009 A(H1N1) which is what we're calling swine flu these days. Patients are understandably nervous for themselves and their families with regards to the spread and severity of influenza illness.

There are 2 available antivirals which are active against 2009 A(H1N1)-- oral Tamiflu (oseltamivir) and inhaled Relenza (zanamivir). For some reason, I've always reached for Tamiflu, and a brief search for a comparison of one antiviral to the other suggests that I am just another victim of an effective marketing campaign by Roche Pharmaceuticals. Nevertheless, be it Tamiflu or Relenza, one of the biggest fears per flu-ologists is that the novel H1N1 flu will become resistant to these worthy drugs, and they will be rendered powerless against the bug.

So what does the CDC have to say on the subject? They along with the WHO (the World Health Organization, that is, not the '60's band) recommend that antiviral treatment be undertaken in accord with the following guidelines:

Treatment is recommended for all hospitalized patients with confirmed, probable or suspected 2009 H1N1 or seasonal influenza.
Treatment generally is recommended for patients who are at higher risk for influenza-related complications.
Treatment should be initiated empirically when the decision is made to treat patients who have illnesses that are clinically compatible with influenza. Treatment should not await laboratory confirmation because laboratory testing can sometimes delay treatment and because a negative rapid test does not rule out influenza.(1)

In other words, if the patient is sick enough to be hospitalized with flu-like illness, initiate treatment immediately. While these antivirals work best if initiated in the first 48 hours of illness, evidence suggests that hospitalized patients with seasonal flu fare better with respect to risk of death and length of hospitalization if Tamiflu therapy is started even if it's more than 48 hours after onset. Those known to be at higher risk of flu-related complications include pregnant women, persons who are immunocompromised (undergoing say chemotherapy or treatment for rheumatoid arthritis), or those with underlying medical illnesses such as diabetes, asthma, or heart disease. And finally, if we providers determine that a patient meets one of these criterion, get 'em going on it and don't wait for final proof!

These recommendations highlight the urgency with which certain subgroups of flu victims should be treated. The CDC, therefore, goes on to make further suggestions as to handle the upcoming flu season and the avalanche of requests for antiviral medications. These include:

Provide information for patients at higher risk for influenza complications about signs and symptoms of influenza and need for early treatment after symptom onset.
Ensure rapid access to telephone consultation and clinical evaluation for these patients as well as patients who report severe illness.
Consider empiric treatment of patients at higher risk for influenza complications based on telephone contact... if this will substantially reduce delay before treatment is initiated. In selected circumstances, providers may consider giving a prescription for an influenza antiviral to selected patients who are higher risk for influenza complications.
Request that patients at higher risk for influenza complications contact the provider if signs or symptoms of influenza develop, obtain the medication as quickly as possible and initiate treatment.
Counsel patients about influenza antiviral benefits and adverse effects, the potential for continued susceptibility to influenza virus infection after treatment is completed (because of other circulating influenza viruses or if illness was due to another cause).(2)

What about antiviral chemoprophylaxis wherein antivirals are given to at-risk persons exposed to someone who is fluish? Please note in no case do these recommendations include giving Tamiflu to any old person traveling and worried regarding flu exposure except as outlined in the 3rd guideline above.

Persons who are at higher risk for complications of influenza and are a close contact of a person with confirmed, probable, or suspected 2009 H1N1 or seasonal influenza during that person’s infectious period.
Health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person with confirmed, probable, or suspected 2009 H1N1 or seasonal influenza during that person’s infectious period.
Antiviral agents should not be used for post exposure chemoprophylaxis in healthy children or adults based on potential exposures in the community, school, camp, etc.
Chemoprophylaxis generally is not recommended if more than 48 hours have elapsed since the last contact with an infectious person.

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1. http://www.cdc.gov/h1n1flu/recommendations.htm
2. This is an abbreviated list. See above web-site for the full printed version.

H1N1 and severe respiratory failure

2009-09-04T11:50:00.008-06:00

Scientists are ferreting out clues to the ferocity with which this new swinish flu attacks the lower airways in some of its victims. Ferrets demonstrate a susceptibility to influenza A very similar to humans and therefore are used as an animal model in flu investigations.

The above picture(1) shows microscopic sections of ferret airways (that is not a goose!), comparing seasonal H1N1 flu (the usual variety that circulates each winter season) on the left to tissue infected by the 2009 A/H1N1 flu on the right. Violet coloration indicates affected surface cells, and both varieties make a mess out of noses with sloughing sheets of dead nasal tissue full of violet-colored intruders as seen in the top pair of slides.

Moving on down to the trachea (which is the largest central airway lined with rings of cartilage that you can feel in the front of your neck), the ferret with seasonal flu middle picture on left is free of viral invasion but the swine-flu ferret victim on the right has dots of violet flu violation throughout its trachea. Finally, and of importance to this discussion, slides from the bronchioles of both ferrets are pictured at the bottom. This tissue was obtained from the smallest airways that go directly into the alveolae or air sacs that hook up oxygen with blood. Seasonal Flu Ferret has normal bronchioles, flu bug free, but Swine Flu Ferret's tiny air passages are teeming with the little buggers.

What's this got to do with the upcoming flu season? One of my patients, an ICU nurse, shared a disturbing report with me yesterday. She said that her unit has been busy this entire spring to summer with youngish patients suffering from severe swine flu-related bronchiolities (inflammation filling these airways with fluid) requiring ventilator support until the infection started to clear. Her information jibed with an August report from the World Health Organization entitled "Preparing for the second wave: lessons from current outbreaks." Per the WHO document:

"Clinicians from around the world are reporting a very severe form of disease, also in young and otherwise healthy people, which is rarely seen during seasonal influenza infections. In these patients, the virus directly infects the lung, causing severe respiratory failure. Saving these lives depends on highly specialized and demanding care in intensive care units, usually with long and costly stays."

This information highlights not only the importance of widespread immunization against the 2009 A/H1N1 flu (which creates so-called herd immunity, slowing down or preventing the lateral spread of flu from person-to-person due to the large number of vaccine-protected people) but also the paramount importance of immunizations for persons with underlying illnesses, particularly asthma, cardiovascular disease, diabetes, and immunosuppression.
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(1) Munster, VJ, et al. "Pathogenesis and Transmission of Swine-Origin 2009 A(H1N1) Influenza Virus in Ferrets." Science 24 July 2009: Vol. 325. no. 5939, pp. 481 - 483.

Why should I get a flu shot?

2009-09-01T14:19:00.003-06:00

Well, there's a hack of a lot of flu coming our way. Consider this:

Flu viruses reproduce every 8 hours.
That's a three times daily opportunity to meet and mate with other influenza viruses in the neighborhood.
If seasonal A(H1N1) rolls in the tracheal hay (that's your airway!) with swine-origin 2009(H1N1), the latter could develop an even more effective way of passing from human to human.

Conclusion? You do NOT want these bad actors fooling around together in your nose and throat. In order to prevent such airway orgies, you need two shots. The CDC currently recommends that you get the seasonal flu vaccine now to prevent crazy long lines in late October when the swine flu vaccine rolls off production lines and into your neighborhood Safeway. So roll up your sleeve, and get shot 1 now.

H1N1 flu shots

2009-08-28T18:04:00.007-06:00

Coming soon to your neighborhood supermarket: An ounce of prevention against H1N1.

More precisely, .0000005 ounce of prevention which is the teensy-weensy amount of killed viral material that scientists from the CDC, National Institutes of Health, and various licensed pharmaceutical companies inserted into syringes as they launched clinical trials of newly manufactured H1V1 vaccine earlier this month. They expect to analyze study results from mid-September to mid-October and then begin the first public immunization programs before Halloween. The trials will provide important information on the vaccine's safety, efficacy, and whether one or two doses are needed to provide optimal protection. (Study results released 9/10/09 indicated that one dose for adults is sufficient.)

We already know that H1N1 influenza, first identified in Mexico in late winter of this year, is the most common cause of flu-related illness throughout the world at this time. While this new viral strain continues to cause low-levels of new cases in all 50 states, it is currently 'widespread' in Maine and Alaska. But the regular flu season has not even started yet, and once the usual seasonal blend of influenzas A and B hits, we can expect a double whammy of flu-driven illness this fall into winter.

Quite a few of you have called our office with logistical questions about how best to protect yourselves and your families against this onslaught of respiratory crud. Here's the latest information:

What can we expect?

We know that H1N1 flu is quite contagious, easily passed person to person via contaminated secretions from coughs and sneezes, and able to survive on surfaces for up to 8 hours. While the initial reports from Mexico were quite disturbing with respect to the severity of illness caused by this strain, the illness lately has been acting a lot like seasonal flu. It does disproportionately affect persons under 60 and and can be unusually virulent in those under 25. Per Dr. Jay Butler of the CDC, "75% of the [H1N1]hospitalizations are in those aged under 49 and 60% of the deaths are in those under age 49." Studies showed that no young adults demonstrated circulating antibodies to H1N1 at the start of this pandemic whereas many older adults apparently encountered a similar influenza variety in the past and were found to have some immunity to this strain.

Experts are unable to estimate the community prevalence of H1N1 as many cases are too mild to come to medical attention. In addition, as H1N1 becomes more prevalent, the CDC no longer recommends that such mild cases be tested to confirm the presence of this specific virus.

As I've mentioned in previously posts, influenza is a tricky and changeable foe which can mutate rapidly. Thus far, thankfully, studies of the virus from recent cases in the southern hemisphere demonstrate no significant genetic change from northern cases investigated earlier this year.

What's the difference between H1N1 and the seasonal flu?

H1N1 is a novel strain originating in swine (but not caused by consumption of pork!) that developed in North American pigs through the mixing in their respiratory tracts of genetic material from swine, human, and avian flus. It is antigenically distinct from seasonal flu which means that its proteins and genetic material are completely different than the ordinary influenza types that circulate each winter season.

Will I need shots for both?

Absolutely. Separate shots will be available for seasonal and H1N1 flu. Preliminary information released in an online version of The New England Journal of Medicine 9/10/09 indicates one dose will be sufficient for adults; the proper dosing for children is not yet available.

The seasonal flu shot and the H1N1 shot can be taken on the same day--but different arms please! The seasonal shot is already available, however, whereas the first H1N1 vaccines will not be distributed until late October. While the optimal time to receive the seasonal flu shot is October or November to assure that immunity lasts through the entire season, the CDC currently recommends that persons receive the seasonal vaccine as soon as possible to assure that both flu shots can be administered to the largest number of people.

How can I get the H1N1 vaccine?

While the CDC was hopeful that ample vaccine would be available by October, production delays will slow delivery of adequate vaccine until later on in the year. For this reason, certain groups have been assigned top priority for the first wave of vaccinations, chosen due to their risk for more serious disease. These include:

Pregnant women
Persons who live with or provide care for infants aged <6>
Health-care and emergency medical services personnel with direct patient contact
Children aged 6 months--4 years, and
Children and teens aged 5--18 years who have high risk medical conditions

What about college-aged children?

The CDC and universities are implementing various programs to limit the spread of H1N1 disease on campus. Some Colorado schools will offer alternative housing for dorm residents whose roommates become ill.

Stay tuned for up-to-date information on the use of anti-viral medications such as Tamiflu for H1N1 prevention and treatment.

Triple Reassortment Swine Influenza*

2009-08-25T12:56:00.004-06:00

*aka Triple Reassortant Swine Influenza

"Six of the eight genetic segments of this virus strain are purely swine flu and the other two segments are bird and human, but have lived in swine for the past decade."
---Raul Rabadan, PhD, computational biologist at Columbia University

And that is why pigs are dubbed "mixing bowls" for influenza viruses. While humans are susceptible to human influenza viruses and somewhat less so to the swine varieties (at least up until now), our airways don't provide particularly good handholds for those influenza subtypes that seek out birds. Pigs, on the other hand, have receptors on the surfaces of their tracheal cells that welcome strains from all three species. From porcine throats and lungs, therefore, emerge new flu varieties with the potential to cause dangerous human disease.

These new flus are called triple-reassortment swine influenza A viruses as they contain genetic material from bird, human, and pig influenza viruses. Until recently, the pigs of North America kept their flu to themselves with sporadic reports of human infections generally limited to those most exposed to pigs in their daily work. Now, however, with another flip of their surface proteins--and flu viruses reproducing every 8 hours have 3 opportunities per day to mix, match, and mutate their DNA in a promiscuous sort of way--the little swinish devils have brought these reassorted flus to human airways. Furthermore, this newest genetic triple threat passes easily from one infected human to another.

With all this mating and mutating, therefore, epidemiologists are finding it hard to predict what's in store as the swine flu (and it is a swine flu no matter what it's called, passed at first from live pigs not pork meat) makes it way back to the Northern hemisphere big time. Fortunately, vaccine production is underway, and immunization programs should begin next month. More on that soon.

What's a Phase 6 pandemic?

2009-08-01T15:05:00.006-06:00

WITHOUT A VACCINE, CDC ESTIMATES GRIM FOR SWINE FLU Denver Post, July 25, 2009

Grim?!? Whoa, that's a pretty strong word. In this weekly flu update, we'll check out the ease with which the H1N1 (formerly known as swine) flu spreads from person to person, and why the CDC is hoping for a timely vaccine against the virus.

What's a Phase 6 pandemic?

Sounds serious, and indeed it is insofar as it speaks of the ease with which this little hummer spreads from one human to the next.

The World Health Organization (WHO) has developed a 6-tiered approach that classifies the worldwide threat from strains of animal influenza newly arrived in human airways. Each higher level indicates an increased penetrance of the virus into human populations. By Phase 6--the current global level of the H1N1 flu--the virus has shifted into a lean, mean, human-to-human infecting machine in at least two countries of one WHO region and with spread detected in at least one country of a different region. This particular influenza virus, therefore, reached Phase 5 once it spread from person to person in Mexico and the United States; its subsequent spring '09 appearance in the Southern hemisphere then raised the threat to level 6.

Experts agree so far that this variety of influenza has a 'substantially higher' rate of transmissibility than the usual seasonal flu although this in itself does not mean that it's more lethal.

So what's transmissibility and what's the H1N1 score?

Influenza is quite contagious as it thrives in infected respiratory secretions and effectively spreads those viral laden droplets into the environment via juicy sneezes and coughs. The smaller the droplet, the longer it floats through the air and the further it penetrates into the airway of the unlucky recipient who inhales it. If the virus is novel--meaning that large portions of the population have never encountered this particular bug before--the risk of contagion is even higher.

Epidemiologists express transmissibility as reproductive number (R0 or R-zero) which is the number of cases caused by one infected person. If the R0 is less than one, the disease fades away, whereas rising R0 numbers mean that the spread of the disease is increasingly harder to contain. Experts think that an R0 more than 2 renders such measures as closing schools and screening visitors from other countries for signs of the disease as virtually useless.

So what's the R0 of H1N1? Compared to the seasonal flu with an average R0 of 1.3, estimates for H1N1 vary between 1.3 to more than 2. Calculating an accurate R0 for novel H1N1 flu is very complicated considering the many unknowns about this pandemic such as the incubation time and the percentage of cases mild enough to escape official notice. But we must assume that H1N1 is sporting a fairly robust R0 considering its current worldwide status, and, for that reason, we desperately need a vaccine to slow the spread of infection.

Upcoming info

The important thing in containing this pandemic, therefore, is the development and widespread use of an effective vaccine. More on that subject next week.

The end of private health insurance?

2009-07-21T13:28:00.003-06:00

I generally don't mix politics with medicine, but I ask you to consider this article from Investor's Business Daily published July 15, 2009:

It didn't take long to run into an "uh-oh" moment when reading the House's "health care for all Americans" bill. Right there on Page 16 is a provision making individual private medical insurance illegal.

When we first saw the paragraph Tuesday, just after the 1,018-page document was released, we thought we surely must be misreading it. So we sought help from the House Ways and Means Committee.

It turns out we were right: The provision would indeed outlaw individual private coverage. Under the Orwellian header of "Protecting The Choice To Keep Current Coverage," the "Limitation On New Enrollment" section of the bill clearly states:

"Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day" of the year the legislation becomes law.

So we can all keep our coverage, just as promised — with, of course, exceptions: Those who currently have private individual coverage won't be able to change it. Nor will those who leave a company to work for themselves be free to buy individual plans from private carriers.

From the beginning, opponents of the public option plan have warned that if the government gets into the business of offering subsidized health insurance coverage, the private insurance market will wither. Drawn by a public option that will be 30% to 40% cheaper than their current premiums because taxpayers will be funding it, employers will gladly scrap their private plans and go with Washington's coverage.

The nonpartisan Lewin Group estimated in April that 120 million or more Americans could lose their group coverage at work and end up in such a program. That would leave private carriers with 50 million or fewer customers. This could cause the market to, as Lewin Vice President John Sheils put it, "fizzle out altogether."

What wasn't known until now is that the bill itself will kill the market for private individual coverage by not letting any new policies be written after the public option becomes law.The legislation is also likely to finish off health savings accounts.

Washington does not have the constitutional or moral authority to outlaw private markets in which parties voluntarily participate. It shouldn't be killing business opportunities, or limiting choices, or legislating major changes in Americans' lives.

A blogger from Maine, participating in a conference call with the President, said he kept running into the above article that claimed Section 102 of the House health legislation would outlaw private insurance. He asked: “Is this true? Will people be able to keep their insurance and will insurers be able to write new policies even though H.R. 3200 is passed?” President Obama replied: “You know, I have to say that I am not familiar with the provision you are talking about.”

Bystolic testimonial

2009-07-17T11:35:00.003-06:00

I wrote some time ago about a medication called Bystolic, a beta-blocker used for hypertension and irregularities in heart rhythm. Beta-blockers also have been used for years to calm the body manifestations of anxiety such as a racing heart, and they are, therefore, useful for stage fright. I have several lawyer/patients who use beta-blockers when they must speak in court. Another patient was having panic attacks that were difficult to diagnose as they manifested with symptoms quite similar to TIAs. After completing a detailed cardiac work-up, I put her on a small dose of Bystolic (2.5 mg. or 1/2 of the smallest available tablet) which controlled both her attacks and her blood pressure.

Here is an e-mail I received from Cheryl on her experience:

I have been using Bystolic for over a month. I love it. Not only is it controlling my anxiety and fast heart rate, my blood pressure is down and I have a generalized good feeling. Things don’t get me worked up like before. And, I’m breaking the 5mg in half. I did have to stop taking it in the evening because my sleep was restless. But, I start my day with a cup of coffee and half a Bystolic and it’s a good thing. I was reluctant after trying samples of Diovan that almost killed me. (Yuk on that one….Poison*).

If I had known how great I would feel on Bystolic, I would have taken it a long time ago. I’m not a pill-popper and dodge it, but this works! I am a health freak and have fought taking meds, but my doctor prescribed it for my racing heart. The benefits make my life happier and healthier.

*This is Cheryl's reaction to Diovan. It often works well for others, and is a good drug for hypertension.

Onsolis

2009-07-17T11:08:00.005-06:00

My dear friend is dealing with enormous post-op pain following a prolonged surgery for a bowel blockage. She's still in the IV drip phase of pain control, snowed under by varying doses of ketamine, hydromorphone, and methadone. The surgical team has called in anesthesia and the pain team to help manage her case, so we are once again dealing with multiple docs who, we hope, are more than less keeping in touch with one another.

Ways to control pain that don't require swallowing pills are important to surgical pain control as well as in situations where oral meds aren't tolerated or aren't enough. I was interested, therefore, to learn today about Onsolis, newly approved by the FDA, as an entirely new approach to the problem. Onsolis uses BioErodible MucoAdhesive (BEMA®) drug delivery technology to deliver Fentanyl across the tissues of the inner cheek into the bloodstream. Up until now, Fentanyl has been available as a skin patch which sometimes causes local irritation and occasionally results in overdose if patients apply heat to the body area on which the patch is stuck.

Gotta be careful with these heavy duty narcotics though, they are not for the uninitiated or narcotic naive patient whose liver is not muscled up for processing these drugs. I once had a patient with dreadful arthritis in her neck. She was prescribed morphine for pain control, and in an effort to be painfree, took way more than she tolerated and died in respiratory arrest. For patients like my friend, however, who have been using narcotic analgesia for some time and cannot reliably use or absorb oral meds, this little patch may be a great boon to their comfort.

Of cockatiels and trumpets

2009-07-03T10:22:00.007-06:00

Some of my patients are 'difficult' insofar as I am stumped as to what they need and how to improve their health situation. One such customer was a middle-aged lady plagued with pain, poverty, and depression. She was a large lady, and part of each appointment was spent in the slow walk from the waiting to the exam room which she negotiated one tedious step at a time with the help of two canes. She always arrived with copious pencil-written notes about her days spent doing little other than getting by.

What her notes never included, however, were tales of her cockatiels. Who knew she raised birds? I certainly didn't. I'm not sure how it even came up, but once we discussed her birds, everything seemed to change. She still came armed with those torn notebook pages full of complaints, but she was also the person who brought pictures of her birds and their tiny little-finger sized hatchlings. She was now, for me, the bird lover who struggled with pain rather than just the pain.

Yesterday's new patient was a nervous young man who at 23 had an engineering degree and spent his working days making sure that the calculations made by his firm on bridge design were correct. I remember a magazine article on school standards (and their increasing laxity) that asked the reader whether or not they would care to drive across a bridge designed by someone in the lowest quartile of their engineering class. My first impression of this fellow was that he'd be a good one to have beneath the bridge upon which we drive with nary a thought as to its safety.

At the end of the physical, I asked him if he planned to go on to a higher degree in engineering. He answered that he felt that engineering was going to be the job that supports his real loves in life, namely playing the trumpet. I'd like, I thought, to drive across bridges designed by this engineer who plays the trumpet. No need anymore for either of us to be nervous.

Abilify testimonial

2009-06-10T18:36:00.004-06:00

I wrote recently about a patient whose 'delusional parisitosis' was ruining her life. She felt that bird mites had invaded her home, her car, and her siblings' homes, making her too anxious and distracted to work or carry on any semblance of normalcy. A psychiatrist started her on Abilify last month during a brief involuntary hospitalization orchestrated by her frantic family.

She came in today, 5 weeks into her Abilify treatment. She looked well--rested and tear-free. She declared that things were 'almost back to normal'; she was back in her home, no longer experienced abnormal skin sensations, and had returned to work. I didn't ask her if the mites were gone, nor did she volunteer anything along the lines of 'what do you suppose that crazy business was all about?' I didn't feel like she needed to acknowledge whether or not the mites were real or imagined; it was more than sufficient that they were no longer front and center in her mind and her life.

I hope her insurance pays for this medication. It's four-plus expensive, but what an amazing difference it's made for her.

Bacteria, bad breath, and oil pulling

2009-06-07T16:19:00.007-06:00

I've been thinking about bad breath and mouth hygiene lately (and as soon as I get the big "L" off my forehead, perhaps I'll think about something fun). First of all, I wonder what to do about patients with bad breath--not the ones who complain of it who frankly never have bad breath on examination, but rather the clueless ones who have bad breath and don't know it. Should I say something to them? Perhaps I could include "Do you have bad breath?" in my review of systems during the annual physical, and if they answer "No," tell them "Not so fast on the negative buster!"

My latest foray into alternative medicine includes a month-long experiment in the Ayurvedic practice of oil-pulling. I'm not quite sure where I came across it, but it seemed like an intriguing way to use up a bottle of organic sesame oil sitting in my 'frig. First of an a.m. on an empty stomach, I sip but don't swallow a tablespoonful of sesame oil. As I bring in the paper, make coffee, empty the dishwasher, and do the little morning chores, I 'pull' the oil through my teeth or poke at the mouthful with tongue against teeth for (theoretically) 20 minutes or until my mouth is too full and I'm too grossed-out to go on which got up to 14 whole minutes today. Spit and rinse follows, then on to breakfast.

Testimonials abound on the Internet in support of the practice which, among other things, is supposed to enhance oral hygiene, and lessen tooth decay, bad breath, and dry lips. So far, one week into it, it only dampens my enthusiasm for breakfast and seems to make me less prone to eating the crap that drug reps bring in to the office (despite new Pharma regulations against the practice!).

An article in the Journal of the Indian Society of Pedodontics and Preventive Dentistry reported a study wherein 10 adolescent boys were somehow convinced to oil-pull in the a.m. for 10 minutes, and then their levels of streptococcus mutans (a bacteria associated with tooth decay) were compared with another group of 10 who swished instead of a morning with chlorhexidine mouth wash. Both groups experienced the same drop in levels of those s mutans bad boys.

But...I dare you to find a bunch of health nuts waxing poetic over the morning use of chlorhexidine mouthwash! Consider this on oil pulling from Molly of SanFrancisco: The really bad stuff that forms plague [sic], is very attracted to the acids in the oil. So it melts this bad stuff and then you spit it out. That's why your teeth get much cleaner than by conventional means, like alcohol based rinses. And so, when you melt this bad stuff, you simply spit it out..buh bye.

On now to my real story here which is breaking news from the first ever symposium on the microbiology of odors held last month in Philadelphia. Israeli microbiologists have developed a new saliva test called OkayToKiss that tests for the presence of certain enzymes produced by gram-positive bacteria (such as s mutans) that make it easier for gram-negative bacteria in the mouth to break protein into malodorous compounds.

The doc-in-charge of the research, Dr. Mel Rosenberg, is described as an "international authority on the diagnosis and treatment of bad breath." He invented a two-phase mouthwash (containing saline and oil) based on his studies of petroleum microbiology wherein he discovered that oral microorganisms from dental plaque when mixed with nontoxic oils became bound to the oil. Voila! Does that not sound like a variation on oil-pulling to you? Check out melrosenberg.com if you want a ton of technical on the process. And the 1-2 mouthwash known as Assuta bested Listerine with respect to longterm control of halitosis.

So back to this OkayToKiss test. Due out next year, this pocket-sized test I gather is a treated piece of paper that you lick and check. If it turns blue, keep your mouth to yourself. This Dr. Rosenberg is a kick--don't miss his smellwell site for more ideas on keeping fresh as a daisy.

September, 2009 update: Still oil-pulling. I can last 15 or more minutes at it, no problem. Teeth so white that my 20-something year old daughter who commented below about how gaggingly gross this sounded is now doing it herself. My first visit with the dental hygienist post oil-pulling is next month; I'll let you know how I fare.

Dying for D

2009-05-30T19:44:00.006-06:00

A lot of you, it seems, have not yet gotten the memo. All this sun-phobia has caused an epidemic of vitamin D deficiency. The latest articles I've seen go by implicate low levels of D as a contribution to non-melanoma skin cancers (thought you were ducking that by avoiding the sun, did you?), bacterial vaginitis(!), and depression. Now this from the Archives of Internal Medicine:

Researchers sorted through the mountain of data generated by the Third National Health and Nutrition Examination Survey looking at D levels as compared to the incidence of dropping dead in some 13,000 participants followed from 1988 through 1994.

Those participants with D levels lower than 17.8 ng/ml (and at least half my patients test into this range!) had a 26% increased risk of dying compared to those more D-endowed. The likelihood of being D-ficient was higher in those who were older, female, nonwhite race (darker skin is not as efficient at producing D when exposed to sunshine), diabetic, smokers, overweight, and in those who did not take D supplements. I have found many who rely on the D added to dairy products or calcium supplements and/or the D in multivitamins are also often deficient.

Take D. Take it everyday. Get a little sunshine on your unsunblocked self.
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Melamed, ML, et al. 25-hydroxyvitamin D levels and the risk of Mortality in the general population. Arch Int Med. 2008; 168(15):1629-1637.

Brain centers in charge of voice recognition

2009-05-25T09:39:00.007-06:00

In everday life, we automatically and effortlessly decode speech into language independently of who speaks. Similarly, we recognize a speaker's voice independently of what she or he says.(1)

My first call of this holiday weekend was a real jaw-dropper. The youngish man was most put out; he'd been assured that his prescription was called in and, on arriving at the pharmacy, found that they had no record of it. In language worthy of a drunken sailor, he anonymously expressed his deep unhappiness, and concluded that my staff and I were copulating pieces of excrement but in different words.

Now I certainly appreciate his aggravation--been there (at the pharmacy as a customer) done that (felt my blood pressure rising that the pharmacy staff had no knowledge of any script) myself. As often as not, it's an oversight or delay at the pharmacy, but I do know (as do you my patients) that we also have system failures at the office. That said, this tirade was inappropriate done anywhere but in the privacy of one's own brain or car, and I would like to know the identity of the caller so we can discuss whether or not he should continue as our patient if he even cares to do so.

So now we're on the topic du post: voice recognition. I remember a much more pleasant call nearly two decades ago when my front desk assistant announced I had a personal call on line 6. I didn't recognize the name she gave me (remember--we do admit to system failures) but I instantly knew the voice of my freshman college best buddy whom I'd lost track of for 17 years. Now scientists have identified the bit of gray matter that lights up with delight or dismay at the sound of a familiar voice.

Using functional MRI scanning, researchers from the Department of Cognitive Neuroscience at the University of Maastricht located an area of the auditory cortex that hums with activity as test subjects decipher the message and the messenger of spoken stimuli. In order to establish the identity of my anonymous caller, I need to find a staff member whose right anterior superior temporal sulcus (this STS is a brain bit located roughly behind and slightly above the right ear) along with the nearby Heschl's gyrus roars with recognition (and righteous indignation) when the message is replayed.

And Mr. No-Impulse-Control, get this, Pat at the front desk has a highly developed STS, and we will smoke you out. And know that a plainly worded message, even one expressing anger appropriately over lost time and effort, would've resulted in a prompt call by me to your pharmacy!
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Formisano et al. "Who" is saying "What"? Brain-based decoding of human voice and speech. Science. 7 November 2008, Vol 322, pps. 970-973.

2009-05-21T00:08:00.005-06:00

Lest you think that I don't observe my own health habits, here's the latest. I've developed a juicy head cold since I got back from South Dakota, so perhaps I got in the line of fire of infected droplets from Mr. Sneeze-in-the-hand who passed not five feet away from me at the Rushmore Memorial. On the plus side, however, I logged well over 4,000 steps* at the office today, leaving the exam room every time I needed to sneeze or cough and then, of course, washing my hands. Unfortunately, I joined the chunky mom and child in the Keystone, SD restaurant by snacking through the day on Milky Way bites (dark chocolate covered!) and chips.

My bro', whom regular readers know as a strict grammarian and my sharpest critic, wrote a limerick in response to my previous post:

A very old guy in Custer
Said it's not beer that loses your luster;
Read your own blog,
Be a stick, not a log,
(And drink coffee to make certain, buster.)

Last week, I received an endoscopy report (complete with color pictures) on one of my patients who underwent the test two days prior to evaluate her upper abdominal pain. She had a mass in her duodenum that looked scary, like something you might see growing on the Great Barrier Reef. The comment section of the report said "Pt. should call the office in 7 days for the report."

Seven days waiting for a biopsy report? Sounds like the week from hell as there's nothing worse, I think, than waiting for test results on a mass found where no mass ought to be. An hour later, the path report came over the FAX--no cancer!! I called her to let her know, although I advised her to call the GI doc to find out what the next step should be. Her response reminded me of a line from Dennis Prager's "Happiness is a Serious Problem":

"...ideally, we should awaken every day and be as happy about our good health as if we had just received the wonderful news that a lump was diagnosed as benign."
_____
*I wear a pedometer every day. I'll refund the co-pay of the first person who shows up in my office for their physical wearing one! People tell me all the time that they don't need exercise as they 'run around all day at the office' or 'park at the end of the lot.' I've often wondered how many steps are involved in said running and parking.

2009-05-19T18:14:00.009-06:00

My father was a psychiatrist. When my friends came to visit, they would ask me--half-joking--if he thought they were crazy. I know for a fact that he passed no judgments on our crazy adolescent antics, but I'm here to tell you that the internist in me is always on alert to the health habits of others. Here's several observations from my just-completed trip to South Dakota:

--The young man sneezed mightily into his hand as he walked away from Mt. Rushmore. He looked with distaste at his mucous-slicked hand, then wiped it half-heartedly on his jeans. Remember, this guy (or his cousin) touched that door knob just before you did.

--This fellow (a dead ringer for TweedleDee's silhouette) jockeyed for position at the toaster during the crowded, freebie breakfast service at the Dew Drop Inn in Rapid City. He was reaching for the whole wheat bread when the little serving lady brought in a heaping stack of chocolate muffins. To heck with bread, he nabbed two fresh muffins.

--This chunky young mom walked into the restaurant with her overweight daughter in tow. They placed their orders, and shortly thereafter the waitress brought a plate of onion rings for mom and a platter of fries for the young lady. Hmm, I thought, but oh well, they're on vacation and going for a treat before dinner. Alas, their second course was ice cream parfaits for all.

--A very thin, very old guy sat at the bar in Custer, SD, reading the paper and nursing a beer before dinner. We discovered that he was a World War II veteran, a banker, a cattle rancher, and the jeep tour driver for the lodge. He regaled us with stories from all his various careers.

I'm having whatever he's ordering!

Delusional parasitosis

2009-05-15T20:35:00.006-06:00

The ones that crawl in are lean and thin
The ones that crawl out are fat and stout
Your eyes fall in and your teeth fall out
Your brains come tumbling down your snout

No lighthearted matter, these creeping mites, for two of my patients. The first middle-aged lady came in last summer toting a small aquarium full of water. Floating within were numerous diaphanous strands that trembled and tumbled as she heaved the case onto the table.

"Bugs," she declared, "the things that are crawling into my nose and making me crazy."

She was not kidding; she was in tears. She didn't say I think I'm going crazy because I imagine bugs, she said these are bugs.

The second lady came with her brother and sister in tow. He was carrying a crystal wine glass filled with alcohol and covered with saran wrap. Within floated three 'mites' captured as they scurried up someone's arm; I can't remember which one of the sibs caught the little buggers. I carefully poured off the alcohol and managed to snag the tiny particles onto a slide.

"Two clumps of fiber and pile of skin cells," I declared on returning to the exam room. "C'mon back and have a look."

Did they say "Oh my goodness, how foolish we feel now?" Nope, they just shrugged and said "we must've missed them which is amazing as they swarm by the thousands up our arms and legs." Lady #1 didn't go so far as to pin down the species of her infestation, Lady #2 was quite clear the pests were bird mites.

This is not only a psychotic syndrome, but the ability to pass the delusion along to others is a known phenomenon dubbed Shared Psychotic Disorder (SPD) which occurs in as many as 15% of cases of Delusional Parasitosis (DP). Must be a huge delusional exaggeration of the way one starts to itch when someone near by starts to scratch.

Per Wolfgang Trabert(1), when SPD patients are separated from the 'inducer,' a significant number of them undergo a spontaneous remission. Indeed, the brother and sister of this patient pulled back from their personal mitey troubles and had Lady #2 involuntarily admitted for psychiatric evaluation. She emerged slightly less upset due to the use of anti-psychotic meds, but still convinced that her house (that she's abandoned), her car (which she still drives but coats herself before doing so in olive oil as mites don't care for the taste), and her new apartment all continue infested.

Helping Lady #2 try to regain some semblance of a normal life is the hardest thing I've ever attempted in 28 years of practice. Her major source of information is birdmites.org. Check it out; is this fact or a web-site run by a bunch of SPD patients?
_____
1. Trabert, W. Shared Psychotic Disorder in Delusional Parasitosis. Psychopathology 1999;32:30-34.

Heart attacks and low cholesterol

2009-05-12T12:32:00.006-06:00

Can you have bragging rights cholesterol and still suffer a heart attack? You bet, read on:

My patient sat relaxed and smiling in the exam room. He was here, per my schedule, for 'follow-up."

"So, what's going on?" I asked.

"Well, haven't you heard?" he asked. "I just had a heart attack a week ago Sunday."

There he sat, tan, comfortable, the only visible sign of less than perfect health in his 61 year old self was a little bit more belly than ideal bulging out at his midriff.

"You're kidding, right?"

"Nope," he replied, "to make a long story short, I had a heart attack while reading the morning paper and drinking my coffee. I started having severe chest pain, told my wife that this was the real deal, and within 78 minutes I was on the table getting a stent placed in my heart"

Gad, this guy has perfect blood pressure (110/72) on a low dose of heart-healthy lisinopril, 'walks some' for exercise which is not enough but more than many people, and has an LDL cholesterol of 80 on no meds. His dad had diabetes and died of coronary artery disease at 73.

The cardiologist found a complete blockage of his left anterior descending artery--the so-called 'widow maker-- on catheterization, which means no blood whatsoever was getting to the front wall of his left ventricle prior to stent placement. An echocardiogram after the procedure showed that only a small part of the apex of his heart was damaged.

When I was in med school, this fellow would've gone straight to bypass surgery followed by a prolonged post-op stay in the CCU. Yet here he was, scarcely a week later, already starting a cardiac rehab exercise program.

Two lessons here: prompt access to modern medicine is grand, and none of us can rest assured in our low cholesterol numbers.

"Why don't we do it in our sleeves?"

2009-04-28T09:07:00.006-06:00

I feel an enormous amount of compassion for the sick people in my exam room. But my fountain of understanding abruptly runs dry when some infectious chucklehead lets loose an unrestrained cough or sneeze as we sit together in that tiny space.

So please, one and all, as we pass through this scary, fluish time in close quarters, check out this video . Give your family, your co-workers, and your doctor a break!

Cytokine storm and the H1N1 swine flu virus

2009-04-25T13:59:00.016-06:00

At a time when the flu season should be winding down in North America and Mexico, scary reports are emerging from our Southern neighbor of a new swine flu variant whose victims are primarily young. Not only does this influenza A strain appear to be a previously unknown combination of bird, swine, and human genetic material, but the course of fatal illness caused by this bad actor seems to be marked by a 'cytokine storm' that leads to grave lung damage in those affected.

Well shoot, who wants to be in the eye of a cytokine storm? Cytokines are worthy molecules that various body immune cells make in response to an infectious invasion. This is generally a good thing insofar as these various chemicals amplify the body's attack on unwanted intruders. As is true of so many physiological functions, however, a little is good but a lot is destructive.

At the heart of the stormy matter are macrophages ('first responder' white cells activated by damaged cells or foreign invaders such as bacteria or viruses) and CD8+T-lymphocytes (circulating white cells that leap into killer mode the moment they get a whiff of flu viral proteins nearby). These white knights in cell membrane clothing produce a whole host of cytokines--including Tumor Necrosis Factor (TNF)-alpha, Interferon (IFN)-gamma, IFN-alpha/beta, Interleukin (IL)-6, IL-1, MIP-1 (Macrophage Inflammatory Protein), MIG (Monokine Induced by IFN-gamma), IP-10 (Interferon-gamma-Inducible Protein), and MCP-1 (Monocyte Chemoattractant Protein) to name a few. H5N1 influenza (bird flu) happens to be a particularly strong inducer of this cytokine over-production due to the virulence and enthusiasm with which it enters human tissues. Whether or not swine flu and this newest swine version causes this kind of cytokine mess is still not known.

So the human lung and too many cytokines is way too much of a good thing, causing swelling, hemorrhage, and tissue death which are, ironically, more a result of the body's defense mode than a primary flu-generated injury. Scientists theorize that young people may have a more robust cytokine response and less H1N1 immunity from previous exposure compared with older populations.

As of today, 8 cases have been reported in the US from California and Mexico that have been identified as the swinish H1N1 flu but mild and self-limited illnesses in those affected. Remember, increasing evidence suggests that robust body levels of vitamin D are flu-protective, so this might be a good time to get your blood tested for vitamin D and step up your supplements under advisement with your physician.

For up-dated information on the H1N1 flu, see Triple Reassortment Swine Influenza, H1N1 flu shots, Why should I get a flu shot?, and What's a Phase 6 Pandemic?

These glasses have got to go!

2009-04-11T15:22:00.005-06:00

I've just returned from a round trip drive to the East coast. Don't ask why, just know that the last time I did that journey, I was 19, and it's quite a different matter to sit in a car that long that far nearly 4 decades later.

We were equipped with snacks, books on tape, and my favorite pair of sunglasses. When I tried them on at the sporting goods store, I was impressed with their style and comfort. I wore them for six months before I noticed that they had skulls embossed on the ear pieces--perhaps some sort of extreme sports insignia? Actually my son brought the look to my attention.

Well I can live with the skull thing, but I discovered during hours of driving into the late afternoon Kansas sun, these shades simply don't fit. The beskulled left ear piece digs painfully into my very own skull just above and behind my ear. So what misery to pick--squinting into the sun (wrinkles! cataracts! an inability to see the road!) or incessant fiddling with the way glasses meet head?

On top of that, my left shoulder began hurting terribly. I'm picturing my aging, degenerating neck sinking into my torso, pinching a nerve on its way to the bucket seat, and I add massaging the shoulder to sunglass fussing to my general in-car fidgets. After ripping the stupid things off when the sun went behind a cloud, I discovered that my shoulder pain resolved within minutes.

I've always told my patients that muscle tension in the neck can easily cause a headache. Apparently pounding plastic into the temporalis muscle on the side of the head can reverse the pain flow down the neck to the shoulder.

Bilateral shingles

2009-03-31T19:55:00.006-06:00

I wished recently for a consult with Dr. House (in the form of Hugh Laurie with the patience of Mother Theresa). My patient felt awful for a week or so. She was having palpitations, her chest hurt terribly with any position change--say with settling back into bed--or with deep breathing, and the skin on the back of her neck hurt terribly. Her appetite was down, she had no pain with swallowing nor acid reflux, and generally felt unwell due to her newly diagnosed rheumatoid arthritis and Crohn's disease.

Her blood pressure was low and her pulse was up, no fever, her chest wall was not painful to touch, her lungs were clear, and her abdomen wasn't tender. Any movement of her torso caused her to cry out in pain. Her blood count and lab work were normal except for an expected elevation in her sedimentation rate (a non-specific measure of inflammation or infection in the body) due to her arthritis and colitis. A chest x-ray was clear, her thoracic spine films looked good, and the EKG showed no evidence of heart troubles.

Yikes, what on earth? Perhaps yeast in her esophagus? Yet she had no trouble swallowing food. Costochondritis (inflammation where the ribs meet the sternum)? No pain on pressing those joints. Acid gastritis? Her pain was positional and not affected a bit by eating. Heart pain? Nope, the pain was totally atypical. Pre-shingles nerve pain? Maybe in the neck, but not on both sides, and what did that have to do with her chest pain.

Two days later she broke out in shingles--on both sides of her head behind and on her ears. So much for conventional wisdom that shingles only affects one side. In fact, 4% of patients break out on both sides of their bodies. Meanwhile, she researched the side effects of Asacol (a medication used to decrease the inflammation of colitis) and found chest pain on the list. She quit the medication, and, within a day, her pain was gone.

So who needs House when patients use the Internet? I regret that I didn't start her right away on one of the drugs that work against shingles (Valtrex, Famvir, or acyclovir). House would've done that.

Meat-related mortality

2009-03-29T14:14:00.006-06:00

I just finished a liverwurst sandwich (delicious with dijon mustard and sliced purple onion); it was 'to die for' but not exactly my definition of health food. Imagine my dismay when to die for took on a more literal meaning as I opened the March 23rd issue of The Archives of Internal Medicine to this headline news: "Meat intake and mortality: a prospective study of over half a million people."(1)

So what do 500,000 meat eaters have to teach us about the guilty pleasure of a liverwurst sandwich? Namely that the consumption of red meat and processed meats (and liverwurst, while not red, is oddly pink in a processed, not-found-in-nature sort of way) is associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality.

In other words, too much meat and you're so much dead meat. My sandwich sits like a guilty lump in my stomach. An accompanying editorial goes on to indict me further: "Far too few clinicians speak out on topics such as this. What the public hears is the side of the profession that is preaching vegetarian diets and not the side of the profession that is discussing moderation as a healthy option." So I'm telling you now, the very occasional processed meat treat may be good for your soul, but mostly you should emulate my favorite dinner--which I had last night--namely a bowl of Bear Naked Granola.

And just to further fuel my discomfort with meat, I have just ordered "Dying for a Hamburger: Modern Meat Processing and the Epidemic of Alzheimer's Disease" wherein the authors make a case that Alzheimer's Disease is spreading like an infectious disease which, per them, is carried in cow meat meals contaminated by prions, the proteinaceous particles associated with mad cow disease. Lovely. I'll let you know if this sounds cutting edge or lunatic fringe.
_____
1) Arch Into Med. 2009 Mar 23;169(6):562-71.

Flector patch

2009-03-21T16:16:00.003-06:00

Looking for the anti-inflammatory relief of Advil or Aleve without the stomach distress? If you're injured and hurting, check out Flector Patch for a brand new alternative in pain control

How gross is this ad?

2009-03-16T18:51:00.002-06:00

Actual advertisement on London bus--does this stud muffin do Pap tests?
(from copyranter.blogspot.com)

Fatty liver disease

2009-03-15T15:12:00.007-06:00

"As the nation gets heavier, our livers will get fatter."
---Chin Hee Kim, MD

Nonalcoholic fatty liver disease (NAFLD) is the most common form of liver disease AND it affects 20-30% of the US population per Drs. Kim and Younossi writing in the Cleveland Clinic Journal of Medicine(1). NAFLD can range from no big deal fat in liver through inflammation and liver cell damage (nonalcoholic steatohepatosis or NASH) to cirrhosis, liver cancer, or liver failure.

The standard, automated laboratory blood profile includes a panel of liver enzymes. These transaminases(2) which are involved in the production of amino acids are part of the biochemical equipment within liver cells. They are normally present in the bloodstream in small amounts, but disruption of liver cells causes their blood levels to rise. A case of hepatitis skyrockets transaminase levels into the 1,000s and beyond, but even very low level elevations found on lab screening are worthy of follow-up because they may indicate an ongoing, asymptomatic inflammatory liver process that can ultimately lead to cirrhosis and liver failure.

Often, elevated liver enzymes or liver function tests (LFTs) in overweight persons demonstrating signs of metabolic troubles (fat concentrated around the waistline, elevated blood pressure, elevated triglycerides, low HDL, or high blood sugar) are the first sign of NAFLD. This fatty liver business is usually asymptomatic and only noted on lab testing. In order to chase down the cause of abnormal LFTs, we next order tests to check for chronic hepatitis B or C infections, auto-immune liver disease, or metabolic diseases such as abnormally stored copper or iron in the liver. An ultrasound of the liver is fairly accurate in assessing the presence of fat in the liver.

Liver biopsy is the best way to determine if the fatty liver troubles are benign or carry a risk of progression from nonalcoholic steatohepatosis to scarring and permanent liver damage or failure. Once diagnosed, the best approach to treating fatty livers is the same strategy that improves overall health in overweight persons on the road to diabetes or heart disease. These include weight loss (including use of bariatric or gastric bypass procedures), trials of various drugs that promote insulin sensitivity such as metformin, Actos, or Avandia or drugs that lower triglycerides and raise HDL levels such as statins and gemfibrozil. Fatty livers are more sensitive to damage from regular alcohol intake.

If you tend to pack the pounds around your waistline, be sure to ask your doctor to test your liver enzymes.
_____
1) Kim, HK and Younossi, ZM. Nonalcoholic fatty liver disease: A manifestation of the metabolic syndrome. Cleveland Clinic Journal of Medicine. October, 2008, Vol 75, pp 721-728.
2) Aspartate transaminase (AST) and alanine transaminase (ALT) levels generally range up to 40 or so. In mild NAFLD, AST <> ALT.

Cures for the red face?

2009-03-07T13:32:00.006-07:00

And who wants a red face? I had a new patient in yesterday who specifically complained of a red nose, and indeed, the tip of her nose was red with tiny enlarged blood vessels visible on its surface (but only seen by me with reading glasses assist!).

Thanks again to TheDermBlog.com (and I highly recommend this site to you), I am able to bring you a little more info on the subject. One of the most common causes of a red face is rosacea, an inflammatory skin condition that often causes red cheeks and nose (and occasionally eyes), that gets redder yet with alcohol consumption, and responds to topical antibiotics like Metrogel. Sun damage also permanently dilates the superficial blood vessels in our skin, particularly visible in those with Type I sun-sensitive skin (as in fair, easily burned, often in red heads and persons of Northern European ancestry). Dr. Benabio notes on his blog that laser treatment can take away those enlarged capillaries at the skin surface.

I also see persons with acne succumb, as did I, to overscrub syndrome, using washcloths and various exfoliants in a vain attempt (in both senses of the word vain) to liberate the pores from pus and oil. I have been following Dr. Benabio's advice to wash the face less often, but it still goes against my basic impulse to scrub early, scrub often and dab with astringent in between.

He recommends anti-inflammatory, anti-redness skin products for the those who carry the red badge of sun damage/acne/rosacea front and center on their face. In particular, he mentioned Aveeno calming lotions with the herb feverfew. Aveeno apparently has gone to some trouble along with a host of phytochemists to remove the pesky parthenolide component of feverfew (which sensitizes the skin i.e. makes it redder) leaving behind its beneficial anti-inflammatory components. In particular, the parthenolide-depleted feverfew inhibits 5-lipoxygenase, a pro-inflammatory molecule that is the target of a new anti-arthritis medication working its way through clinical trials. Maybe feverfew should join the A-list of herbals that we smear on and swallow (it's supposedly good for migraine prevention as well) along with vitamin C and green tea.

Well, of all my skin troubles, redness is not one. Testimonials for Aveeno (and Eucerin) anti-redness creams abound on the internet. Let me know if you try it and like it!

Vitamin A supplements and cancer risk

2009-03-01T16:14:00.004-07:00

A little is essential, a lot, apparently, is too much of a good thing.

Enamored with the potential of anti-oxidants in fruits and vegetables in cancer prevention, scientists theorized that concentrating these worthy phytonutrients in supplement form might be even better yet. Several studies through the years designed to test this theory on vitamin A derivatives such as carotene (that substance which imparts the orange color to carrots, sweet potatoes, melons, etc.) have been abruptly halted when smokers enrolled in the trials who took the real deal beta-carotene preparations developed lung cancer at a significantly higher rate than those on placebos.

University of North Carolina researchers took another tact and arrived at the same conclusion. They examined data from 77,000 Americans over 10 years--correlating use of dietary supplements with subsequent cancer diagnoses. Note that these subjects were not assigned to a certain vitamin or placebo but rather self-reported their use of over-the-counter vitamin pills.

Not only did beta-carotene again prove problematic in a cancer-causing sort of way for the smokers in the study group, but retinol and lutein demonstrated a potent total dose-related association with lung cancer risk. The longer a person took these supplements, the greater their risk compared with those smokers who did not use them--53% for retinol and 102% for lutein!

Lutein, of course, is recommended to help prevent macular degeneration, an age-related eye condition that can result in significant vision loss. The researchers did not comment on the conflicting reasons to take or pass up lutein, but perhaps persons who smoke should pass up the lutein.

Vitamin D and URIs

2009-02-26T20:14:00.008-07:00

When all around the wind doth blow,
And coughing drowns the parson's saw,
And birds sit brooding in the snow,
And Marion's nose looks red and raw.
---William Shakespeare

Denver weather includes some wind, no snow, and no brooding birds sighted in our bushes. Lots of patients coughing in the waiting room, however, drowning in their own secretions, their throats, noses, and eyes red and raw. Colorado scientists, revisiting data from the Third National Health and Nutrition Examination Survey, conclude, as have others before them, that a lack of vitamin D is at the heart of these viral matters(1).

They conducted a 'probability survey' based on six years of results looking for an association between a person's vitamin D levels and a recent personal history of an upper respiratory tract infection. Indeed, those persons with puny little D levels (<10 ng/ml) were nearly twice as likely to have had a recent viral URI as those with robust amounts of D on board (30 ng/ml or more).

To give you a notion of what's common here in sunny Colorado, I don't see one person in ten whose D levels break the 30 nanogram level. In many patients who claim to take at least 400 units of D per day in their multi-vitamin pills, levels hover in the low teens.

No one has time for a viral URI. If you don't want the problem, check and see if you have D problem; get your D level checked.
_____
( 1) Arch Intern Med. 2009;169:384-390.

Winter vomiting disease

2009-02-15T19:18:00.004-07:00

Lovely, huh? WVD is the UK name for the 1-2 day intestinal crud whose hallmark is...vomiting! And I can personally attest that it's a toilet-hugging disaster--been there hugged that all yesterday afternoon.

As noted in The Rocky Mountain News recently, WVD--caused by the norovirus (and rather picturesquely as the 'small round structured virus' or SRSV)--is currently epidemic here in Colorado. Here's what Brit SRSV expert Professor Steve Field had to say:

Generally you do not need to go and see your doctor.

Because, dear patients of mine, if you go and see your doctor with it, as about 10 of you did last week, she will get it too. That said, I finally got my son to call my doctor--the lovely and talented internist Adele Sykes--to rush over ASAP (leaving her Valentine's Day dinner party to do so) with a phenergan shot to put me out of my misery. Now I know why all of you who are her patients love her so--she was a veritable angel of mercy in a red sweater with a red band about her more or less reddish hair, and she certainly saved my sorry self from hours more of misery.

Maybe, then, we should have those of you who peel yourself off the bathroom floor to visit us with WVD sneak in the back door where a gowned and glove assistant will shoot you up too. And if you're too sick to travel, know that this too shall pass provided you don't pass out and break your head open.

How would you have handled this one?

2009-02-04T23:52:00.005-07:00

My long-time patient has struggled with alcohol abuse in the last two years. She's been in and out of rehab plus had several hospitalizations with serious illnesses indirectly linked to her addiction. Now she's back to work and looking the best I've seen her in ages. She came in alone yesterday regarding a mild skin ailment--her daughter usually accompanies her-- and walked slowly and a little unsteadily into the exam room due to a 'minor ankle sprain'.

After our pleasant visit, I gave her a hug and realized she smelled of alcohol.

Screening for post-partum depression

2009-01-27T11:03:00.007-07:00

For those of us who have abruptly run out of estrogen--before a period, after delivering a child or miscarrying, and entering menopause--it is no news that sudden declines in this hormone can precipitate anxiety and depression. Pediatricians at the University of Colorado have devised a quick and easy 3 question screen to identify women at risk for significant post-partum mood disorders.

Women are instructed to answer 'most of the time,' 'some of the time,' 'not very often,' and 'never' to the following statements:

I have blamed myself unnecessarily when things went wrong.
I have felt scared or panicky for not very good reason.
I have been anxious or worried for not very good reason.

Dr. Stephen Stahl has pointed out a phenomenon he calls 'kindling' with respect to hormone-related mood swings, namely that a history of responding to hormone changes in a sad or anxious sort of way makes it more likely that a woman will have a similar response to such episodes in the future. I think this 3 question tool would be useful in identifying women having a rough go of it mood-wise through the other biggest hormonal challenge of a woman's life, namely menopause.

Pyridium (phenazopyridine)

2009-01-20T10:36:00.008-07:00

Chances are good that this specimen will look familiar to those of you who have been treated for a urinary tract infection known as cystitis. While waiting for the antibiotics to start to work killing the unwanted bacteria invading your bladder, your doctor may have given you Pyridium, an analgesic that soothes the burning pain and spasms of the infection and turns your pee the color of orange Kool-Aid in the process.

A case report in the Mayo Clinic's journal last year(1) is a good reminder that even that which seems innocuous-- a drug taken for a day or two to jump start recovery from a bladder infection-- can have serious side effects. This little old lady with a history of recurrent urinary tract infections (a problem common both to little old and not-so-little, not-so-old ladies) complained her urine was orange and her hands were blue. No problem with the orange urine, we see that of course all the time with the initial use of Pyridium. But what was up with the alarming discoloration of her hands and her ear lobes?

The satisfying pink color of our palms derives from the oxygenated blood carried in the arteries within. Hemoglobin combined with oxygen or oxyhemoglobin imparts that familiar red hue to arterial blood. In order to grab an oxygen molecule, the iron in hemoglobin must be in its reduced or ferrous state with a free electron which can bind to a free electron hanging off the oxygen we absorb through our lungs. When iron is oxidized into its ferric state, a lack of a free electron means no oxygen-binding resulting in methemoglobin which is brown and causes a dusky discoloration to skin. In a normal healthy state, enzymes act to reduce methemoglobin back to oxyhemoglobin.

What's all this got to do with seeking a little relief from a bad bladder day? While a little relief, i.e. a day or two of Pyridium is a good thing, ongoing use of the drug--in this case ten days--is a bad thing. Pyridium and other drugs that diminish the activity of reductase enzymes can result in methemoglobin production. A little abnormal hemoglobin makes your digits blue, a lot makes you seize, fall into a coma, and die.

I've not seen a case of this in all the years I've prescribed this analgesic for UTIs. But this is a good reminder that some folks, on receiving a prescription of thirty Pyridium with the instructions to take it three times daily as needed for bladder pain will do just that, take the entire prescription rather than quitting its use when the bladder no longer pains.
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(1) Singh NK et al. Elderly Woman With Orange Urine and Purple Hands. MayoClinProc. July 2008;83(7):744.

Sleep deprivation and susceptibility to colds

2009-01-13T20:53:00.004-07:00

What a sorry parade I've had through my office the last month. Not only were these poor souls coughing their brains out (and sharing their respiratory droplets with me!), they had: company coming, an upcoming trip to London, an important work presentation, a parent in the hospital, an enormous party to host, and finals to study for (and take). There's never a good time to be sick, but somehow we often seem to be sick when we can least afford to take to our beds. So here's interesting medical news from Carnegie Mellon University in Pittsburgh.

Psychologists there polled 153 healthy subjects over 14 consecutive days about how long they slept and how rested they felt. And then--get this--they quarantined off this group who quite clearly were paid for this study, inoculated their noses with infected droplets from other people's noses (!) and checked out who fell ill and who did not.

Participants reporting less than 7 hours of sleep were nearly 3 times as likely to get sick than their 8+ hours-of-sleep colleagues. And those with less than 92% sleep efficiency meaning that they actually slept less than 92% of the time that they were in bed were over 5 times more likely to succumb to the germs in the donated mucous.

So ah-hah! That explains it--you stay up late cleaning house for company, finishing your work before your trip, fretting over your ailing parent, studying for exams, you walk through the supermarket and the bag boy sneezes on you, and poof! done deal! you're sick. So get some sleep and I will too in case you can't sleep, get sick, come to my office, and cough on me.

Caffeine-induced hallucinations

2009-01-13T20:41:00.003-07:00

Psychologists at Durham University in the UK polled students there about their caffeine intake as it related to hearing voices, seeing things or people that weren't there, or the predisposition to out-of-body experiences. Turns out, the more coffee (or tea) you quaff, the more likely you are to have paranormal encounters.

Study author Dr. Simon Jones allowed, however, that these result might simply indicate that "People who tend to see or hear things may just be more naturally prone to drink a lot of coffee."

Do you see dead people at Starbucks? If you're the sort--and I certainly am-- who enjoys other people's surveys, log-on to Caffeine Questionnaire . The researchers are still collecting data on close encounters of the caffeinated kind.

"Shampoo your hair, not your body"

2009-01-02T21:09:00.004-07:00

It's dry skin city here in Denver year-round but especially in winter when the air is cold as well. As a result, I see any number of patients with bizarre skin rashes that look icky and infectious but are the result, rather, of too much hot water and not enough moisturizer.

This skin care tip comes from Dr. Jeffrey Benabio's The Dermatology Blog. He notes that shampoo is specifically designed to remove oils from your hair and will do the same to your skin. Rather than lather yourself like an Irish Spring commercial with rich shampoo bubbles (or soap bubbles for that matter), check out his other tips on this post and the rest of his blog.

Fidgeting and weight loss

2008-12-27T14:14:00.009-07:00

I got a pedometer that actually works this holiday season. I discovered not only do I get well over half of my recommended 10,000 steps in a 90 minute Jazzercise workout (did that yesterday), but also that I don't sit still very long. This reminded me of a study I wrote about some time ago, so I thought I'd share it with you that you might consider the health benefits of racing around looking for your keys etc. as you consider your New Year's Resolution List (1. Fidget more, 2. Run upstairs to answer the phone instead of putting the handset on the table next to your recliner, etc.).

Consider inclinometers and triaxial accelerometers. Gizmos found in the instrument panel of a fighter jet that were sewn for this study into the high-tech underwear encasing the more or less active behinds of twenty Minnesotans. While all of the subjects were self-proclaimed 'couch potatoes,' half were lean and half were mildly obese. Dr. James Levine and colleagues then recorded 25 million underwear-generated data points on posture and movement from each subject over ten days. The Mayo Clinic investigators believe the results may explain why some persons tend to put on the pounds more easily than others.

Healthy adults gain weight when energy in (food) exceeds energy out (daily activity). While energy expenditure occurs during exercise, a large part of our daily calorie output is Non-Exercise Activity Thermogenesis or NEAT. Dr. Levine defines NEAT as "physical activities other than volitional exercise, such as the activities of daily living, fidgeting, spontaneous muscle contraction, and maintaining posture when not recumbent." The more you twitch, squirm, and generally fussbudget through your daily activities, the more calories you burn in this unexpected way. The researchers discovered that their obese volunteers were seated daily for 164 minutes more than were lean participants. In fact, if the heavier group had demonstrated the same NEAT behavior as their skinnier colleagues, they would've burned off an extra 350 calories per day or the equivalent of 7 pounds per year.

The Mayo endocrinologists had previously conducted research on the effects of overeating on NEAT. They stuffed an extra 1000 calories/day over 8 weeks into sixteen normal weight volunteers. During the two month feeding extravaganza, the subjects increased their energy output in subtle but significant ways, burning the majority of the extra calories as NEAT. Based on these studies, the researchers theorize that while obese individuals may "have a biologically determined posture allocation" (genetically inclined to hit the recliner), perhaps they can be taught to consciously overcome their torpid destiny with increased body busyness as part of a weight loss program.

"Studied calm"

2008-12-20T20:14:00.003-07:00

I'm still reading Jerome Groopman's book "How Doctors Think", and I still highly recommend it to you. Not only does he illuminate the processes--some good, some ill-considered--that doctors use to arrive at clinical decisions, he recommends various participation strategies to patients that they should use to keep their doctor on an objective path to a diagnosis.

Dr. Harrison Alter is an ER physician that Groopman interviewed for this book. Alter notes that the emergency room atmosphere can be hectic and chaotic, and he personally works on fostering "studied calm, consciously slowing his thinking and his actions with each patient in order not to be distracted or pressed [into a hasty decision]. "

Well, you don't have to practice in an ER these days to feel pressed for time. I too have to make a conscious decision to slow down and forget the schedule, settling into my chair and focusing on the patient and what she's saying. Sometimes, this take-a-deep-breath-and-listen attitude pays off big-time.

I was running nearly 15 minutes late when I called Ms. V in from the waiting room. She's a 70-something dynamo, raising her teen-aged granddaughter and taking care of her ailing spouse. The previous morning, she'd had nothing to eat in preparation for a glucose tolerance test. After two hours at the lab where she drank the hyper-sugary Glucola and had hourly blood draws, she headed home, lightheaded and nauseous. Once there, she proceeded to begin cleaning the kitchen, leaning into those counters with her usual elbow grease. Moments later, she dropped to the floor, hitting her head and not really coming to until the paramedics arrived. While she was cleared for home at the ER, the doc there urged her to follow-up with me.

Ah, that is so you, I said to Mrs. V, cleaning up in lieu of relaxing over a late breakfast. On the other hand, I thought, it is so not you to faint. Groopman warns against making clinical judgments based on what we know or expect about a patient. I checked her goose egg of a lump on her head, took her blood pressure, then asked "So anything else going on?"

Well, she said, she'd been having episodic shoulder pain, did I think perhaps she had strained a muscle? And she'd nearly fainted in the Sears parking lot the week before. Ms. V has hypertension, high cholesterol, pre-diabetes, and her EKG at my office looked vaguely abnormal. I sent her directly to the hospital for admission to the cardiology service, and the following morning they put a stent into her nearly obstructed main coronary.

Here's to studied calm.

Living through cancer

2008-12-15T20:42:00.006-07:00

A friend and I are gathering material for a how-to guide for cancer patients. Last week's JAMA had an interesting essay on that subject by Deborah Lewis, a social worker and breast cancer survivor. Titled "Legacy," her comments address her cancer experience as it relates to her father's death from heart disease. In particular, she found herself "playing follow-the-leader behind my father's tough but frail, limping frame" because she discovered that parents teach their children how to handle illnesses, aging, and death. She notes:

Before I got sick I thought people could choose how to confront serious illness. Once could either wallow in self-pity or buck up and move that rubber tree plant. Now that I've had cancer I understand that there is no deliberation and thought. You handle it the way you are going to handle it. Either you have high hopes or you don't; sometimes the ant just can't.

But she proves that she mostly can, living through her treatment in the way she saw her dad manage his own heart disease. Her imagined conversation with him:

Me: One time I threw up while I was running, heaving behind a distant neighbor's bush, my hands braced on my knees while the sweat dripped off my forehead. I wiped my mouth with a leaf and finished my run.
Dad: You're proud of that, aren't you? The vomiting and running thing?
Me: Yes, actually. I am.
Dad: I am too.

Social anxiety disorder

2008-12-14T16:14:00.008-07:00

(aka generalized social phobia or GSP)

No one likes to be criticized, but criticism affects some more than others. I believe, for instance, that women who are unable to extract themselves from abusive relationships are more likely to react strongly and fearfully to criticism which further traps them in a toxic bond. Psychiatrists at the National Institute of Mental Health theorized that individuals with GSP who are fearful of social situations may demonstrate a stronger brain reaction to criticism than persons free of such anxieties.

They performed functional magnetic resonance imaging scans on subjects with GSP and controls. While under observation, the scanees read comments such as "You are ugly" "You are quite the looker" or "He'd look better with a paper bag over his head."

The GSP victims got all hot and oxygenated in their medial frontal cortices (brain area in charge of representation of self) and their amygdalae (brain area responsible for fear reactions) when they were slipped a slip with a personal insult. They had no such reaction to praise, nor did negative comments about others raise their amygdaloid activity.

Comments such as 'buck up honey, all those people are human just like you and they all go to the bathroom just like you' are unlikely, therefore to change the neural activity of those with GSP. Anti-anxiety agents that tone down the amygdala are helpful, and further research into changing neural circuitry is anticipated.

Early a.m. calls

2008-12-14T13:08:00.003-07:00

Ordinarily I'm up by 6:30 a.m. I recognize, however, that patient problems don't follow my schedule, even my more leisurely Saturday morning agenda. I also know that nagging problems have a way of seeming more urgent through the wee hours of the morning, so that which is not an emergency (say the discomfort of a bladder infection) can move a patient to place a call to me at oh-dark thirty.

That said, here's the gist of my conversation with a patient of one of my call partners at 6:30 yesterday morning:

Pt: I've had an irregular heart beat on and off for two weeks now.

Me: Is it worse this morning? Are you having shortness of breath or chest pain?

Pt: No. It's just been on my mind and I thought I'd run it by someone.

Turns out this fellow is quite the work-out fiend, feels fine when he works out without any sensation of skipped beats (typical of benign premature contractions), and I think he just wanted reassurance before he went off to his early morning work-out. I was tempted to berate him a bit for his timing (I know some people call off-hours because they know they'll get right through to the doctor), but I held my tongue as he was not my patient.

Would I have been justified in schooling him on after-hours etiquette?

Irritable bowel syndrome

2008-12-06T17:25:00.008-07:00

Irritable bowel syndrome or IBS is a diagnosis of exclusion. In order to conclude that a patient suffers from IBS--a cluster of unpleasant abdominal symptoms including pain, bloating, gas, constipation, and/or diarrhea--we first must exclude other possible reasons that they may be suffering so.

There's a lot to be said about IBS and the many ways that it can seriously affect quality of life even if it does not result in serious illness. The pain can be quite debilitating and result in frequent absences from work or school. An article in last month's British Medical Journal discussed three simple strategies that significantly decrease the discomfort of IBS.

In a meta-analysis (a study of studies that combines results of multiple trials to amplify the significance of results) researchers found that fiber, anti-spasmodics, and peppermint oil all performed significantly better than placebo in relieving the pain and screwy bowel movements of IBS. They reported the number of patients needed to be treated for one to experience significant relief from the heartbreak of IBS were: 11 for fiber supplements (using psyllium compounds such as Metamucil) 5 for anti-spasmodics (hyoscyamine sold as Levsin, NuLev, Transderm Scop, and generically), and just 2 1/2 patients needed treatment with peppermint oil (187-225 mg. in water 2-4 times daily, available OTC) for 1 to feel better!

"How Doctors Think"

2008-11-30T18:44:00.007-07:00

I love highlighters. And I adore those tiny sticky strips with which I mark interesting passages in the books I read. So imagine my delight when a well-known pharmaceutical company via their local sales rep gave me four highlighters, each with scores of matching sticky tabs bursting out the sides. Of course, all these freebie pens bore the branded name of an expensive, widely-advertised anti-depressant.

Before I get to my point here, let me assure you that these gifts in no way influenced my prescribing habits. The pens, in fact, were all dried-up and hopeless for highlighting, but that made me no less likely to dole out the drug. The tabs were all I could hope for, but I promise you I've written not one additional prescription based on my delight. My patients often do well on this med, and that makes me more likely to prescribe it. Many who love the mood boost stop taking it, however, due to intolerable side effects, and that makes me less likely to write for it.

So there's a little insight into how this doctor thinks, but what I'm really plugging here is Dr. Jerome Groopman's must-have book "How Doctors Think." I'm halfway through it, and pages read thus far bristle with my ill-gotten, dirty-drug-money sticky tabs, each one flagging a point I wish I'd made in a book I wish I'd written. Not only should doctors read this book to understand why we think the way we do or to change our cognitive strategies in useful ways, you and I as patients (or as people who love and support patients*) should pay close attention as well.

Regular readers know that I've spent more than a little time these past two years as a designated listener and an advocate for friends and family working their way through the medical maze. I've seen how my colleagues listen or don't, and how they arrive at outrageous conclusions...or good ones, and the ways in which doctor/patient interactions influence the outcomes. Dr. Groopman has lots to say on the subject; more to come in later posts.
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*Two other excellent books that will help you become your own best advocate are Sick Girl Speaks and Pursued by a Bear.

Geraniums for the common cold

2008-11-22T13:04:00.006-07:00

Argh, it's starting already, the steady stream of the walking wounded with their steady stream of respiratory secretions. All of them sharing a small exam room with me, one after the other, and looking for relief for their common colds.

I want to shout to the waiting room, go home, rest, drink fluids, don't cough on me. I understand, however, that no one's got time to be sick, and they wouldn't be in my waiting room if they didn't feel awful. So I was interested to read in last month's Health magazine (it comes free with my morning paper subscription) that a South African geranium used early on in the course of a cold may shorten the illness by two days.

There's a host of studies supporting the efficacy of extract of Pelargonium sidiodes (EPs or essence of geranium). Doctors at the National Medical University in Kiev invited 206 cold victims down to the lab (but I'll bet they passed up the opportunity to get up close and personal in an exam room with these people). All the patients were assessed for their Cold Inventory Score (CIS)* intially and after treatment with EPs or some murky liquid placebo.

Darned if those dosed with the real botanical deal didn't blossom forth to health at double the rate of the control group by day five. And ten days into the illness, the experimental group was more than twice as likely to zero out on their CIS score compared to their phyto-free colleagues.

So who wants to try Umcka ColdCare? You can get it in Denver at Sunflower Market or Vitamin Cottage, or find a store near you online at Nature's Way and hook me up with your testimonial.
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*The CIS is a fancy way to prove the obvious, namely that the person in front of you coughing, sneezing, and wiping a Rudolph Red nose has a cold. The researchers asked "Do you have nasal drainage, sore throat, nasal congestion, sneezing, scratchy throat, hoarseness, cough, headache, muscle aches, and fever?" They then computed the sum of symptom intensity differences (SSID) of the cold intensity score (CIS) from day one to day five. Don't ever think that there's no scientific method behind phytomedicinal research!

Been there, done that? Share your cancer advice

2008-11-15T12:42:00.002-07:00

I asked one of my patients years ago about the best advice and the worst advice she'd received during her treatment for breast cancer. I don't even remember what she said was the best so horrified was I to hear that my advice was the worst.

I had told her she should consider quitting her job in order to deal with the upcoming treatment. I meant well; why spend energy on work when you will need all your inner resources to undergo chemotherapy and radiation? Now I know that 1) if you quit work you lose your insurance, and 2) ongoing work may provide a measure of satisfaction and normalcy to a life that has been transformed by a cancer diagnosis. I currently advise newly diagnosed patients to consider filling out paperwork to activate the Family Medical Leave Act so absences for treatment or side effects won't jeopardize their job.

I am collaborating with my friend and colleague Gail Harrison (who has been there/done that cancer journey) on a book for newly diagnosed cancer patients. Please consider sharing your stories if you have been down that road as well, or pass this questionnaire on to a friend or family member who has been through this experience.

Getting a call back from the doc!

2008-11-09T20:38:00.003-07:00

Just finished a week of testing for my nearest and dearest. Getting the results was a bit of a challenge, even when I pulled rank with the "This is Dr. Paley calling Dr. R. for test results" which presumably pushed pushy me to the head of the phone call line.

Here's an article I wrote several years ago on the subject. I'd love to hear your stories about getting through (or not) to your physician.

"Hands, touching hands...

2008-11-07T20:06:00.004-07:00

Reaching out,
Touching me,
Touching you.
--Neil Diamond

Yech, maybe not. Consider this study out from the University of Colorado in Boulder.

Scientists in the ecology and evolutionary biology department there used gene sequencing techniques to check out the bacterial communities living on hands in the University community. Not only did your average student mitt carry around 150 different species of bacteria, left hands and right hands carried different species, coeds had a greater diversity of species than their male colleagues, and regular hand washing did not cut down on the wide spectrum of bacterial types.

Do we dare shake hands ever again, or just nod and smile with shaking hands when we meet another traveling petri dish on the road of life? Study co-author Rob Knight has this reassuring news for the shakers and movers amongst us: "The vast majority of bacteria are non-pathogenic, and some bacteria even protect against the spread of pathogens."

Huh?

2008-11-06T12:25:00.002-07:00

Pt: I have a tickle in my throat, so I tried not breathing for a couple of hours.

(Seriously, he was perfectly serious).

"I need a breast biopsy..."

2008-11-05T20:14:00.006-07:00

per the frantic e-mail on my desk, "but can't afford it. Can you order the new blood test instead/ how much will it cost?"

Argh, that dreaded phone call about the abnormal mammogram. I've gotten one as have many of my patients. Follow-up, at times, is simply a matter of additional mammographic views, maybe follow-up films in 3 or 6 months, perhaps an ultrasound. Radiologists are extremely cautious in their reports, often calling patients back for further imaging, and sometimes--insomnia city-- advising a biopsy.

I've read hundreds of abnormal and suspicious reports. Often, there is a 'vague rounded density' that turns out to be just the superimposed shadows of breast tissue heaped on breast tissue, all normal. Frequently, there are 'microcalcifications' that look benign but a short-term follow-up is ordered to assure the little flecks are stable and not increasing in number.

But... this lady's report said "highly suspicious" and "spiculated" and these are not hedge words but a near definite diagnosis of cancer. This is not a dink around with a brand new screening test sort of report, but a work out a payment plan and get that biopsy done report.

Tomorrow: What's up with this new screening test? I didn't know, so I looked it up.

Glycemic index

2008-10-26T12:05:00.006-06:00

Bagels and cornflakes and jelly beans, oh my. These--plus baked potatoes--are the worst of the worst of food choices for those of us who do not want to develop diabetes. These foods not only have a high glycemic index but also a high glycemic load. So flakes in the a.m. may leave you flaky and foggy-brained long before lunch.

All carbohydrates are not created equally in that some raise your blood sugar more rapidly than others. The glycemic index (GI) is calculated by measuring the change in blood glucose level that occurs when a person who has been fasting consumes that food. The elevation is then compared to the blood glucose response associated with a standard highly refined, high-carb food such as white sugar (which has a GI of 100).

The higher the GI, the more the food acts in the body like pure sugar, stressing those balancing mechanisms charged with keeping our blood sugar in an ideal operating range. Cornflakes (GI=92) send blood sugar soaring, causing the pancreas to respond with the release of lots of insulin which then efficiently sweeps the carbs into the cells. This causes blood sugar to plummet, leaving Kelloggs consumers with a mid-morning blood sugar too low to sustain brain functioning. While a trip to the office jelly bean (GI=78) jar may restore the blood sugar briefly, this quick fix just perpetuates the vicious cycle.

But nothing is really all that simple. Milk (GI=27) on the cornflakes changes the cereal's effects in unpredictable ways. And some foods with high GIs may have low glycemic loads (GL) which measures the actual blood sugar response to typical servings of foods. So a low GL (considered to be less than 10) on a high GI food choice indicates that you'd have to eat a ridiculous quantity to raise your sugar in ways predicted by its GI. For instance, pineapple has a moderatly high GI of 66 but a low GL of 7. You would have to consume 1 ¾ pounds in a sitting to raise your blood sugar in the same way that a handful of raisins (GI 64, GL 28) would.

Is your head swimming as if you just ate a baked potato (GI 85, GL 26) without sour cream, butter, and a steak (GI 0, GL 0) on the side? Experts agree that this approach may be too complex for many of us, encouraging us instead to eat foods that are not highly processed--which generally increases GI--and a diet that includes a wide variety of fruits, vegetables, and low-fat dairy products.

LDL particle size

2008-10-22T19:21:00.009-06:00

LDL stands for low density lipoprotein, a worthy protein that picks up cholesterol particles that have either been absorbed from your diet or manufactured by your liver and totes them out to the cells. And it's a good thing that we have LDL-C; our cellular membranes are made out of cholesterol as are our steroid hormones. But as you know, while a little LDL-cholesterol (LDL-C) is a good thing, a lot is not. In susceptible persons, excess LDL-C enters the arterial wall where it may become oxidized and set off a world of inflammation and cholesterol schmutz known as atherosclerosis.

Turns out, there's bad LDL-C and then there's really bad LDL-C, and the difference lies in the particle size. There's no improving on the metaphors of noted lipidologist Dr. Thomas Dayspring, so here's the scoop in his own words:

Large-sized LDL is a beach ball. It bounces off the artery and goes back to the liver. Small LDL is a bullet. It lacks vitamin E, is very prone to oxidation, and crashes right through the artery.

So how do you know if your cholesterol is bouncing or crashing? LDL particle size is measured in the pricey VAP test which stands for vertical auto profile, but the information is actually right there on your standardized lipid profile. If you've got triglyceride levels over 200 and HDL-cholesterol (that's high density lipoprotein or the good stuff) levels below 45 (35 for the guys) we're probably talking bullets in your bloodstream.

Any hope of changing bullets to beach balls? Well surprise surprise, it's the same old song as always--weight loss and exercise. But wait, there's drugs that help as well, including Tricor, gemfibrozil, niacin, and the diabetic medication metformin, Actos, and Avandia.

"Happiness is a Serious Problem"

2008-10-12T13:17:00.004-06:00

Current events make the pursuit of happiness even more of a challenge than usual. One of several books I'm juggling now is Dennis Prager's 1998 bestseller "Happiness is a Serious Problem." Perhaps we are missing some opportunities to increase our satisfaction with our personal situation. Here's Prager's take on health:

Take the expectation of health. For most people, the only time good health brings them happiness is when they do not expect to be healthy and then find out that they are. Imagine that you discover a strange new lump on your body. You go to the doctor, who tells you that it looks suspicious and that you should have a biopsy. After waiting a week for the results, you learn that the lump is benign. That day will be one of the happiest days of your life.

Now this is remarkable because the day before you discovered the lump you were not one bit healthier than you were on the supremely happy day you learned that your lump was benign. Nothing in the state of your health has changed, yet you are now profoundly happy. Why? Because on this day, you did not expect to be healthy.

...[I]deally, we should awaken every day and be as happy about our good health as if we had just received the wonderful news that a lump was diagnosed as benign.

No talcing please!

2008-10-06T20:38:00.004-06:00

I first heard this one 30+ years ago, and I always wondered if it was an urban myth of the bizarre variety. But here it is again, this time backed by research from Harvard Medical School. Epidemiologists there sorted through years of data from the Nurses Health Study regarding who used talcum powder on their nether parts, and whether those who did were more likely to contract ovarian cancer compared with those who dusted not.

Turns out that those who took a weekly powder were 36% more likely to end up with ovarian tumors, and a daily dousing raised the risk 41%. Talcum powder is made from hydrous magnesium silicate which has properties similar to asbestos. Neither talc nor asbestos has any business on your bum!

"Wild thing, I think you move me..."

2008-10-04T12:14:00.007-06:00

"It is highly possible that estrogen modulates motion abilities..."
---Karl Grammer of the Ludwig Boltzmann Institute for Urban Ethology

Well, duh Dr. Grammer, just ask an aging postmenopausal woman as she gets out of a chair about the lack of estrogen and the consequent lack of ability to move. Anyway, that was a mini-rant and NOT what this post is about.

In the 'what WILL they study next' dept., we have the following information out of the University of New Mexico. Evolutionary psychologists there were wondering how human females attract mates at the appropriate time of the cycle to generate species-appropriate reproductive behavior. They recruited lap dancers from local clubs to collect data on tips earned as correlated with phase of the menstrual cycle.

Women, as opposed to say a lady chihuahua or chinchilla do not go into heat but rather have a 4-5 day fertile window mid-cycle called the estrous phase when they are highly fertile. The researchers compared tips generated during these ovulatory days compared with those brought in during the luteal phase (post-ovulation time when perhaps a woman might be more inclined to eat her mate rather than mate her mate) or while the dancers were menstruating.

Sixty days, 5300 lap dance incidents later, here's the scoop. Data from 11 women with normal menstrual cycles indicated estrous earnings of about $70 an hour whereas hourly income fell 33% to $50 for those in the luteal phase and plummeted to $35 an hour for those who were menstruating. The seven women on birth control pills earned less throughout the study period.

So there's apparently 'something in the way she moves' during estrous that attracts clients like no other time of the cycle. And no estrous? May as well move on to another profession because she's not moving up in this lap dancing business. All good for the future of pill-free couples, but no wonder that some of my patients lose that loving feeling whilst on birth controll pills.

Beta blockers and post-traumatic stress disorder

2008-09-29T15:10:00.004-06:00

One of my family members watched another person die suddenly, violently, and unexpectedly this weekend. I think I'm more freaked than my near and dear one is, but here's my doctorly thought processes after I was done flipping out.

Norepinephrine (NE, aka noradrenaline) is a neurotransmitter integral to the stress response and the formation of emotional memories. The beta-sympathetic nervous system (the automatic 'fight or flight' response that occurs without conscious activation) is mediated by NE which enhances the vivid but not necessarily accurate memories associated with highly emotional experiences. Think of a moment that was a charged one for you, say where you were when President Kennedy was shot (if you're old enough) or when you first heard about the World Trade Centers, and notice the details of that memory compared with other, blander recollections.

Experts call the development of post-traumatic stress disorder (PTSD) a 'derailment of memory process.' Not everyone is prone to an exaggerated or detrimental response to strongly charged experiences, but those who are can develop stubborn and destructive behavior patterns that ripple way beyond the actual trauma over time. While bioethicists argue over the morality of supressing intense and unpleasant memories, for better or worse it is possible to attenuate these memories through the use of beta-blockers. Amazingly, not only do the benefits of such therapy accrue when the medication is used shortly after the traumatic even, but also when the event is re-enacted through scripted imagery after some time has passed.

Should I offer beta-blockers (such as propranolol or metoprolol) to my family member? Perhaps I should just take a deep breath and take some myself.

The amygdala and the social conservative

2008-09-20T16:44:00.008-06:00

I've mentioned before that I have an overactive amygdala. Through a series of genetically determined events that I've explained before here, I get an intense second-hand fear response that renders me unable to watch scary movies. Just can't take it when the actress hears a noise and heads right down to the cellar to investigate when I know full well she should run even as I also know it's only a movie.

Now anxiety is a good thing when it sets off an appropriate 'fight or flight' response that allows us to recognize danger and either run or creep down those stairs provided we're fully certified in the martial arts (of course, karate is no use at all against the supernatural...). And it's a bad thing when it renders us unable to leave the house or apply for a job (met a patient like that just yesterday). But who'd have thought that an overactive--or indifferent--amygdala might affect our political beliefs? Well, color me conservative as I read the following from Science Magazine.(1)

Political scientists teamed up with psychologists in Texas and Nebraska to find out if our political beliefs might have a biological basis. In their own words:

In a group of 46 adult participants with strong political beliefs,individuals with measurably lower physical sensitivities tosudden noises and threatening visual images were more likelyto support foreign aid, liberal immigration policies, pacifism,and gun control, whereas individuals displaying measurably higherphysiological reactions to those same stimuli were more likelyto favor defense spending, capital punishment, patriotism, andthe Iraq War.

During session one, the scientists quizzed the group--preselected for the strength of their political convictions no matter what the content of their attitudes-- on their political beliefs, demographics, and personality traits. When the subjects next came down to the lab, they were hooked up to physiological equipment that measured change in skin conductance as well as the strength of their blink or startle response. They were then shown three threatening images (a very large spider on the faceof a frightened person, a dazed individual with a bloody face,and an open wound with maggots in it) or three sweet little pictures (a bunny, a bowlof fruit, and a happy child) interspersed amongst non-charged visuals.

Arousal causes increased moisture on the skin which increases conductance and fear causes a hard flinch or blink response of the muscles around the eye. Well I don't think I'd have a problem with a maggot show, but I know my heart rate would rise and I'd shut my eyes in moment to a large spider crawling on someone's face. The investigators found that an exaggerated response to the threatening pictures did correlate with a more conservative or socially protective attitude.

While the researchers were reluctant to conclude just what cause and effect processes were at work, they conjectured that "political attitudes and varying physiologicalresponses to threat may both derive from neural activity patterns,perhaps those surrounding the amygdala. Amygdala activity is crucial in shapingresponses to socially threatening images and may beconnected to political predispositions."

Please note that in no way do I imply that all social conservatives have an exaggerated fear response. Nor do I think that close vigilance on the part of our society with respect to external danger is a bad thing.
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Oxley, DR, et al. Political Attitudes Vary with Physiological Traits. Science19 September 2008: Vol. 321. no. 5896, pp. 1667 - 1670.

Viagra, women, and antidepressants

2008-09-19T15:38:00.004-06:00

Depression is a surefire way to kill your libido. Treating depression with antidepressants is also a surefire way to kill your libido. Initially, patients may be so relieved to no longer be depressed that they are willing to give up their sexual interests for the medication benefits. After awhile, however, the increased pleasure in life and relationships makes intimacy issues unacceptable.

Doctors at the University of New Mexico wondered if phosphodiesterase type 5 inhibitors (aka Viagra, Cialis, or Levitra) might improve the sexual outlook for women whose spirits have risen on antidepressants even as their libidos have fallen. Viagra and company are known to lift certain parts in men on depression meds.

Over a period of 4 years, they randomized 98 women whose depressions AND sexual interests were completely squashed on serotonin reuptake inhibitor type medications. Taking no one's word for granted, they not only followed up the women's sexual activity event log, but also administered the Clinical Global Impression function scale, the Female Sexual Function Questionnaire, the University of New Mexico Sexual Function Inventory (female version of course), AND the Hamilton Depression Rating scale (just to make sure no depression was creeping back in the picture).

The women on the real deal Viagra sent their Clinical Global Impression sexual function scale soaring to nearly double the levels of their pre-treatment activity. They also improved their scores on their Sexual Function quizzes. The investigators do note that this study selected for a group of women motivated to improve their sexual functioning and relationships, and therefore the findings might not be generalizable to all women experiencing such troubles while on antidepressants. It's also possible that filling out forms and quizzes on sexual functioning might enhance sexual interest.

I find this study particularly interesting as Viagra-like drugs work particularly well in men through the promotion of blood flow into certain parts that must be engorged with blood for proper sexual functioning. It is encouraging to find that the medications can increase interest and activity in women whose sexual response is less dependent on the localized pooling of blood.

Herd Immunity...

2008-09-14T16:02:00.006-06:00

or why you should get a flu shot.

Flu season is coming, and hopefully this year's outbreaks will be preceded by a robust flu shot season. Here are the 2 most commonly cited reasons why my patients decline the vaccine:

I always get the flu from the flu shot. While some people notice fluish sorts of symptoms such as mild fever and muscle aches after receiving the shot, the inactivated viral particles which comprise the vaccine cannot cause disease.
I never get the flu. Well, lucky you. Remember, however, those who await your arrival back home. Perhaps you generally don't get the flu, but if you with your hardy immune system pick up a mild case while in close proximity with the coughing public, that young child, elderly grandma, or chronically ill spouse could be vulnerable to an amplified version of same with devastating or even fatal results.

Be a good member of the herd. When you get vaccinated, the influenza virus does not get a free ride in your respiratory tract on to its next victim.

You can change your wicked ways...

2008-09-07T13:01:00.003-06:00

but at the heart of your matter, your poor choices live on.

The Coronary Artery Risk Development in Young Adults (CARDIA) study followed twenty years of health outcomes in over 3500 young adults. The researchers studied modifiable risk factors such as cigarette use, prehypertension (BP's 120-139/80-89), LDL-cholesterol, and fasting blood sugars.

Many of the subjects with less than sterling health habits didn't smoke that much nor did they have huge elevations in the other parameters studied. Many of them turned their acts around and improved their lifestyle choices over the course of the trial. Despite improvements made, their early adult profiles were more predictive of the presence of coronary artery calcification (CAC) after age 35 than their most current situation. CAC has been shown to correlate with the presence of atherosclerotic changes in coronary arteries.

Voltaren Gel

2008-09-01T20:27:00.005-06:00

This is a great idea, but the logistics are awkward.

Voltaren is an non-steroidal anti-inflammatory (NSAID) pain reliever, and a rather effective one at that. It is available in pill form as the generic diclofenac. The downside of any NSAID is its adverse effect on the stomach and intestinal tract, causing pain, gastritis, ulcers, and diarrhea. In addition, the drugs can increase the risk of stroke and heart attack, and, in susceptible individuals, can decrease blood flow to the kidneys thus increasing the risk over years of use of decreased kidney function. Specific to Voltaren is the risk of "severe hepatic reactions, including liver necrosis, jaundice, fulminant hepatitis with and without jaundice, and liver failure" per www.voltarengel.com. Well shoot, who wants any of that?

We do, however, want arthritis pain relief, and Voltaren does that well. So Novartis minced it up and put it in an alcohol-based gel so that we could smear it right on our throbbing joints. Once absorbed through the skin, it reduces arthritic hand pain 46% after 6 weeks of use, and pain levels plunge 51% after 3 months of slathering it on arthritic knees. Drug levels reaching your stomach, kidneys, and liver are 6% that of an oral dose so, while the risks are not nothing, they're a whole lot less than the pill delivers.

The problem is in the how much cream how often department. The web site recommends 2 gm four times daily to upper extremity sites and 4 gm four times daily for the lower extremity. A tube of toothpaste is 170 gms so that amount of Voltaren Gel would get you through just over ten days of knee treatment. The stuff is definitely gooey, lightly but pleasantly scented, and dries within 4-5 minutes leaving a light sheen but no residual sticky stuff. I cannot imagine using it during the workday if I wore pantyhose. Pulling them back up again after gelling your hip would be like getting a wet bathing suit back on a small child. But then again, who wears pantyhose anymore? What about for one throbbing , chronically hyperextended index finger swollen from years of writing chart notes and prescriptions? The very thing I think, but you can't wash the area for 1 hour after each application.

The other problem is cost. By my calculations, you would apply your way through $172 worth of gel to service one bum knee for a month. Does insurance pay? Dunno, but I kind of think not.

Red Yeast Rice

2008-08-24T20:10:00.011-06:00

I was very grateful that i didn't have to be put on Lipitor. I just took one every evening after dinner, that was it, That easy!
--A happy Red Rice Yeast consumer on Amazon.com

Interesting stuff, this red yeast rice (RYR).* Used for over 1,000 years in Chinese medicine to promote circulation, this medicinal food is made by fermenting rice with red yeast or monascus purpureus. One of its active constituents --monacolin K-- is also known as lovastatin. Monacolins inhibit hydroxymethylglutaryl-CoA reductase (HMG-CoA reductase) which is an enzyme essential to the body's production of cholesterol. In fact, lovastatin was the first statin drug marketed in the U.S. years ago under the trade name Mevacor.

So is RYR an effective, natural, and SAFE way to lower your cholesterol? Even though the Chinese have a century+ of casual, everyday, human trials, the first formal study of the substance was conducted there in 2002. The results confirmed its efficacy: total cholesterol, LDL cholesterol, and triglycerides dropped by 23, 31, and 34 percent, respectively and HDL levels increased by 20 percent. In other words, RYR did all the good things that statins do because RYR is basically a statin or rather a statin is basically RYR. Other studies, one of which was conducted by the American Heart Association, confirmed the general findings although the benefits weren't quite as robust.

The doses used in these studies were 1.2-2.4 gms/day; some Asian diets include up to 55 gms of RYR per day. Because agents such as RYR and statins decrease the production of coenzyme Q10 which is important to energy production in muscles, supplementation of CoQ10 is recommended with either the nutraceutical or the pharmaceutical approach. The standard dose of lovastatin, however, is 20-40 mg/day whereas the daily amount present in most RYR preparations varies between 5-15 mg.

ConsumerLab.com is an independent testing laboratory that evaluates the quality and contents of nutritional supplements. In a recent investigation, they looked at different RYR products both for the amount of active ingredient (lovastatin) and for the presence of citrinin, a renal toxin that may be produced by yeast grown on cereal grains such as rice. Nature's Plus® Herbal Actives Red Yeast Rice contained very high levels of lovastatin whereas Walgreen's brand contained very little of the active monacolin. Four products had citrinin contamination.

What's in it for your brain? Recent Taiwanese studies of RYR compared its protective effects on cells under ambush from beta-amyloid (the sticky protein that gums up the brain in Alzheimer's disease) with those of lovastatin. The RYR won hands down in not only protecting against cell death from beta-amyloid but also in decreasing inflammation and oxidative stress. This same research group found that rats infused with beta-amyloid learned more, had better memories, and accumulated less beta-amyloid when they signed up for RYR supplements with their kibble.
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*Red mold rice (RMR) if you're a Taiwanese biotech sort, and red mould rice if you're British.

Making scents of the gene pool

2008-08-17T12:35:00.009-06:00

Is this your man?

Here's an interesting theory on how we choose our mates, and how birth control pills may be messing with our offspring's chances of survival. Well, obviously, if we don't have children at all based on the use of BCPs, this is a moot point. Assuming, however, that we choose the father of our future kids during a phase in our life when we're not quite ready to make them, here's the scoop.

Scientists believe there are advantages to dipping into a gene pool far different from our own when constructing the DNA of the next generation. Not only will this strategy decrease the likelihood of passing along two copies of a gene mutation for an inherited disorder, research suggests that the children produced from a thoroughly mixed-up match of chromosomes will also be resistant to a wider range of diseases. Those genes in charge of the composition of a person's immune system are called the major histocompatibility complex (MHC), and MHC heterozygosity (meaning mom's MHC contribution is quite a bit different than dad's) gives the kids a survival advantage in future battles against a wider array of disease-causing pathogens.

Interestingly, MHC is a major determinant of body odor in mice and men and women too. The olfactory neurons of mice in charge of odor recognition respond to fragments of MHC molecules even when these peptide pieces are present in extremely small quantities. Many rodent studies confirm that mice prefer nonself MHC-types as mates.

So what's this got to do with BCPs? A 1997 study found that all male subjects and those female participants not taking contraceptives preferred the smell of used T-shirts from persons with MHCs different than their own. The more the subject liked a T-shirt's odor, the less similar their MHC profile to that of the T-shirt's owner. No such correlation was found between Pill-users and their favorite unwashed T-shirt smells.

So if you want to party hearty with respect to producing hardy children with top-notch immune systems, sniff out potential mates in a Pill-free mode before you mate.

How a Corvette smashed my nail

2008-08-16T17:11:00.004-06:00

My patient arrived at his physical with a blackened fingernail. When I asked him how he damaged his finger, he replied "I passed a Corvette on the highway, and that's bad luck." I replied that mostly Corvettes are going too fast to pass, bad luck or not, but what did that have to do with his nail. Here's the scoop.

For reasons unknown, he'd always believed that overtaking these sports cars was an invitation to disaster. Recently, however, he decided to defy his magical thinking and left a 'vette in the dust. Within 15 seconds of completing the deed, he got a flat tire. While changing the tire, 1) his girlfriend's nose got smashed by the car trunk as it swung open, and 2) he smashed his finger with the tire iron.

Never a dull moment at these physicals!