Sunday, December 28, 2008

A lovely thought

My patient Tricia asked about my Mom. When I told her she had died some months previous, and about how she had had enough and had been ready to die, Tricia smiled and said: Ah, a life concluded, not interrupted.

Tuesday, December 16, 2008

What did Lotrel ACCOMPLISH?

Blood pressure is a 'surrogate marker.' This vital sign is easily obtained at home, at the grocery, and in the doctor's office, and the success with which any antihypertensive medication lowers the BP is correlated with the final desirable outcome of blood pressure therapy, namely decreasing the risk of heart attack, stroke, and death by cardiovascular disease. In order to best accomplish our goal of avoiding those pesky outcomes, large studies have been undertaken to see which BP meds work best.

The Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension or ACCOMPLISH trial compared the effects of two combination therapies on cardiovascular events in thousands of hypertensive patients over the age of 55. These subjects were already hypertensive, many were on more than two medications, and only a third of them or so had their blood pressure within the therapeutic goal of less than 140/90. All of them had some sort of health trouble which significantly increased their risk of future problems, including a history of stroke, heart attack, diabetes, enlarged heart, decreased blood flow to their legs, or kidney disease.

They discontinued their current meds; half began Lotrel which is a combination of Lotensin (aka benazepril) and Norvasc (aka amlodopine) and the other half started benazepril plus a water pill known as hydrochlorothiazide (HCTZ). HCTZ has been considered first-line therapy for high blood pressure.

But ACCOMPLISH became one of those 'stop the study' studies by the end of three years. In other words, the benefits of the Lotrel combo were so compelling with respect to preventing unwanted cardiovascular death and disease--decreasing risk of same by 20% compared to conventional therapy--that the researchers called off the trial in order that everyone might benefit from the now proven superior approach.

So take that HCTZ at least when it comes to treating a high risk population. Here's what Dr. Franz Messerli had to say:

This landmark study unequivocally relegates hydrochlorothiazide from first-line to third-line therapy at least in a patient population with similar demographic and clinical features as in ACCOMPLISH. The issue is not to be taken lightly, since hydrochlorothiazide remains one of the most commonly prescribed antihypertensive drugs. Every year more than 100 million prescriptions of hydrochlorothiazide are written in the US. Almost half of those prescriptions are written for hydrochlorothiazide alone.

Some persons don't tolerate Lotrel very well, suffering a cough from the Lotensin part or swelling from the amlodopine component. Lotrel is available in some strengths as a generic, though it is thus far one of those pricey generics.

Saturday, December 13, 2008

Floppy Eyelid Syndrome


You're probably thinking well shoot, I've already got that. You may well have saggy eyelid syndrome--you know, look in the mirror, gently shove the skin below your eyebrows off your upper lids and poof, the young, wide-eyed ingenue reappears. But this is FLOPPY Eyelid Syndrome, first described in 1981 by two researchers checking out the lids on middle-aged obese men. Associated with sleep apnea, this lizardish look not only includes the saggy lidded thing but also redness and irritation in the no-longer-so whites of the eyes.

We know that sleep apnea can seriously affect the heart (right-sided failure) and brain (increased risk of small vessel disease and 'mini' strokes). But why the eyes? Some investigators feel the cause is mechanical stress--i.e. smashing and stretching the eye against pillow--which is supported by the fact that one-sided sleepers often get one-sided F.E.S. Others wonder if alternating ischemia (not enough oxygenated blood) followed by reperfusion (flood of oxygen-rich blood when the apnea ceases) results in tissue inflammation. Studies of floppy lids (what happened to the sleeper upon which these lids resided!?!) showed an inflammatory injury reaction consistent with both stress and ischemia as seen in other tissue types.

Not only does F.E.S. limit the field of vision (while providing, perhaps, some sun protection in a visor sort of way), but the redness and irritation along with that iguana image may necessitate a surgical lid lift, one that the insurance company would be willing to fund!

Wednesday, December 10, 2008

Medical advice from Whole Foods vitamin clerks

I wonder what their credentials are. And what's in adrenal extracts anyway? Whose adrenals are dried and powdered within, and could they be just offal?

Sunday, December 07, 2008

Ergonomic snow shovels




Wendy did a recent blogo-riff on snow shovels. Must be a Canadian thing as Jean had a thing or two to say on the subject last winter. More than likely it's a consideration for those of us middle-aged and beyond, and it just popped on my radar screen and lumbar spine this past week here in Denver.

Ergonomics is the study of people at work, and the science of fitting equipment and work place to worker to optimize performance and minimize injury. "Your online guide to ergonomic snow shovel" says it all:

The gardens, or lawns are covered with snows and the road is also covered with snow that piles up to any feet. The snowfall creates a lot of inconvenience and we wish that the days of snowfall are numbered...The act of removing snow is also back breaking work and many people go to the doctor to rid themselves of the ailment they have got on them during snow shoveling. The snow shovel is an important tool and it becomes very important during the days of snow. ...There is a lot of research going into the making of these snow shovels and the result is different types of snow shovels.

Well, I got a back pain on me when I used our new snow shovel on the first snow this season. My husband, noting that plastic rimmed shovels break easily, bought a metal-edged scoop. Cold metal on wet concrete is an ergonomic no-no. The characteristics of an ergonomically correct snow shovel have been described in exacting terms: plastic blade, 16 1/2" x 14 1/2" with a 42" adjustable shaft for a short person such as I've become, no steel-reinforced edges (note to husband!), and an angular shaft. And ergonomically correct snow shovel reviews are fun to read:

With a shovel like this, the user can thankfully proclaim "Who needs a snowblower?" Of course, snowblowers might make the job of clearing snow easier, but they are expensive, noisy, smelly, and can cause numbness in the hands. The ergonomic shovel will allow the operator to breathe clean air and experience healthy physical exercise. The chances for injury will be reduced as will the snow in the driveways and on the sidewalks of America.

But oh Wendy and Jean, wouldn't you wuv a SnoWovel Wheeled Snow Shovel as pictured above?

Sunday, November 23, 2008

Exam room etiquette

I'm currently reading Pursued by the Bear, a book by 70-something year old psychologist about his 8 year journey through the medical world in pursuit of treatment for 3 different kinds of cancer. Dr. Singer's book is both hilarious and insightful; I highly recommend it to you. A lot of the book explores the relationship between patients and doctors. Here's his take on exam room etiquette, and one of his only observations with which I take issue:

[The doctor] tells me to get dressed [and] leaves the room (you have noticed I am sure that doctors seem unable to tolerate you in the process of dressing or undressing? They don't have problems with you naked or very scantily clad, but the act of removing or putting on clothing seems to be too personal or obscene to be allowed in their presence. It's the action itself that seems off-putting to them. My theory is that in the act of dressing or undressing, your personhood, your humanity cannot be denied--you are someone doing something--I move, therefore I am. Naked you can be an object)...

I always meet my patients while they are dressed, invariably leave the room while they are undressing, attempt to examine them in a way that reveals only that part which I am currently inspecting, and always leave the room while they dress. While we are both dressed, I feel our 'equal partnership' status is intact. When they are undressed, I am very aware that this is an unusual and privileged interaction between two people, doctor and patient. While disrobing or re-robing, however, I feel like I have no business in the room, that, as Dr. Singer writes, the act is indeed 'too personal' though certainly not 'off-putting', and that to stay there would overstep the boundaries of our professional relationship. Once my patient is dressed, we once again enter our partnership agreement where I offer my knowledge and observations and ask my patient to consider with me the options for care.

Are you offended when your doctor scuttles out of the room after the exam is over? How do you feel about conducting the pre- or post-exam interview while still undressed and gowned?

Monday, November 10, 2008

Here's your iliac crest


His-self: It was hard to find a picture of an iliac crest suitable for inclusion in a family-friendly blog, but at least this model left his Calvin Klein's on! It's that bone your thumb finds as you place your hands on your hips.

Sunday, November 09, 2008

Waist circumference



It's the new vital sign. Waisted fat (i.e. fat socked beneath the abdominal musculature and carried front and center like an unfolding pregnancy) is known to be a potent marker and cause of both cardiovascular and diabetic risk. While the ideal dimensions of a healthy waistline are in dispute, thus far 40 inches/102 cm. for men and 35 inches/88 cm. for women are cited as goal.

How to measure a waistline is a hot topic. In fact, the International Chair on Cardiometabolic Risk, an organization headquartered in Quebec City, established a sub-committee to review the existing medical literature on the subject and establish a waist circumference protocol. Let it never be said that we doctors don't take our tasks very seriously.

The expert panel reached two conclusions: 1) "It didn't matter" where you measured distended abdomens with respect to predicting mortality from diabetes, cardiovascular disease, or all other causes. If the silhouette looked apple-ish (think Tweedles Dee and Dum), that defined the problem, and the bigger the gut, the worse the risk. 2) They decided to establish a protocol nevertheless to put an end to the "mass confusion" that existed on the subject so that both providers and patients could measure midriffs and follow weight loss progress.

They concluded for purposes of simplicity that the top of the iliac crest (aka pelvic or hip bone located on the side of the body at roughly, well, the waistline!) was a good anatomic marker easily found by physicians and the public alike. And in a bit of good news, spokesman and sub-panel chair Dr. Robert Ross assures us that the bathroom scale may not be the first reporter of success in weight loss programs, but rather that waist circumference may fall in a reassuring and healthful sort of way before the pounds start to drop off.

Monday, October 27, 2008

Shingles shot

Comment from a 65 year old nurse who came in today with a painful case of shingles on her abdomen:

I could kick myself for not getting the shingles shot.

This after spending 4 and 1/2 hours in the ER two days ago with the pain that preceded the outbreak. She got a CT scan, an ultrasound, many exams, and a raft of bloodwork looking for other causes for the pain.

While people are getting more and more familiar with the patchy, one-sided, blistered skin associated with an outbreak of shingles, many patients don't realize that severe pain is often the first sign of the disease and can predate the rash by several days.

For more information on shingles, see The shingles shot.

Wednesday, October 22, 2008

Estriol and wrinkles

Estriol is the darling of the natural hormone set. A weak little estrogen, it is, in fact, a metabolic byproduct of the normal breakdown of the body's two stronger circulating estrogens, estrone and estradiol. Enormous quantities are necessary to preserve bone mass, but itty bitty bits dabbed on your aging visage may improve the quality of your skin.

A .3% topical cream, available by prescription from compounding pharmacies, was applied daily to the wrinkled surfaces of a group of perimenopausal ladies. Not only did skin elasticity and firmness improve after six months of use, but also wrinkle depth and pore size decreased. Skin biopsy specimens (now how much did they pay these ladies for that?) showed increased numbers of collagen fibers. Serum hormone levels did not change and there was no evidence of any systemic hormone effects, suggesting that topical estriol is safe for use in women unable to use full-dose estrogen replacement therapy.

Thursday, October 16, 2008

Working memory and menopause moments

Wondering why you're wandering around the house in pursuit of who can remember what? Check out Working memory and menopause moments.

Sunday, October 12, 2008

Cipro side effects


Chances are good that if you go to an urgent care center for treatment of a urinary tract infection, you will end up with a prescription for Cipro. This fluoroquinolone antibiotic is also commonly used for intestinal infections, and its cousin Levaquin is a favorite choice for the treatment of pneumonia. Some of my patients request these antibiotics by name as their use was particularly effective for some previous bacterial infection.

Powerful medications are a good thing when battling serious infections, but you should know that the fluoroquinolones now have a 'black box warning' per the FDA. This cautionary material is rimmed by a bold black square in the PDR and on the product insert. This particular alert was issued 7/8/08 and reads in part:

Fluoroquinolones are associated with an increased risk of tendinitis and tendon rupture. This risk is further increased in those over age 60, in kidney, heart, and lung transplant recipients, and with use of concomitant steroid therapy. Physicians should advise patients, at the first sign of tendon pain, swelling, or inflammation, to stop taking the fluoroquinolone, to avoid exercise and use of the affected area, and to promptly contact their doctor about changing to a non-fluoroquinolone antimicrobial drug.

The achilles tendon is particularly susceptible to this inflammatory weakening, and, per a physical therapist I know, the loss of tendon strength and substance associated with drug-induced tendinitis is particularly devastating and hard to reverse.

So while fluoroquinolones, when indicated, are effective drugs and potentially life-saving, their routine use in uncomplicated urinary infections is unwise. Ask your doctor about using other choices in cystitis or bladder infections, and ask him/her to consider ordering a culture of your urine sample to confirm that your infection is susceptible to the antibiotic prescribed.

Friday, October 10, 2008

Post-operative pain management

My medical partner and I are routinely aggravated by the following situation. Our patients are admitted for surgery, say a knee replacement or an appendectomy. They are released from the hospital on meds for pain with instructions to call us for follow-up and refills. We think the prescribing surgeon ought to stick with the program. Now I'm rethinking this strategy.

My friend E. who is now 2+ weeks post-op extensive abdominal surgery for cancer has been on high dose pain meds and anti-anxiety drugs. Her surgeon abruptly decreased the former and discontinued the latter two days ago, then added ibuprofen and Tylenol in place of the dropped narcotic doses. E. sailed through Thursday, feeling so wonderful that she went with her cousin up Trail Ridge Road, a spectacular mountain road which tops 11,000 feet in spots. The trip was a treat, but she began to feel shaky on the way home and had a full-blown panic attack early Friday morning. Queasy, breathless, and in pain, she called me over to help.

So what was going on? Was she queasy from pain, withdrawal, or ibuprofen? Was she anxious from a lack of anxiety meds, withdrawal from tranquilizers, increasing pain, or the fear that she'd have another panic attack? Was she in pain from doing too much too soon, undertreated post-operative healing, withdrawal cramps, or from ibuprofen-induced colitis? Or all of the above?

Perhaps a top-notch cancer surgeon, which I believe her oncologist to be, has no more business adjusting meds than an internist such as myself has performing cancer surgery.

Wednesday, October 08, 2008

Aching feet in Denver, Colorado

As a primary care doc, I'm the 'first responder' to that which ails my patients. When any particular problem steps out of my areas of expertise, I refer. I present to you the difference between a helpful consultation and one that makes you wonder why we bothered.

Both patients presented to me with foot pain. Patient #1 had pain along her arch, worse first thing in the a.m. or after rising from a chair. I figured she had a falling arch and/or a chronic sprain in her midfoot, but she did not improve with arch supports. Podiatrist #1 sent me a letter that reiterated the history, diagnosed it as 'left foot pain,' but she did not have further recommendations for this patient's care.

Patient #2 had right heel pain that began after she increased her physical activity. I felt she had plantar fasciitis. She had tried stretching and OTC arch supports, so I sent her to Podiatrist #2 as this pain was seriously interfering with her daily activity as well as her ability to stay active. He diagnosed:

1. Fractured calcaneal exostosis
2. Chronic proximal resistant plantar fasciitis
3. Hyperpronation of the right foot
4. 2-3 mm. limb length discrepancy left longer than right

He recommended custom prescription orthotics, and spent some time with her discussing the deformity of her foot based on her fractured heel spur. He told her the pros and cons of extracorporeal shockwave therapy, and gave her literature on the procedure.

Now granted these two problems are different but which podiatrist do you think I will use in the future? His name is Joseph Mechanik, DPM of the Colorado Foot Institute, and I recommend his services to you. His evaluations are consistently thoughtful and careful.

Monday, October 06, 2008

Antipsychotics and the elderly

In my mom's final months at home, she had several days where she was profoundly delusional. On one occasion, she called a meeting with her 'board of directors.' They voted unanimously to fire J., the home caretaker. After the decision was made, Mom became very agitated, following J. around the apartment and insisting that she leave. By this time, Mom was very unsteady on her feet, and falling was a serious danger.

J. slipped into the bathroom and called me from her cell phone. I knew that once Mom slept, she would no longer remember the incident, but, until she did, the situation was untenable. She couldn't stay alone, she'd never calm down as long as J. stayed, and with one slip of the foot, she'd surely fall and break a hip.

This sort of dilemma is not uncommon in older adults with dementia. Per a recent study in the Archives of Internal Medicine(1), however, darned if you drug and darned if you don't. Mom was a danger to herself in her delusional state, but researchers from the University of Toronto found that the use of antipsychotic drugs during such episodes is associated with a significant risk of real harm.

They compared the incidence of any medical events serious enough to lead to hospitalization or death in elderly persons some of whom had been newly prescribed antipsychotic medications in the previous month. Those who received such drugs were over 3 times as likely to experience such untoward outcomes compared to the old folks who remained drug free. One could argue that the group who required antipsychotic intervention on average was sicker than the control group, but this risk rose 3.2 times with the newer 'atypical antipsychotics' like Resperidal and as much as 3.8-fold higher when older antipsychotic agents such as haldol were used.

The investigators concluded that these drugs should be 'used with caution even when short-term therapy is being prescribed.' Well, I guess so!
_____
(1)Rochon, PA, et al. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med. 2008 May 26;168(10):1090-6.

Sunday, October 05, 2008

Licofelone and osteoarthritis

I noted in my last post that osteoarthritis may be a misnomer as many consider this form of joint breakdown to be non-inflammatory. If that is the case, than osteoarthrosis would be a better name for the degenerating backs, fingers, knees, and hips of those who are middle-aged and beyond.

Just a moment's research, however, has led me to believe I typed too soon--the cartilage breakdown associated with osteoarthritis (OA) is indeed inflammatory in origin; there just aren't any white cells in the joint fluid to prove it. OA-related joint destruction is generated by cytokines which are pro-inflammatory molecules that cause a cascade of destruction when produced by cells under siege.

Turns out there is actually a world of inflammatory trouble going on in those aching knees. An enzyme called 5-lipoxygenase is turning arachidonic acid (produced from high omega-6 foods such as fatty red meats and egg yolks) into leukotriene B4 which along with certain cytokines such as tumor necrosis factor mediates structural cartilage damage and the formation of bone spurs.

A drug called licofelone is now in Phase III clinical tests as a dual action agent for the treatment of OA. Not only does licofelone function as a COX inhibitor like aspirin, ibuprofen, and Celebrex, but it is also a LOX inhibitor that puts a lid on all this hyper lipoxygenase business in osteoarthritic joints. As such, it decreases the pain of OA and modifies the joint destruction (as in slows it down!!) so maybe your original issue knee joints will last as long as you do.

Saturday, October 04, 2008

Spondylosis


This is a common observation made by radiologists reading MRI reports of the cervical or lumbar spine. I usually ignore it, but I realized recently that I didn't really know what it meant. So now I do, and soon you will too.

Spondyl- refers to the joints and bone of the vertebral column and -osis means abnormal. Now there's a fancy diagnostic term that really is a non-diagnosis. Do I need a several thousand dollar imaging test to tell an aging someone with back pain that they have an abnormal spine?

More specifically, however, spondylosis is applied to those age-related changes in your backbone that leave you stiff and sore. This is a wear-and-tear sort of phenomenon, that which I used to call osteoarthritis or degenerative arthritis. But now I know that -itis means inflammation and, on average, if you're old and degenerating, your collagen and tendons are breaking down in an -osis not -itis sort of way. Therefore, arthrosis(1), tendonosis(2), ligamentosis(3), and degenerative discs(4) leave your vertebrae spurred and misaligned (see x-ray above) and your spinal nerves pinched and complaining.

Spondylosis city here. What a drag it is getting old.
_____
(1) abnormal joints due to cartilage breakdown
(2) abnormal tendons due to collagen breakdown
(3) I'm not even sure that's a word, but if it is, can't you just feel those thickened and stretched old ligaments allowing one vertebra to slip slideways on the next one down?
(4) the spongy, springy collagenous shock absorbers that are no longer so spongy and springy

Tuesday, September 30, 2008

Team players

One of my good friends is in the hospital right now recovering from extensive abdominal surgery. She's doing beautifully, but, as expected after a 10 hour operation, the road back to health is slow and painful. Each morning, her 'surgical team' breezes through, asks her how she is feeling, then flitters out without really hearing the answer. Imagine their surprise when they announced that it was time to stop the IV pain meds, and she announced "I'M NOT READY!"

The surgical team scuttled out the door and discontinued the IV drip for pain.

One day later the 'psychiatry team' shows up. Team members are one unhappy-looking med student and one psychiatry resident. They ask permission to be there, permission to talk in front of me the visitor, but choose not a we're-all-just-human-here sort of opener such as "Geez, what a journey you've been on, how are you holding up?" Rather med student leads off with "Are you feeling a little anxious?" Hell yes, major surgery, slow discouraging recovery, still got chemo treatments left to go, what on earth do you expect... says my friend.

"Well," says Dr. Psych Resident, taking charge, "your team asked our team to come in and find out why you're anxious." I kid you not, and he said it with a straight face. He continues, "They wondered what the problem was."

The problem? That one team needs another team to find out why a post-operative patient in pain reacts strongly to a surgeon who won't listen to what she says.

Sunday, September 21, 2008

Denosumab

Current choices in therapy for osteoporosis are something short of satisfactory. Estrogen works well but many women are reluctant or unwilling to take it for long due to its association with increased risk for breast cancer when used over a period of years. The bisphosphonates-- Boniva, Actonel, Reclast, and Fosamax-- are a good, non-hormonal choice if you don't mind taking a pill on an empty stomach 1/2 hr. before eating in the a.m. then sitting bolt upright 'til breakfast so the drug won't cause acid reflux and heartburn. Evista works but may give you blood clots or hot flashes, and Forteo is a dandy boost for way low bone density if you're o.k. with a daily shot.

Thank heavens, a new choice is moving through phase 3 studies on its way to the old gal market (guys can get osteoporosis too, but their major problem now is that no one thinks to check them for it). This medication, denosumab, is a selective inhibitor of
receptor activator of nuclear factor-{kappa}B ligand (RANKL). No surprise that a ligand know as RANKL is the cause of our skeletal woes joining the ranks of other things that rankle in our golden years--thinning hair, receding gums, falling arches, and teen-aged boys.

Here's the scoop. RANKL is a protein made by osteoblasts or those cells in charge of making new bone cells. RANKL hooks up with RANK to activate the RANKL-RANK pathway which then activates osteoclasts or the cells that break down bone. This whole bone thing is a regular Ecclesiastesian cycle, all this building up and breaking down at the right time and right place. When your season turns to menopause, however, the balance shifts, and suddenly you're breaking down via osteoclasts more than you're building up via osteoblasts.

Enter denosumab, a human monoclonal antibody that grabs the RANKL before it can grab the RANK. In doing so, the drug acts like osteoprotegerin(OPG) which was the normal RANKL inhibitor back in the day when you didn't need to worry about the state of your bone density. Apparently, both estrogen and Evista increase levels of OPG whereas denosumab has a biological activity equivalent to it.

So what do you have to do to be on denosumab? Get up early, stand up straight, endure hot flashes, worry about your breasts? No, none of that. Denosumab is administered as a shot twice a year, a shot under the skin no less, not like one of those stingy tetanus jabs into your deltoid muscle. Here's what
lead investigator Steven Cummings, MD had to say about that: "it's a whole lot easier . . . to give what is essentially [like a] flu shot."

Thursday, September 11, 2008

Panic attacks and menopausal women

The first time I had a panic attack, I assumed that my heart rhythm was abnormal, and that was why I felt like I would lose consciousness as I drove to Boulder. By the second panic attack, my educated guess was that a tumor was pressing on my trachea, and that was why I could not draw a deep breath and might have a seizure at the wheel. Needless to say, driving after my snowy day collision with a moving van became a bit of an ordeal. As a result of my experience, I know that panic attacks are not about an anxious fear that you might die but rather a strong bodily feeling that you will die.

I was interested, therefore, to read a study in last year's Archives of General Psychiatry about cardiovascular outcomes in postmenopausal women who suffer from panic attacks. Panic attacks are common among women in this age group (although mine occurred over a decade ago). Researchers collected data from nearly 3400 women who participated in the Women's Health Initiative Observational Study.* The women self-reported whether or not they'd experienced panic attacks over a 6-month period, then they were followed for the occurence of coronary heart disease (CHD), stroke, or death in the next 5 years.

A 6-month history of full-blown, real deal, I-can't-get-a-deep-breath or I'm-going-to-die sort of panic attacks was significantly correlated with both outcomes in a scary sort of way. The women demonstrated a 4.2 fold increased risk for CHD, a 3.08 increased risk for the combined outcome of CHD or stroke, and (yikes!) a 1.75 times increased risk that those subjects who ducked heart attack or stroke would die of any other thing.

No surprise, panic attacks are awful, and they simply are not good for you.
_____
*Participants in the WHIOS were those women who either were not eligible for the hormone portions of the WHI but agreed to provide investigators with other information about their lifestyles and health outcomes. This particular sub-study was the Myocardial Ischemia and Migrained Study.

Friday, September 05, 2008

Zetia and cancer

So first we find out that maybe Zetia (ezitimibe) isn't all it's cracked up to be. In an earlier study of patients with familial hypercholesterolemia--as in big-time LDL-cholesterol elevations of 300 and beyond-- the addition of Zetia to Zocor, a combination also known as Vytorin, did not slow down progression of arterial disease as measured in the carotid artery. Worst case scenario, we thought, was that Zetia wasn't really much use, and perhaps, we theorized, these high LDL patients do not represent our typical everyday high cholesterol patients so why compare outcomes in the one to clinical courses in the other?

Until now. Just out this week in the New England Journal of Medicine are the results of the SEAS trial(1), as in Simvastatin and Ezetimibe in Aortic Stenosis. This study compares the use of Vytorin to placebo in old folks with narrowing of their aortic valves. Mattered not in these elderly valves whether the owners used Vytorin with respect to progression of the stenosis or cardiac disease in general. What mattered, however, mattered a lot in fact, is that the seniors randomized to active treatment were significantly more likely to get cancer and borderline more likely to die of it.

In this same issue of the NEJM, another group looked at cancer data from two other Zetia studies. After studying the combined data from these larger, ongoing trials, they concluded:

There was no overall excess of cancer (313 active-treatment vs. 326 control) and no significant excess at any particular site. Among patients assigned to ezetimibe, there were more, albeit not significantly more, deaths from cancer (97, vs. 72 in the control group; P=0.07)... The available results from these three trials do not provide credible evidence of any adverse effect of ezetimibe on rates of cancer.

Oh gad, now what to do? An accompanying editorial theorizes that Zetia might not only interfere with the absorption of cholesterol but also other molecules that affect the growth of cancer cells. And the doctors conclude: "Physicians and patients are unfortunately left for now with uncertainty about the efficacy and safety of the drug."

I think I'm done with Zetia.
_____
(1) Rossebø AB, Pedersen TR, Boman K, et al. Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis. N Engl J Med 2008;359. DOI: 10.1056/NEJMoa0804602.

Saturday, August 30, 2008

Endothelium


People should think more about their blood vessels. In particular, consider the single layer of cells known as the endothelium that line them. Roughly fried eggish in appearance, healthy endothelial cells maintain a Teflon like coating that allows for the smooth passage of blood. Under siege, however, say as they're scraped across asphalt when you fall off your bike, endothelial cells act like Velcro and raise little chemical flags that attract white cells and clotting factors to stick to their surfaces.

Unfortunately, certain factors in modern life cause this same Velcro response in your blood vessel lining. Doughnuts, french fries, cigarette smoke, air pollution, unflossed gumlines, and waisted fat (i.e. the metabolically active fat that clings to your midline) all send your endothelium into high-level alert.

'Use it' or 'lose it' definitely applies to your endothelium. The more pressure and friction exerted by the circulating blood during exercise, the more the cells flatten and align in the direction of blood flow, thus expanding the vessel and increasing the delivery of oxygenated blood. The most important factor that stimulates the release of endothelial relaxing factor is increased blood flow. When flow decreases on a regular sit-on-your-butt sort of basis, the cells increase their volume, lose their alignment, and heap up like cobblestones thus creating a bumpy, narrowed passage.

Blood vessels love:
  • Normal blood pressure
  • Exercise
  • Mono-unsaturated fatty acids
  • Omega-3 fatty acids
  • Oatmeal
  • Dark chocolate
  • Grape juice
  • Air filters
  • Vitamins C & E
Blood vessels hate:
  • Hypertension
  • Inactivity
  • Saturated and trans-fats
  • Fast food
  • Obesity
  • Particulate matter in the air
  • Periodontal disease
Your choice: cobblestones covered in Velcro or fried eggs coated in Teflon. What's in your blood vessels?


Tuesday, August 19, 2008

Fallen arches: Yet another strategy





Yes, I'm still fussing over my feet. So much so that my friend remarked to me recently as we moseyed along L.A.'s Huntington Beach, "Gosh you talk about your feet a lot." Well color me old and tedious carrying on about my fallen arches whilst walking on a glorious day by the Pacific Ocean. Actually, all I was saying at the moment was that wet sand was the perfect medium upon which to walk with aging feet.

Turns out this is all another instance of Joni Mitchell's lament:
"Don't it always seem to go
That you don't know what you've got till it's gone?"


Not that I didn't know the moment when my arches crashed painfully to earth. What I didn't know was that I'd totally lost contact with my abductor hallucis longus muscle until my neurokinetics therapist told me to contract it.

Bob Gaas: Move your big toe away from your other toes.

Me: (after staring out my toe awhile) Gad, no can do. I have no idea how to do that.

BG: Don't worry, just look at it awhile each day, your abductor hallucis longus muscle just hasn't been used in a long time.


Turns out that the AHL muscle forms the floor of the arch, and if you are so out of touch with it that you can't move your big toe towards the middle of your body, you haven't got a prayer of getting your arch back. Bob assures me that if I can get my AHL function back AND move it independently of both my extensor hallucis longus (EHL) and my tibialis anterior (TA), I will sort of get an arch back. More importantly, my feet won't hurt so much.

Talk about needing a life. My evening activity now as my spouse and I work on the New York Times crossword puzzle is to multitask by discretely feeling along the medial border of my foot beside the arch, searching for life in my AHL muscle. And I am pleased to report we, my AHL and I, are back in touch, big-time! My next stupid person trick is to learn how to move it without activating my EHL (that's the muscle and tendon that flexes your big toe up off the ground) and or my TA which pulls the whole ankle back.

Want to play along with your feet? Your tibialis anterior tendon can be found on the front of your ankle just in front of the inside ankle bone. Cock your foot up and watch it pop out. The EHL tendon is just to the outside (little toe side) of the TA tendon. Point your foot down, then pull your big toe up and that tendon bulges upward.

There's more for those of you who note, as do I, that the passing years are less than kind to your feet. Bob Gaas has agreed to host a group session on getting back in touch with your aging tootsies. Let me know if you're interested.

Saturday, August 16, 2008

"Cause of death"

Death certificates are the final period at the end of a life sentence. I've filled out more than a few over the two-plus decades I've been in practice. The hardest part of this difficult job is the last section on the form, namely 'cause of death.'

Here's exactly what the State of Colorado requests:

Immediate cause [Enter only one cause per line for (a), (b), and (c).] Do not enter mode of dying (e.g. Cardiac or Respiratory Arrest) alone.
(a)__________________________________________
Due to or as a consequence of
(b)__________________________________________
Due to or as a consequence of
(c)__________________________________________



Generally, the funeral director is standing by the front desk, deathly impatient, waiting for me to fill this form out in a moment stolen between appointments. But I find it very hard to think this out in a hurry yet essential that I give it my full attention and best shot.

I'm not sure who signed my Mom's certificate. I can't read the writing, it may be the doctor who visited her on one or two occasions. I'm not objecting to the lack of visits as I made it clear in an officious sort of way that I would mostly handle things pertaining to my mother's health care. So I guess I can scarcely be offended that whoever filled the certificate out listed "End Stage Dementia of Alzheimer's type" as the cause of death. Period. No (b)'s or (c)'s about it.

Well, Mom did not have Alzheimer's type dementia at all but rather multi-stroke dementia, and she doubtless died of a pulmonary embolus or a cardiac arrhythmia. But what she really died of was an "I've had enough" attitude due to or as a consequence of immobility, loss of independence, pain, bronchitis, and one tiny stroke too many.

I was interested, therefore, to read a column in a June issue of JAMA about the Genug Syndrome. Dr. Jennifer Soyke of Eugene, Oregon, writing in a regular JAMA feature called 'A Piece of My Mind', talks about the at-home death of one of her elderly patients. When she discussed the question of the actual cause of death with her patient's loved ones, they decided the lady had died of genug syndrome (genug is Yiddish--and German--for "Enough already!"). They did not want her life and her peaceful death summed up as a medical diagnosis. So Dr. Soyke ended up listing cause of death on the certificate as 'respiratory arrest secondary to genug syndrome.'

Now that's some kind of medical chutzpah. And speaks eloquently of a life well done.

Saturday, August 09, 2008

How to take a blood pressure reading

Blood pressure reading does not seem to be done correctly in any medical clinic. And yet, the single most important thing physicians do in their medical life is take an accurate blood pressure measurement.
--Clarence Grim, MD, Medical College of Wisconsin


Well this is Grim news indeed for those of us who've been at this for decades. Per Grim(1), a proper blood pressure assessment is nuanced and time-consuming, an unwelcome proclamation in a world where appointment time in your average PCP's office (that would be mine) is limited and largely unreimbursed.

So here's the scoop. Ms. Patient needs to be sitting in a chair, back supported, feet flat on ground for 5 minutes before the exam, her arm on a table such that the center of the BP cuff, which needs to be the proper size relative to the circumference of her arm, is at heart level. Then, get this!, I'm to take readings in both arms (do I have to let her rest between measurements for another five?), and I can't chat as I measure. That's my downfall, I'm usually grilling her about her day, her job, her kids, her opinion of the Rockies (watch that pressure soar), when what I really need to do is just shut up and pump the cuff.

Research suggests that our worst failing as BP measuring health professionals is that rest thing, we don't let the patient rest. Here's what Joseph Izzo, MD, hypertension researcher extraordinaire has to say about that: "The problem is that physicians cannot afford financially to take the time to properly measure blood pressure--they aren't compensated."

And I would add that none of my patients spend their day at rest, so oughtn't we be measuring their pressures in real world, on-the-go conditions, when time constraints and tonight's preseason performance by the Broncos is driving their hearts and their minds?
_____
Mitka, M. Many Physician Practices Fall Short on Accurate Blood Pressure Measurement. JAMA, June 25, 2008-Vol 299, No. 24.

Saturday, July 26, 2008

Overactive bladders

This posting is not really about twitchy aging bladders that can't hold their own against a simple cup of coffee without whining uncomfortably for attention, but rather about the effect those frequent signals to head for the head have on our already addled brains.

Here's how the bladder connects with brain. That 'gotta' go now' message is sent to Barrington's nucleus, the brain center in charge of bladder contraction and urination. But no simple reflex here; rather than just send back a simple command to let 'er rip or hold on a moment dear, Barrington's nucleus feels compelled to tell the locus ceruleus all about it. This is the area in our noggin in charge of arousal and attention. I guess it makes sense because someone's got get up, find the loo, and transport the bladder there to do its business.

So researchers in Pennsylvania asked a group of rats to participate in an experiment wherein their bladder outlets were surgically narrowed to mimic an obstructed or overactive bladder(1). While Barrington's nucleus showed decreasing activity in the obstructed rodents compared to a control group (which may explain why people with OAB leak without knowing it until it's too late), the obstructed group demonstrated a hyperactive locus ceruleus.

Because the locus ceruleus is connected to the cerebral cortex, an area in charge of thinking, mood, and memory, the Philadelphia investigators conjectured that this hyped up bladder thing ultimately could affect behavior in an adverse sort of way. Indeed, the poor blocked-up rats brain activity consistent with chronic hyperarousal as seen in persons feeling anxious or stressed. And when the rats with obstructed bladders slept, their brain activity showed theta waves associated with restless sleep.

Researchers concluded: "Overactive bladder as a result of partial obstruction is particularly prevalent in the elderly, a population that is also vulnerable to neurobehavioral deficits and sleep disturbances. The present findings suggest that this visceral dysfunction may contribute to neurobehavioral and sleep deficits in this population."

Of course, surgically obstructed male rats are one thing, and aging women with overactive bladders quite another, but OAB may be just another brick in the deteriorating wall of our aging brains.
_____
(1)Rickenbacher, E. et al. Impact of overactive bladder on the brain: Central sequelae of a visceral pathology. Proc Natl Acad Sci U S A. 2008 Jul 21. [Epub ahead of print]

Monday, July 14, 2008

Diastolic dysfunction

The diagnosis of diastolic heart failure, unfortunately, is often missed by unwary physicians.
---heartdisease.about.com/od/livingwithheartfailure/a/diastolic_HF.htm


Before I say more than a few words about diastolic dysfunction, I want to note that I am mostly not unwary. Who'd want to go to an unwary physician anyway? I will admit, however, that I was a little unwary regarding the consequences of diastolic dysfunction, but I am no longer so. Here's the scoop.

If diastolic dysfunction is a new one to you, I'm here to tell you it was not part of my original medical education. When I learned about heart function gone awry, it was all about a delivery deficiency. In other words, a failing heart is unable to squeeze out sufficient blood with each beat. As a result, tissues receive less oxygenated blood, the lungs receive less blood to oxygenate, blood backs up as it waits for its turn to pass through the stressed-out heart, and the lungs, liver, and legs fill with fluid. All this is now known as systolic heart failure or a failure of the heart to adequately eject blood during contraction aka systole. What a messy fluid build-up and lack of blood flow results from systolic heart failure after heart attacks, viral infections, rhythm disturbances, or alcohol toxicity among other things.

So several years ago, I started seeing 'diastolic dysfunction' showing up on echocardiogram results. "What on earth," I asked my friends the cardiologists, what were they seeing on ultrasound examinations of the heart that qualified as an abnormality of the relaxation phase of the heartbeat.

Whereas systolic dysfunction is a delivery problem as noted above, I learned that diastolic dysfunction is an acceptance problem. Once blood is squeezed out during systole, the heart relaxes to accept a new load of blood in preparation for its next beat. The heart muscle slackens, the mitral valve opens, and blood rushes in to the big chamber known as the ventricle. Just to get that extra kick, the top chamber known as the atria squeezes a bit more in just before the ventricle begins to contract once again. If the ventricle is stiff, however, from years of working out against high blood pressure, diastole does not go so well. The ventricle is unable to accept as much blood.

Early on in diastolic troubles, that last atrial squeeze gets the heart volume up to normal. The patient motors on oblivious to the chaos brewing in his/her overworked heart (Naw, Doc, I don't check my blood pressure. I feel fine.) Then stiff becomes stiffer in a ventricular sense, and the heart no longer fills with enough blood to meet the demands of exercise. Fluid begins to back up in the lungs when the patient tries to mow the lawn or go for a walk. The volume overload in the lungs creates pulmonary hypertension which further accelerates the diastolically failing heart thing.

What brought this all to my mind? One of my patients, younger than me, came in with swollen legs. She's a skinny lady, so her edematous ankles were particularly alarming. She has an unfortunate history of hypertension, high cholesterol, smoking, and an inability to exercise for years due to a back injury. Her echocardiogram showed that her heart was pumping okay but she had serious diastolic dysfunction and severe pulmonary hypertension. As if this was not sufficient trouble, her chest x-ray shows one side of her diaphragm is paralyzed, so we are currently looking for a possible lung cancer high in her lungs squashing her phrenic nerve.

So that is why I: 1) ask my patients not to smoke, and 2) press them to keep after their pressure.

Saturday, July 05, 2008

Family and fiber: Colorectal cancer risk

I'm always recommending a screening colonoscopy to my patients 'of age,' after all, I had one, therefore, so can they. Here's the top two excuses (after 'I'm a chicken' and 'I'm embarrassed') that people give me for not undergoing this important screening test, and here's what I have to say to them:

1) No one in my family has colon cancer. While having a first degree relative (parent or sibling) with a history of colorectal cancer (CRC) increases risk 2-fold, 80% of persons who get CRC have no such family history.

2) I eat a high fiber diet. Boston doctors undertook a prospective study of nearly 89,000 women ages 34-59 in 1980.(1) They found no association between dietary fiber intake and the risk of CRC during 16 years of follow-up.

One might raise the question, as did Dr. Neil Raven(2), as to what really constitutes a high fiber diet. He responded to the above study in a letter to the editor wondering if the flaw in the study's design might not be that Boston women who say they eat high fiber aren't really as fiber-filled as they think. He cited information from Dr. Denis Burkitt, a physician who spent time in West Africa studying lifestyle and disease. Per Dr. Raven:

Burkitt began his lecture with a slide showing a stool of a typical Western, "civilized" person, a sausage-shaped thing, familiar to most of us, in a toilet bowl. His next slide was of a stool of a typical rural West African, which looked like a flat cow pie. Burkitt postulated that the West African's stool moved more quickly through the colon, giving carcinogens contained on its surface less time to be in contact with the mucosa — thus less time to induce carcinogenesis.

During the question-and-answer period, many questions from the audience concerned how one determined whether or not a diet was high in fiber in the sense Burkitt meant. Burkitt shook his head at all the salads, cereals, and breads offered as sources of fiber. He showed a slide of the staple cereal eaten by West Africans, which looked, in its wooden bowl, not too different from the stool that came out the other end. The only thing the study by Fuchs et al. proves is what anyone who heard Burkitt's lecture already knew: the American public has been sold a sugar-coated misconception.

_____
(1)Fuchs, CS et al. Dietary Fiber and the Risk of Colorectal Cancer and Adenoma in Women. NEJM Volume 340:169-176 January 21, 1999 Number 3.

(2)Raven, ND. Dietary Fiber and Colorectal Cancer. NEJM Volume 340:1924-1926 June 17, 1999 Number 24.

Tuesday, July 01, 2008

"The middle of my foot hurts"


My old arch is falling down (click on image; watch it throb!)

"Have you ever heard of Liz Franks?" the octagnenarian asked me, waving her foot in the air.

"Yeah," I said slowly, "I've heard of it [her?!?]. My voice screamed 'haven't a clue,' but my patient proceeded with her story.

"The middle of my foot hurts sometimes when I walk. The PA at my podiatrist's office says it's a Lisfranc injury and it has something to do with a separation in the bones of the feet. He told me that's why my foot hurts and the top of it swells."

Ah, yes, Lisfranc's as in Lisfranc's fractures. And now I had the entire Lisfranc's file open in my brain and the sum total of its contents revealed in those three words.

I looked it up later on the Internet, and learned that Doc Lisfranc was a field surgeon in Napolean's army, and the joints named after him are in the midfoot where the long bones or metatarsals below the first and second toes meet the various bones under the ankle. Wang, whoever he is, has seriously injured his and won't be playing for the Yankees for awhile. On average, Lisfranc's injuries occur abruptly and dramatically in athletes or in those who've fallen from great heights or been injured in car accidents. Lisfranc joints can be subtly sprained in athletic endeavors.

In no case, per my search, do Lisfranc dislocations or fractures occur in little old ladies who now and again get pain whilst walking. Pain in the midfoot of the aged is either midfoot impingement syndrome or degenerative arthritis of the middle of the foot including, perhaps, the Lisfranc joints.

The midfoot is the highest point of the arch. As we age--and by we, I definitely include me--the arch sags or just plain goes to ground causing the bone ends to crash into each other in a painful, unsupported sort of way. As a result, with each weight-bearing step the bone ends grind together. This daily grind, over time, wears down the joints causing degenerative or osteo- arthritis.

While merely impinging on one another's space, this bone on bone action causes episodic pain with weight-bearing activities. Once arthritic, the pain is more consistent, and the entire top of the foot can be painful and swollen. As with all archless conditions, standing in bare feet aggravates the pain; I advise all my flatfoots--including myself--to immediately slip their aging feet into arch-supported clogs or sandals on rising in the morning. Good Feet has a lightweight orthotic perfect for wearing with open-toed shoes.

And, as you may know, I am also a great fan of YogaToes, the plastic toe separators, which pull the toes and their metatarsal bones out of each other's face and space.

Sunday, June 29, 2008

Enduring love or just never letting go?

When it is our time to grieve, we must live each day as it comes,
dealing with both the mundane routine of living and our inner struggle.
Grieving and living through the entire experience of bereavement will
change us, and if we do it well, the change will be for the better. We
know we are becoming whole when we can look to the future with some
readiness to engage once more.
--Carolyn Jaffe "All Kinds of Love: Experiencing Hospice"


Grief, of course, has been a part of my life and thoughts this past year, both during the final months of my mother's life and the time since she died in late March. I have been surprised at the ease with which I've made this transition since her death, realizing though that she and I had ample time to say good-bye and knowing that she was ready to exit when she did. Interesting research from UCLA(1) suggests that those who experience what is termed 'complicated grief'--defined as feelings of loss that are so overwhelming that the person is debilitated and unable to resume normal life--have characteristic patterns of brain function underlying this show-stopping state of mind.

Psychologists there studied a group of women who'd experienced the loss of a mother or sister in the previous five years. The subjects were classified as either complicated or noncomplicated grievers. Using functional MRI imaging (fMRI), a technique that can identify which parts of the brain are actively at work, the researchers found that all the women lit up their pain centers when they viewed either pictures of their loved ones or words related to loss. Neutral words or pictures of strangers did not elicit this response.

They were surprised, however, to discover that those women suffering from ongoing complicated grief also activated the nucleus accumbens area of the brain. This region is the neurological command center for experiences of pleasure and reward. While it is unclear why this occurred, lead researcher Dr. Mary-Frances O'Connor theorized that intense attachment in complicated grief activates reward centers in ways similar to that experienced by contact with the loved one before death occurred. Those with fMRIs lit up in reward centers all reported 'yearning' but there was no correlation with the time that had passed since the death.
_____
O'Connor, MF, Craving love? Enduring grief activates brain's reward center. Neuroimage 2008 May 10. [Epub ahead of print]

Tuesday, June 24, 2008

Just ashed my Mom...


and she knew that this was a great final resting place. She started life in Leadville, Colorado, and arrived back there on June 21, 2008, her 88th birthday!

Tuesday, June 17, 2008

Aromatase inhibitors and body aches

Many breast cancers behave enough like normal breast tissue that they are stimulated to grow in the presence of estrogen. While premenopausal women produce most of their circulating estrogen in their ovaries, the postmenopausal set converts androgens (male hormones) from their adrenal glands into estrogen via the aromatase enzyme.

For that reason, the risk of recurrence of estrogen receptor positive breast cancers can be reduced by either blocking cellular estrogen receptors with tamoxifen or preventing the production of estrogen with aromatase inhibitors. In fact, use of drugs such as exemestane (Aromasin) or letrozole (Femara) over 5 years has been shown to improve disease-free survival compared with 5 years of tamoxifen therapy.

Unfortunately, some women do not tolerate therapy with aromatase inhibitors due to joint pain. This discomfort may be due to the effects of lack of estrogen on tissues of the musculoskeletal system similar to the body aches experienced by some women as they enter menopause. Here's an excerpt from a March, 2008 issue of JAMA as one woman describes her experience with Aromasin:

As planned, I switched to taking exemestane [from tamoxifen]. But while taking it, I was feeling like I was a hundred years old. When I got up in the morning and opened my hands, all my joints would be sore and my arms hurt. All of my joints felt creaky. I started thinking, why should I stay on the exemestane for another 2 1/2 years? Why am I doing this to myself? So I called my doctor and asked him to switch me back to tamoxifen.

Tuesday, June 10, 2008

Of frogs, princes, shoes, and feet

One of my favorite books whilst growing up was an illustrated version of Grimms' Fairy Tales. Contrary to popular belief, the princess in the tale of The Frog Prince was so sickened by the attentions of the slimy frog that she "...picked [him] up with her finger and thumb, carried him upstairs, and put him in a corner." When he came creeping up requesting a spot beside her in bed, "she felt beside herself with rage and, picking him up, she threw him with all her strength against the wall, crying 'Now will you be quiet, you horrid frog?'"

So what's this got to do with horrid feet? I've been vainly attempting to replace my broken down not-so-New-Balance exercise shoes. Alas, New Balance no longer makes that model, so I must've tried on a dozen pairs of other NB styles at DSW's Denver store. Thank heavens the help pays you no mind there, because I was close to heaving a shoe or a salespunk, which one mattered not, at the wall. I left with sturdy Easy Spirit slip-ons, but no go-fast shoes.

Today, I scored by stepping out of the NB box into Balance shoes (that's Balance with a backwards B that looks like d that rhymes with c that stands for made-in-China comfort). Danced my heart out at Jazzercise an hour later with no pain at all.

The moral of my story is don't settle for sore feet. Try rolfing, neurokinetics, orthotics, Yoga Toes, orthopedists, and kiss as many shoes as you need to so that your feet can carry your heart, brain, bones, and muscles intact to the finish line.

Wednesday, June 04, 2008

Lipotoxicity

It starts with ectopic lipid deposition. Don't you just hate that--looking for fat in all the wrong places...and finding it? But we're not talking thighs, waists, and back ends here, but rather heart, muscles, liver, and pancreas.

Researchers theorize that our overconsumption of lipid-rich foods results in oversecretion of insulin. As a result, our livers produce too much sterol response element binding protein 1c (you might know it as SREBP-1c) which results in that organ gearing up to take those extra calories and turn them into fat molecules called triglycerides. Great gobs of these calorie-dense triglycerides then float through the bloodstream on their way to some storage depot where they will sit waiting for the coming famine that never comes. It's merely annoying to wear the extra fat in rolls about your waist, but it's downright toxic to stow them in your heart, muscles, liver, and pancreas.

Ectopic fat, i.e. triglycerides stored in all the wrong places, results in a world of metabolic trouble with a capital T that rhymes with D that stands for diabetes. Once in muscle cells, the fatty acids cause the muscle tissue (our biggest bodily consumer of sugar) to resist the actions of insulin, thus preventing the uptake of sugar out of the bloodstream and into these cells.

Fat stowed in pancreatic cells further amplifies this metabolic mess by killing off the very cells that make insulin. When the human body goes one Big Mac over the line, therefore, we not only eat fat but our liver makes more fat, our muscles become insulin resistant, and our pancreas are rendered less able to make more insulin.

Too much fat in, too much fat made, too much fat stowed in the wrong places. The lipotoxic effects of overeating, the lipocentric theory of diabetes. Two lessons: 1) Don't ignore the high triglyceride levels on lab panels--they're a huge red flag that you're on the way to diabetes, and 2) Don't discount the enormous value of any weight loss, even a little, with respect to preventing and treating diabetes.

Sunday, June 01, 2008

Young@Heart

Want to smile and feel good about growing older? This movie is about remarkable old people in a singing group. Remarkable not because they've aged without physical ailments but rather because they've aged with spirit and humor despite their infirmities. The documentary follows them through the initial rehearsals to their sold-out performance with interim stops for a show at a local prison, and several trips to hospitals.

I need to find a singing voice and a fifty-something musical director in 20 or so years so I too can be young@heart.

Wednesday, May 28, 2008

Sleep apnea and memory problems

You snooze, you lose. Neurons, that is, in charge of memory function, lost when you go apneic (quit breathing) while sleeping. Check out the details at Menopause moments.

Tuesday, May 27, 2008

Highways, blood vessels, and indoor air

A lot of research suggests that particles from outdoor air affect vascular function, especially at high doses. We wanted to see whether the concentration of airborne particles in a regular, normal home would be sufficient to cause similar effects, so we removed them, and indeed we found they had [adverse] effects.
---Dr. Steffen Loft, University of Aarhus, Denmark


The air here in central Denver hangs heavy in the winter and is downright visible in the summer. If ever I deluded myself in thinking that staying indoors protected me and mine from the crap in our air, Dr. Loft has proven otherwise.

Loft and company studied a delegation of Danes living near heavily trafficked roads(1). These old folks, ages 60 to 75, spent four consecutive days in their homes-- two breathing high-efficiency particle-air (HEPA) filtered air and two without. The filter removed 60% of the resident schmutz in their air and improved their flow-mediated dilation (FMD or FMV) by more than 8%. FMD is an indirect measure of the healthy function of blood vessels.

Is 8% a significant boost to vascular function? Again, per Dr. Loft: "...I believe people with overt, severe cardiovascular disease have a reduction in microvascular function in the region of 30% to 40%. I think this improvement is something like what you might expect from a well-working drug."
_____
(1)Brauner EV, et al. Indoor particles affect vascular function in the aged. An air filtration-based intervention study. Am J Respir Crit Care Med 2008. 177:419-425.

Wednesday, May 21, 2008

Yoga Toes vs. a Trip to the Orthopedist


They both cost me roughly the same--about $45. The former got me two clear plastic toe separators with a lifetime guarantee against breakage. The latter got me 5 minutes of his time, plus assurances that 1) my flatfeet were the source of my pain (I knew that) and 2) my posterior tendon was not hopelessly and permanently stretched (I didn't know that, but hoped it was true).

Here's my conclusion after one month of Yoga Toe workouts (stick your toes into the Yoga Toes, lie down, watch TV). Spend your money on them and skip the copay for the overpriced specialist. Compare and contrast:

December, 2007, I walk 5 blocks to an antique/thrift store on Colfax Avenue. My feet hurt so much that I wonder if I'll be able to make it home. No cell phone along on my retail adventure, so no choice but to hobble home.

May, 2008, I visit the Black Hills of South Dakota and scramble up a steep slope for 25 minutes to take in the breathtaking view (and try as I might, I can't make the guys there on Mt. Rushmore come through). I skid down (on feet not back end) and walk briskly back down the path to the car. No pain at all.

Thursday, May 15, 2008

Lovaza

"And I'll need a script for Lovaza..."

Dang, one of those humbling moments. What on earth is Lovaza? Should I just ask or should I excuse myself for a moment on the pretext that I need a new prescription pad, then look it up quickly in the PDR? Well, by hook or by book, I found out what it was.

Lovaza is Omacor. Omacor, by any name, is a high potency omega-3 fatty acid supplement, but that particular name was entirely too similar to Amicar, a drug used to prevent or treat serious bleeding in hemophiliacs. Not that anyone would have trouble reading my writing, but if they should, that's a heckuva mistake to make.

I always ask my patients about the supplements they take during their annual exams. As a result, I know that most everyone is on to the fish oil fad instead of the previously top popular vites C & E. Research suggests that use of these oils can prevent sudden cardiac death(1), decrease risk of Alzheimer's disease(2), improve the mood(3), and lower triglycerides.

So why pay for fancy prescription strength Lovaza when you could do a 3 for 1 deal at Puritan.com(current sale price)? The two products have similar EPA and DHA content--one capsule of either the OTC or rx variety has roughly 1,000 mg of these worthy fatty acids which is the recommended dose for persons already diagnosed with coronary artery disease. Patients with elevated triglycerides (blood fats) should consider a daily dose of 4,000 mg.
_____
(1)Is it death or tuna casserole deficiency?
(2)Be the right sort of fat head
(3)Fishing for a good mood

Wednesday, May 14, 2008

Cough CPR

If you're like me, you've received multiple copies of the e-mail that sings the praises of coughing your way out of cardiac arrest. The method remains controversial and has earned itself a place on "urban legend" web-sites. A Polish cardiologist, however, continues to investigate the method and would like to pull it out of the mythic category into everyday practice.

Sudden cardiac death caused by rhythm abnormalities of the heart which cut off circulation to the heart and brain takes out 300,000 Americans each year. Dr. Tadeusz Petelenz notes that patients have a 20-30 second prodromal period prior to pitching marked by dizziness, shortness of breath, nausea, sweating, and weakness. If properly trained, a quick thinking cardiac patient can launch into cough CPR, maintaining consciousness long enough to call for help.

Animal studies support the physiology behind this maneuver. Forceful rhythmic coughing causes an upswing in pressure through the chest cavity. With each cough, blood is squeezed out of the lungs, back through the heart, and into blood vessels serving important organs such as the brain. With each deep inspiration between coughs, blood zips back through the right heart chamber and into the lungs and the coronary circulation.

Over 100 of Dr. Petelenz's at-risk patients were taught cough CPR and successfully hacked their way out of nearly 300 prodromal events. They required medical assistance through 73 events during which they were unable to cough up their blood pressure. Doubtful colleagues at the Annual Congress of the European Society of Cardiology objected that there was no coughless control group, but who would want to be assigned to that bunch of deadbeats now that Dr. P. has fair evidence that it works? If I were a patient at high risk for sudden cardiac death, I'd rather cough than wait to see if this prodrome was the big one.

Sunday, May 11, 2008

Carotid bruits

We're always looking for an easy-to-use, 'crystal ball' of a test that will predict cardiovascular risk. Since we can't actually visualize the blood vessel walls, we use 'surrogate markers' that are more or less associated with unwanted future outcomes like stroke and heart attack.

The carotid arteries are well-placed for easy access as they head upwards through the neck on either side of trachea. Not only does atherosclerotic narrowing in these essential vessels increase risk for embolic stroke (where little bits of clot and cholesterol guck break off from the walls and block the blood supply to parts of the brain), the health of these vessels is a good predictor of overall vascular health.

Thickening of the carotid walls known as intimal-medial thickness or IMT is a known risk factor for heart attack and stroke. Although this can be measured without actually needling these big old arteries, and thank heavens for that, carotid ultrasound technology is not readily available in the average PCP's office. Advancing age, LDL-cholesterol levels, and diastolic blood pressure(1) are good current predictors of IMT thickening(2). These measurements can be used then as surrogate markers raising suspicion that a person rating high in all three areas might well have carotid artery disease.

The latest issue of The Lancet confirms that another test easily performed on aging persons during their annual physical provides additional cardiovascular risk assessment. Around the age of 50 or so, I begin to feel for normal pulsation in the carotid arteries (but not both at once as bilateral pressure on these vessels can induce fainting!) as well as listen with my stethoscope for the unwanted, rhythmic whish of a carotid bruit that occurs as the heart contracts and sends a surge of blood through narrowed old carotids.

Doctors from Walter Reed Medical Center analyzed data from thousands of carotid arteries and their attached humans with respect to risk of heart attack with or without death in follow-up. Those whose carotids hummed at outset were twice as likely to have a heart attack in the 2-7 years that followed, and had nearly thrice the risk of cardiovascular death.

So ask your doc to check up your neck at your next physical.
_____
(1)Diastolic pressure is the lower reading on blood pressure measurement which measures the amount of pressure in your blood vessels as your heart relaxes in preparation for the next beat. The upper or systolic number is the pressure generated as the heart contracts. Diastolic hypertension is also a known risk factor for abnormal thickening of the heart wall.
(2)Davis, PH, et al. Carotid Intimal-Medial Thickness Is Related to Cardiovascular Risk Factors Measured From Childhood Through Middle Age. Circulation. 2001;104:2815-2819.
(3)Pickett, CA, et al. Carotid bruits as a prognostic indicator of cardiovascular death and myocardial infarction: a meta-analysis. The Lancet. 2008; 371:1587-1594.

Tuesday, May 06, 2008

Methylfolate and depression

...or how to B undepressed.

Folate is a B vitamin that occurs naturally in green leafy vegetables. It plays a host of important roles in the human body, and is so essential to the proper construction of the nervous system of a developing human that the FDA mandated in 1996 that its synthetic form--folic acid--be added to breads, flours, and other grain foods.

The trouble with folic acid supplementation or even naturally occurring dihydrofolate from food sources is that the body must convert them into the active form which is L-methylfolate (known as MTHF--yes, I thought of that word too the first time I read it). Some people are better MTHF producers than others. For purposes of our discussion, we will focus on the effects of MTHF deficiency and the fully developed brain.

The brain is tightly guarded by the 'blood-brain barrier.' Certain molecules can't pass through the blood vessel walls into brain tissue, and folate is one of them. MTHF, on the other hand, slips right in, and a right good thing it does because it is an important co-factor in producing the three most important neurotransmitters involved in mood regulation. If you're low on MTHF, studies suggest that you may subsequently run low on dopamine, norepinephrine, and serotonin. We're talking transmitters with a capital T that rhymes with D that stands for depression.

A host of research shows that supplementing methylfolate--thus skipping the necessary internal steps to activate folic acid--improves depression under a host of circumstances. This being an older person's health blog, let me illustrate with one study which supplied sad, old people with MTHF.

Researchers coaxed 20 elderly people who were not only Italian but also depressed to take 50 mg daily of MTHF rather than antidepressants. Four said the Italian equivalent of 'what's the use' and quit. The remaining subjects showed significant improvement in their depressive symptoms.

But you don't have to be old to enjoy the potential mood elevation of MTHF. A product called Deplin is now available by prescription and specifically indicated for use in patients having a less than stellar response to antidepressants. Theoretically, it might also be useful for persons with mild mood disorders not on other medications.

The basic science literature supporting the theory that MTHF improves brain function is large, but clinical research, except for the random Italian or so, is sketchy. Thus Deplin has been designated a 'medical food' which apparently does not have the stringent proof requirements of prescription drugs. Nevertheless, no adverse effects of MTHF supplementation have occurred, and a downloadable coupon at deplin.com makes this an affordable gamble of a therapy.

Saturday, May 03, 2008

Menopause moments

Milk in the cupboard, cornflakes in the 'frig. Women of 'a certain age' find these moments infinitely amusing...and definitely scary. Are we overwhelmed, inattentive, out of estrogen, or slipping down the road to dementia?

I invite you to check out my newish blog Menopause Moments. Share a momentary brain lapse that made you laugh, then read the latest research about what constitutes a menopause moment (aka senior moment), and what you can do to assure that yours will never become a permanent state of mind.

Friday, May 02, 2008

Unipedal standing

Less scholarly, perhaps, to just call it standing on one foot. Unipedal or onefooted, these Japanese orthopedists wondered if a daily balancing act might make old people less prone to pitch to earth and break their hips(1).

During their six month study, they divvied a pack of old folks at high risk of falling into two groups. The test subjects stood on one foot, then the other, one minute per side for three sessions each day. The other group just stood their ground in the usual manner.

Dr. Sakamoto previously calculated the load-bearing effects of stork-like posturing on the femoral head(2) or that part of the hip bone connected to the pelvic bone. This area is susceptible to loss of bone density and fracture when an old person goes to ground. He concluded that unipedal standing placed a load equivalent to 2.75 times the body weight on the involved femoral head, and one minute of time spent doing so was the equivalent of 53 minutes of walking with respect to benefits to bone density.

Let's see, one minute per side x 3 sessions per day equals six minutes of balancing acts vs. 318 minutes of walking. Well, how would you rather spend your discretionary time?

Alas, either six months is not long enough to determine the benefits of unipedal standing on old Japanese fogies, or you can't fool Mother Nature. At the end, there was a sort of significant decrease in falls in the test group compared to controls, and only one hip fracture in both groups.

I don't know whether I'm going to do this or not. Maybe if I could wear my Yoga Toes while balancing and thus do all my weird self-trials at once.
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(1)Sakamoto, K et al. Effects of unipedal standing balance exercise on the prevention of falls and hip fracture among clinically defined high-risk elderly individuals: a randomized controlled trial. J Orthop Sci. 2006 Oct;11(5):467-72.
(2)Sakamoto, K. Effects of unipedal standing balance exercise on the prevention of falls and hip fracture. Clin Calcium. 2006 Dec;16(12):2027-32.

Thanks to Jacob Schor, ND and his always excellent newsletter for calling my attention to these articles. You can subscribe at denvernaturopathic.com.

Thursday, May 01, 2008

Stowed St. Francis in snow



Mom's St. Francis statue in his new home in Colorado Springs. Looks right at home, doesn't he? That snow is right here, right now, in not-so-sunny Colorado.

Photo courtesy of Tobi.

Tuesday, April 29, 2008

Stiff feet and Yoga Toes

Twenty-six bones in the feet, and all 26 of my Mom's moved as one. Zero flexibility in her old feet, and I'm here to tell you that was no small part of her mobility challenges.

As so many aging children of elderly parents do, I kept close watch on the physical changes my parents endured through the years with an eye towards my future. And I decided as I followed Mom down many a hallway, I do NOT want wood for feet.

No surprise that my arches had already fallen, they did so painfully about 8 years ago. As I researched this stiff foot thing, I discovered the too many toes sign and posterior tibial tendon dysfunction. I went to an orthopedic specialist in feet who assured me that while I had the first, I did not have the second. That's all I got from him for my $45 copay, but a little reassurance is always helpful. For quite a bit more, I bought Good Feet arch supports which resulted in 2 of the most painful months of walking I've ever experienced.

But now, color me green with 'range-of-motion' envy. I had a patient in recently with the most flexible forefeet I've ever seen. She could wave bye-bye with those toes in great sweeping motions so freely mobile her digits. And her secret? "Oh no," says she, "I didn't always have such clever feet. I owe it all to Yoga Toes.


Shoot, I had to get me a pair of those Yoga Toes. The picture on Amazon is inscrutable--they're actually clear plastic toe separators (and no longer available on Amazon!). When I put them on at work, my medical assistant declared them the very thing for painting your nails without smudging them.

Will they restore range of motion to my tired dogs? I'll keep you posted.

Sunday, April 27, 2008

Leftover life: Stowed!

Mom's condo is empty at long last. Two station wagon loadfuls, and a final truck's trip for the couch to another family's living room with the same color decor as Mom's.

I just spoke with a young woman from Craigslist who is delighted with the 1950's style Smith Corona manual typewriter and rapturous over the prospect of the vintage black Singer sewing machine. All of Mom's life lovingly tucked away in hearts and homes.

I sometimes wondered if I'd lost my mind (or perhaps would lose it) handling each and everything with care as to the perfect disposition. Now I know it was the best way to honor her life and say good-bye.

Thursday, April 24, 2008

Hemorrhoids and spicy foods

Are you a PLWH? Chances are good that you are as about 50% of adult persons are indeed living with hemorrhoids. Does the thought of spicy in (like, say, red hot chili peppers) leading to hot out (now I don't have to explain that, do I?) make your hemorrhoids cringe? Rest easy and indulge; research* indicates your hemorrhoids are not a risk from your spicy excesses.

Italian researchers, about 50% of whom doubtless had hemorrhoids, randomized 50 adults with big-time 'rhoids to receive two blue capsules at two different meals either packed with red hot chili pepper powder or placebo powder with no kick at all. They prepared the real deal capsules with the amount of spice needed to achieve "spicy enough" status (as defined by the Association of Teachers of Italian Cuisine) if the contents had been added to a normal dish rather than the colons of the test subjects.

One week, half the group popped hot and the other half downed not. The following week, the capsule allocation was reversed. On a visual scale of 0 to 10 (can you picture the visuals here?), the subjects were asked to rate the situation down under with respect to bleeding, swelling, itching, and burning before and after.

The results? Spice in is not a problem at the end of the line.
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*Altomare DF, et al. Red hot chili pepper and hemorrhoids: the explosion of a myth: results of a prospective, randomized, placebo-controlled, crossover trial. Dis Colon Rectum. 2006 Jul;49(7):1018-23.

Sunday, April 20, 2008

When can you stop having mammograms?

I mentioned in a previous post that the American Cancer Society identified age 70 as the end of the line for low risk women to get Paps. Ducking the date with the speculum (the first of which, incidentally, was fashioned out of a pewter spoon) is one of those age DOES have its privileges things.

What about ending the annual encounter with the mammogram machine? European investigators presented the results of two large studies at last week's 6th European Breast Cancer Conference that address the ideal interval and cut-off age for older women and breast cancer screening.

In 1998, The Netherlands extended the national breast cancer-screening program to women up to age 75 from the previous age limit of 70. Investigators tracked the incidence of death from breast cancer in women ages 75-79 during the time period 2003-2006, five years after the expanded screening offering began. Compared with a ten year period beginning in the mid '80s, the breast cancer mortality for this age group dropped nearly 30%. Clearly, mammograms done on women in their late 70s were picking up breast cancers that would have otherwise proved lethal if not detected.

Researchers on the UK Breast Screening Frequency Trial randomized 100,000 women ages 50-62 to receive mammograms either annually or every 3 years. The two groups were followed over 13 years, and the risk of breast cancer death was virtually the same whether the women were annually squashed in the mammo machine or submitted to the test once per 3 years.

One of the reasons, investigators theorized, that women over 70 benefitted from screening is that their breast tissue was less dense, and thus mammograms were easier to read and more accurate at detecting early cancers. Senior researcher Jacques Fracheboud noted, however, that "it is not necessarily an argument for continuing screening beyond 75 because many tumors found at this stage are slow growing and may never reach the stage of causing a problem."

Breast density is a consideration for the somewhat younger group as well. Those women ages 50-62 with dense breasts--i.e. hard to image with mammograms--may well be doing themselves a disservice to embrace the every 3 year embrace of the mammogram plates. Before you decide that this interval is for you, or before you chuck the test at 75, check with your doctor to see if these decisions are appropriate in your case.

Friday, April 18, 2008

Leftover life to stow, Part II

I posted some time ago about the difficult but important task of shutting down a life. At that time, my Mom was still alive, newly in the nursing home, and I was taking the first few passes through her beloved condo. The best experiences then were giving away her plants, her craft supplies, and her books to people who were so excited to receive these bits of her life into theirs.

So now I'm down to the hard stuff, all the things that I'd look at and think ohnotnow, maybelater. Later is here. A wonderful friend joined me today, a woman long on organization and free of the emotional baggage that I bring to the task. Whenever I dithered and gave her the ohnotnow on a vase or a piece of art, she'd gently bring me to the ohyeahnow place.

So everything is sorted, stacked, and ready for transport. Some advertised on Craigslist, some ready for the art or natural history museum, a stack for me, a stack for my brother, one for charity, and one for the wonderful friend who spent the day holding my hand and honoring my Mom's leftover stuff.

Wednesday, April 16, 2008

Make friends and sleep

If you can't sleep, connect with an endearing community of insomniacs. There's bound to be such a chat room somewhere on the Internet. And if a great night's snooze leaves you little time to bond with friends over dinner, don't lie awake worrying that your health will suffer. Matters not whether you're sleeping or networking, researchers have proven that either activity will enhance your health.

Previous research has shown that poor sleep raises body levels of an inflammatory molecule called interleukin-6 (IL-6). On the other hand, another study found that old guys who hung out with their buddies had less IL-6 than the isolated curmudgeons. IL-6 levels are directly correlated with an increased risk of cardiovascular disease.*

Dr. Elliot Friedman and colleagues asked 135 aging Wisconsin women about their relationships with their friends and their beds. They then correlated those results with blood levels of IL-6. Those women who enjoyed both early evenings with others AND late evenings with covers had almost no IL-6 noted compared to their sleepless, disconnected colleagues. Fortunately, either good friends or great sleep was also enough to reduce IL-6 to "virtually undetectable" levels.
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*Cardiologists at the University of Pittsburgh reported in the November, 2005 issue of the American Heart Journal that women at risk for heart disease with the highest levels of two or more inflammatory markers (C-reactive protein, IL-6, or serum amyloid A) were more than four times as likely to die during their 5 year study compared with similar women who had no such laboratory signs of increased inflammation.

Tuesday, April 15, 2008

Estring and breast cancer

"If you run out of estrogen," a menopausal expert once told me, "you WILL dry up." As in symptomatic-genital-shrink-and-shorten sort of dry up. Yet many women are uncomfortable about the use of estrogen, particularly as it is associated with a slightly increased risk of breast cancer. For those of you passing up hormones or for those of you with a personal history of breast cancer, here's some important information.

Estring is a product that delivers estradiol locally right into the appropriate female passage via a silastic ring which is left in place for 3 months. During this time, the ring releases 2 mg of estradiol which is the equivalent of 1-2 days' worth of full-dose, oral estrogen therapy.

Menopause experts Drs. Nicole Brooks and Andrew Kaunitz note that they prescribe this treatment to a number of patients in their practices who are breast cancer survivors due to the ultra-low levels of estrogen that are absorbed via this route. Estradiol tablets--sold as Vagifem--are also effective in improving vaginal symptoms, but estrogen absorption into the general circulation is higher with their use compared to that with the ring. Some women complain of breast tenderness with the use of Vagifem. Estrogen creams produce the highest systemic levels of estrogen of all the local treatments and are sort of gooey.

While the estrogen absorption of Estring is ultra-low, the price is ultra-high.

Sunday, April 13, 2008

When can you quit having Pap tests?

Age has its privileges. Per the American Cancer Society, no more Paps needed:

  1. When you're over 70 AND
  2. You've had no abnormal tests in 10 years AND
  3. You've no new risk factors for cervical cancer such as a new partner.

Saturday, April 12, 2008

An Aged Athlete

From a simpler time, when old was old, and physically fit was not (old that is):

An old-time champion pedestrian, whose record 30 or 40 years ago aroused the country, has recently at the age of nearly 70 performed the feat of walking from Philadelphia to New York, a distance of 96 miles, in a little over 23 hours and finished the task in excellent physical condition. This is a good example of the fact that the physical organization of man need not necessarily go to pieces before the allotted three score and ten, when, according to some, the system is worn out and useless. Of course, this man is an exceoptional case, but he shows what the possibilities are, and probably a great man other individuals of as great age could do likewise.

----JAMA, June 23, 1906

Sympathy cards

Cards, notes, calls, these expressions of sympathy are simply the best. Whether they share a wonderful memory or just say "Sorry to hear about your loss," they are a source of enormous comfort. I won't let another passing of a friend's loved one pass without sending my thoughts along.

Monday, April 07, 2008

Fall prevention

My friend Anita has suggested a mantra for growing older (nofallingnofallingnofalling). Having spent more than a little time trailing after an extraordinarily shaky old lady, I do not believe that this mantra has the proper rhythm to keep an old person upright. I found that singing "The Hokey Pokey" with gentle taps to the appropriate foot had just the rhythm for easy ambulation.

Dr. Frederick Carrick of the Carrick Institute searched for music to stay upright by, registering one clinical trail with the NIH under the title "Fall Prevention in a Geriatric Nursing Home Setting Using the Music of Nolwenn Leroy."* Who then is Nolwenn Leroy?

She is a 25 year old French pop star who's shuffle along music can be found at Nolwenn Sings for the Unsteady. While Dr. Carrick found her tuneskys superior to other musicians including Mozart for modulating the gait of walkers walking with walkers, I don't get it. I'd sooner do the Hokey Pokey myself.
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*"Music to stand bolt upright to."