Friday, February 29, 2008

What's a triglyceride?

Blood sugar is circulating glucose, and triglycerides are circulating fats. Both of these nutrients are on their way somewhere other than the bloodstream --sugar to the cells for ready energy, and triglycerides to storage sites on your hips and back end for the theoretical famine that never comes.

Elevated triglycerides indicate that you eat too much, you weigh too much, or you are becoming resistant to the effects of insulin. An elevated triglyceride level may indicate a future risk of diabetes. Not only are triglycerides a marker for trouble, they ARE trouble when present in the blood in elevated quantities. They are toxic to the beta-cells of the pancreas, so as one becomes resistant to insulin and triglyceride levels rise, these circulating fats kill off the insulin-producing cells of your pancreas in a vicious, diabetic circle. They are also toxic to heart muscle cells, and, when stored in the liver, can contribute to the development of liver disease especially when combined with alcohol.

Furthermore, exercise physiologists have found that triglycerides stored in muscle cells make it very hard to lose weight. Intense aerobic exercise is needed to use up these muscle fat stores before overall weight starts to fall. Elevated triglycerides also cause HDL-cholesterol levels to fall, a combination called atherogenic dyslipidemia which means an abnormal pattern of blood fats well-known to leave cholesterol plaque in your arteries.


Here's the latest two-fer-one pill newly approved by the FDA. Two-fers are a real boon to patients with age and weight-related metabolic troubles who struggle with hypertension, cholesterol abnormalities, and abnormal blood sugar levels. Not only are two-fer drugs less expensive by one co-pay, they increase compliance by decreasing pills swallowed per day. I love Lotrel (now available generically, combines an ACE inhibitor with a vasodilator for really good blood pressure control) and lisinopril/HCTZ which pairs an ACE inhibitor with a diuretic, also for hypertension. Diabetics also have a choice of this-plus-that drugs, including Actosplusmet and Janumet.

The problem with medicating cholesterol troubles is that no one drug addresses all the fat-related abnormalities. The statins have little effect on triglycerides and virtually no effect on HDL-cholesterol, drugs like Tricor don't change LDL-cholesterol much, and nobody likes niacin. Niacin, however, favorably lowers triglycerides and raises HDL-cholesterol, and the manufacturers of Niaspan have gone to a lot of trouble to make their extended-release niacin more tolerable.

Up until this month, we had two cholesterol-lowering two-fers. Vytorin teamed up Zocor and Zetia, but we all know what happened to Zetia this year. The other one called Advicor pairs lovastatin, a weakish sort of statin, with niacin. Enter Simcor, a combo of Zocor (simvastatin) plus extended-release niacin. Not only did study patients on Simcor 1000/20 achieve significantly better cholesterol scores compared with those on simvastatin 20 mg alone, the combination product lowered triglyceride levels by 27%.

Wednesday, February 27, 2008

Smart dressing

Well, I'd like to write a post about dressing smartly in a professional yet feminine sort of way. Alas, in yesterday's Chico's and clunky Clarks, I am supremely unqualified to do so. This post, actually, is about the new materials that wound dressings are made out of, and the people who need them.

It's a fact, elderly people live dangerously. The statistics are grim; their chances for pitching over while tottering about the bathroom or pitching out while their supposed to be in bed are huge. And the consequences of their injuries are often disabling and life-threatening.

Two weeks ago, my Mom reached out for something on her bedside table. Overextended she grabbed for the corner of her bedside table with the skin of her forearm and headed for the ground, leaving not a scratch but a divot in her arm. This open sore has reached Grand Canyon proportions, festering with infected goo and harboring a large piece of partially dead tissue in the middle.

The nurses have done a marvelous job of working on her arm, but Mom's immune system is as tired as she is. How then to do the best we can cleaning up the infection and promoting the growth of new tissue from below? I'm a cognitive sort of doc, and talking with Mom about her wound simply will not make it better.

Besides the good ministrations of her doc at the home, I am privileged to have made the acquaintance via the blogging world with Suture for a living, aka Dr. Bates, an Arkansas plastic surgeon. No point in recreating all her information on these fancy new dressings; check out her post at
Dressings for wounds. They've got dressing for dry wounds, fragile skin, festering wounds, hemorrhagic wounds, and wounds that smell bad. I am pleased to have Dr. Bates and Duoderm on our side. Now if only some fashionista would take me shopping.

Sunday, February 24, 2008

Lung volumes

When I showed up this a.m. at the nursing home, Mom was sleeping deeply, and her color looked bad. As usual, she'd thrown off her oxygen, so it was no surprise that her oxygen saturation was low. But 71% low?!?!? A normal level is greater than 90%--no wonder she was totally out to lunch.*

Why so low? My mother suffers from osteoporosis, and her curved spine restricts the expansion of her lungs. In addition, everyone, curvy backbone or no, restricts their lung volume when lying down, particularly if they carry a lot of weight around their midriff which she does not. She'd also recently had a dose of pain meds (having torn a chunk of her forearm out when reaching for an item on her bedside stand), and was breathing shallowly in her drugged sleep. Finally, she had radiation to her lungs many years ago (take that you stupid lung cancer) which left stiff scar tissue in place of elastic lung. All together--twisted back, lying down, drugged sleep, and radiation fibrosis--equals a low lung volume also known as restrictive lung disease.

So what then of the barrel-chested folks with obstructive airway disease? These people, generally ex- or current smokers, have destroyed tissue so that their lungs which once had the even sort of holes of a synthetic sponge now have wildly uneven air spaces like a natural sponge. The tissue no longer springs back into place as they breathe out. In fact, the expanded airspaces start to push on the tiny airways during the course of exhalation which shuts off the exit route for the used up air.

As a result, their lungs are hyperexpanded (increased lung volume), but the extra volume is made up of old, dead air that is devoid of fresh oxygen. While their total lung volume is up (as opposed to the patients with restrictive lung disease), their vital capacity--i.e. the amount of air exchanged with every breath--is way, way down.

Gotta love your lungs. Don't smoke, hold your breath during high pollution days, and save your spine from collapsing through exercise and proper nutrition.
*Speaking of idioms, I went to the nurses' station at the home one day and informed the wonderful French nurse on duty that my Mom was completely out to lunch. She rose in alarm, "Non, non, she had lunch in her room! She should be there!

Saturday, February 23, 2008

Postural perseveration

Necessity is the mother of invention...necessity is the mother of invention...necessity is the mother of invention...
--My Mom

There are days that my Mom doesn't know who I am, and days where she can't even talk. Today she was firing most neurons in a satisfying way. We talked over coffee on a wide variety of subjects--why her oxygen level is low, what is diffusing capacity, how cooking freed pre-humans to develop large and energy intensive brains, how our human genome fosters obesity and diabetes through overeating, etc. In short, the first hour of our visit was a remarkable conversation with Mom as she used to be.

As we rolled to the dining room, however, the situation changed. She'd now been up an hour, and fresh blood to brain was starting to slow. Towards the end of our free flowing talk, she'd wondered if inventors were generally poor as the lack of resources available in poverty might make them more resourceful. "Necessity," I reminded her, "is the mother of invention."

She proceeded to repeat that old adage, first in a thoughtful, musing sort of way, then in an increasingly broken record sort of automatic repetition. Pure perseveration this--an uncontrolled repetition of a word or phrase, and a sure sign the brain is slipping its gears. In short, she was having another postural TIA.

"Oh Jude," she finally gasped, "How do I turn this off?" She became too agitated to eat. I took her back to her room and helped her into bed. As is often the case when gravity robs her brain of blood flow, she was scarcely able to move her left leg to negotiate the three steps from wheelchair to bed. I should've known better, an hour of talk is too much of a good thing.

Friday, February 22, 2008

Skinny white women who smoke...

are prime candidates for osteoporosis. And these same skinny ladies who age into frail old ladies (still smoking or not) are prime candidates for broken hips. And here's the story about how they might die.

Mrs. I was my patient, a family friend, and a neighbor. Her husband called me early one morning to say she'd fallen in the bathroom and probably fractured her hip. I hurried right over to wait with them for the paramedics. As I sat and chatted with Mrs. I, she on the tile floor and me perched on the can, I couldn't shake the gloomy thought that there was a high likelihood she'd be dead in several months. Now 92, she'd last made her daily walking trip to the local store at age 90, always with cigarette in hand.

The orthopedist gave us two options: do nothing and she'd see out her days in bed and in pain. Go for a new minimal sort of surgery where a pin could be inserted through the skin into the fracture site under local anesthesia, and she might walk again. No problem with that decision.

Walk she did, and home she went. Unfortunately, as the physical therapist worked with her to once again negotiate the steep stairs in her house, she stumbled and fractured some ribs. The pain put a stop to all her rehab efforts; she moved to a hospital bed in the downstairs office and spent more time in it and less time in a wheelchair. One night, Mr. I again called me. She'd sat bolt upright in bed struggling to catch her breath. A blood clot had probably broken free from her pelvic veins and traveled into her lungs, blocking a blood vessel there. It probably broke up then as her breathing eased rather quickly.

Two weeks later, unfortunately, another clot escaped her pelvis, a big one this time. Her breathing became labored, then stopped altogether.

We all have to go some time, some way. Few live into their 90s, and Mrs. I had lived well. But skinny white ladies who smoke can duck this scenario perhaps with changes in lifestyle choices long before they age.

Tuesday, February 19, 2008

Successful aging

My 79 year old patient Ms. H was in yesterday to discuss her hip pain. She'd just returned from a cruise down the Nile and a visit to the Great Pyramid of Giza.

"Paley," she advised (my only patient, incidentally, who calls me by my last name), "Travel while you're still young."

Her Giza gripe was that she'd been unable to enter the pyramid because the entrance passageway was too short to allow a normal height individual to walk through but rather required a virtual duck walk to navigate. And her arthritic hip completely precluded such a maneuver. Still more aggravating to her was the ease with which an 88 year old traveling companion duckishly negotiated the cramped walkway.

But all in all, Ms. H declared the trip "fabulous." While her duck-walking friend can certainly be dubbed the 'remarkable elderly,' Ms. H more than qualifies as resilient in her adjustment to a painfully arthritic hip and her willingness to take it on tour.

I'd declare them both successfully aged. What constitutes successful aging and how we can advise our patients to achieve same is a matter of much research and publishing in the medical literature. Certainly, the best advice is to choose your ancestors carefully as studies suggest that the offspring of remarkable elderly on average go down the same road even if they don't eat sprouts and drink green tea.

For those of us who trusted the luck of the draw in parentage, here's good news from The Netherlands. Researchers on the Leiden 85-plus Study* sought out the Leidenian octagenarians, evaluating the success of their senescence from two points of view. Using standardized scales for physical, social, and psychocognitive functioning, they found that a mere 10% of the participants could be labeled successful from an overall functioning point of view.

When they interviewed the subjects, however, on their views about growing old, successful or not, they found most of them viewed aging well as "a process of adaptation rather than a state of being," valuing "well-being and social functioning more than physical and psychocognitive functioning."

Coping, adjusting, redirecting, and staying resilient even if not necessarily upright or duck-walking may be the secret to gilding the golden years.
*von Faber, M, et al. Successful aging in the oldest old: Who can be characterized as successfully aged?, Arch Intern Med. 2001 Dec 10-24;161(22):2694-700.

Saturday, February 16, 2008

Keeping track of toilets

Overactive bladders are common in women of age. These twitchy holding tanks no longer relax to accommodate a load of urine sent down from the kidneys. Sudden and unpredictable contractions, therefore, cause women to scurry for the nearest restroom. We laugh amongst ourselves, we older women do, that we all know the location of bathrooms in all our favorite stores, a skill made easier for many as we already found them when we used to tote around small children.

All joking aside, European doctors wondered if women who leak REALLY know where all the toilets are. Dr. Annette Kuhn and her colleagues(1) sent questionnaires to 270 women with stress incontinence(2), overactive bladder, or well-behaved bladders. The authors visited the toilets to validate the groups' answers. Their conclusion?

Women with overactive bladder are more likely to exhibit precautionary voiding prior to leaving home and have significantly more detailed knowledge about toilets in their neighbourhood...The overactive bladder seems to have a greater influence on behaviour and on quality of life than stress incontinence which could mean that they are more tortured by their symptoms.
(1) Eur J Obstet Gynecol Reprod Biol. 2006 Nov;129(1):65-8.
(2) Stress incontinence is notable for leakage with events such sneezing, coughing, or running. It is caused not so much by bladder overactivity as age- and pregnancy-related slumping of the bladder and urethra.

Thursday, February 14, 2008

Exercise and illness

Consider, briefly, the brave little mice of Urbana, Illinois. Despite coming down with influenza, these rodents rallied themselves off their couches and hit the exercise wheel for a gentle workout in the first days of the illness. They envied at first their colleagues who were allowed to continue vegging out in front of the TV, but were grateful in the final analysis to the scientists who urged them onward.

Those aging mice who overcame aches and fever to sweat it out a little on the wheel were significantly more likely to survive the virus than their sedentary buddies. Those go-getter mice, however, who followed the 'if a little is good, more is better philosophy' were also more likely to suffer complications or death from the flu.

Dr. Jeffrey Woods and colleagues theorized that the mice who motored fared better due to the inflammation modulating effects of exercise. Dr. Woods said "We think what leads to mortality is not the virus per se, but the host's response to the virus, and what exercise does is actually decrease the immunopathology within the lungs."

Better then to meet this flu season (and the morning paper predicts a brisk uprise in cases in the coming month) in good shape. Once you succumb (and no thanks to the lady who coughed up a storm in my exam room yesterday WITHOUT covering her mouth), a little treadmill workout may be a good thing.

Wednesday, February 13, 2008

Verbal fluency

Verbal fluency (VF) is defined as the ease with which a person can find the right word and use it at the right time. Verbal fluency tests generally involve a timed interval in which a person is asked to name as many animals (fruits, vegetables, words that start with Q, etc) as they can during that time.

I test my verbal fluency every day in the consultation room as I explain this, that, or the other medical condition to a patient with more or less ease. Progesterone definitely slows down my VF as does a lack of estrogen. Progesterone is known to have sedating effects on the brain, and my frontal lobe is clearly affected by my periodic use of Prometrium, a proprietary formulation of natural progesterone. A dose at bedtime gives me a great, dream-filled sleep but leaves me fumble-mouthed on the job the following day.

Likewise, estrogen has a strong influence on verbal memory, and some of my patients who choose to motor into menopause without HRT find their word-finding abilities seriously impaired. Estrogen supports the function of cholinergic neurons in the brain (those brain cells that communicate one to another via a neurotransmitter called acetylcholine). Cells in charge of verbal memory and executive functioning are cholinergic neurons and thus affected by lack of estrogen. Likewise, anticholinergic medication such as antihistamines (which are used as over-the-counter sleep aids) also can leave the user tongue-tied with respect to VF.

Not only does dementia cause decrease in verbal fluency, so often do head injuries (as the frontal lobe sitting just behind the forehead, is often first to hit the windshield in accidents), Parkinson's disease, schizophrenia, diabetes, and alcoholism. Persons with chronic lung disease are known to have cognitive troubles whether or not they're running short on oxygen levels. Ohio investigators found that 20 minute exercise sessions significantly increased verbal fluency scores on patients with COPD.

Sunday, February 10, 2008

"My toe hurts" Part II

When last I visited the world of painful, old toes, I mentioned that my mother's big toe was suffering from arterial insufficiency--bright red when she was upright and gravity pulled oxygenated blood in, and pale, waxy white when she propped it up on a footstool.

This mid-sixties year old lady had a really painful toe. Not only painful but an alarming shade of purplish-black at its tip. Same story last year, she related. Then, as now, it was winter, and walking barefoot on tile floors caused the tip of another toe to become ugly and painful.

Chilblains, I declared, with the smugness of an internist who's seen this sort of thing once before. Particularly common in persons with poor circulation, and this woman had known hypertension and high cholesterol, chilblains are caused by constriction followed by inflammation in the small arteries of toes and occasionally fingers in response to cold. They are typically red or purple, itchy or painful, and particularly ugly if they ulcerate. I started this patient on a medication that promotes dilation of blood vessels and advised her to wear warm footwear, even indoors.

Pride goeth before the wrong diagnosis, and she returned shortly thereafter with the toe worse than ever and another one toe starting to turn a worrisome shade of black. I called Dr. Alan Synn, one of those marvelous send-'em-right-over kind of specialists, who ultimately discovered that our patient was throwing off little clumps of cholesterol/clot gunk from her diseased leg arteries. These bad actors then coursed down the vessels into the much tinier ones in the toes where they lodged, cut off blood flow, and caused the skin at toe tip to die from lack of oxygen.

He subsequently put a stent in the offending, atherosclerotic artery. She continued on the dilating medication, took a trip to Mexico where the warm air to toe connection hastened healing, and she's doing just fine now.

Wednesday, February 06, 2008

Mobic and Caramel Pudding

The perfect reward for a morning spent clearing heavy, wet snow from the sidewalks of our corner lot. Pain relievers for the body and soul...

Saturday, February 02, 2008

Who needs a shingles shot?

Leftover chickenpox can cause a world of trouble.

My 59 year old patient was miserable. I saw her two days after the onset of painful blisters on her ear and in her ear canal. Besides the discomfort, she had terrible bouts of vertigo, and her mouth drooped on the same side as the blisters. "What is it?" I asked neurologist Adam Wolff, MD by phone. "Ramsay Hunt Syndrome," he answered, kindly not adding the word 'obviously.'

Nearly all of us of a certain age have done battle as children with the herpes zoster virus. Way back when, we broke out in the characteristic bite-like rash of chickenpox. Since then, we have carried the residual zoster virus-particles in our nerve cell bodies along the spine and the base of our brain. Our immune system has kept a lid on the little buggers who now wait for an immune lapse so they can break free of surveillance and multiply along the axons of the nerves. When they do, we will develop a painful blistering rash in the area of skin supplied by the affected nerves, and, occasionally, paralysis in the facial muscles or other neurological syndromes such as Bell's Palsy or this Ramsay Hunt business.

While immune problems from cancer, chemotherapy, AIDS, or steroid therapy increase our risk of shingles, just ourselves growing older are at elevated risk. And the older we get, the more likely we are to develop complications with shingles, in particular a prolonged pain syndrome known as post-herpetic neuralgia (PHN) that can last for months to years past the breakout.

Researchers from the Mayo Clinic sorted through scores of medical records from adult Minnesotans to determine the incidence of recurrent herpes zoster (HZ) illness in both the healthy and immunocompromised residents of the area prior to the availability of the shingles shot (Zostavax). Most Minnesotans with HZ troubles were free of immune troubles, succumbing to shingles at a rate of 4 per 1,000 each year. The older the subjects, the more likely they were to let loose their resident HZ and suffer from painful complications. Specifically, 68% of the affected group were 50 and over, and 1 in 4 of them developed HZ-related complications.

So who needs a shingles shot? It is specifically indicated for persons over 60 who wish not to suffer from PHN in their golden years. Trust me, my patients with PHN find those years of pain not so very golden. While it is not yet tagged for persons between 50-59, this younger group of oldsters could benefit as well. The problem for them, for now, is that insurance may not pay for this pricey shot until the FDA approves the vaccine for that age group.

Happy-well vs. Sad-sick

Harvard researchers say the choice is mostly up to you. Some sixty years ago, they began to study successful aging in several hundred college sophomores. This satisfying outcome was gauged in those who made it to their 70's as follows: four objective variables--physical health, mental health, social support network, and years of active life, and two self-reported measurements--life satisfaction and personal assessment of physical health. High-scorers were dubbed the 'happy-well' and, obviously, the losers were the 'sad-sick.' The real losers were actually the prematurely dead but that was not a measured end-point. So what were the most significant predictors of successful aging?

Avoidance of alcohol and cigarette abuse before age 50 followed by education and exercise. These top four healthy behaviors were rounded out by stable marriage, appropriate weight, and positive coping mechanisms--all deemed by the study authors to be at least partially under individual control. Of those factors deemed to be beyond a person's control, only the diagnosis of depression significantly affected the quality of aging.