Friday, March 28, 2008

Godspeed Evelyn Paley

Goodbye, my lady love,
Farewell, my turtle dove,
You are the idol and darling of my heart,
But someday you will come back to me,
And love me tenderly,
So goodbye my lady love, goodbye!

Born 6/21/20, died 3/27/08

Sunday, March 23, 2008

Menopause moment

Moment, shmoment, this turned into a day long lapse.

After looking frantically about for my cellphone, I called it to see if I could hear the ring somewhere in the house. No sooner did I hang up but my home phone rang, my office manager calling to say my MIA phone was ringing on my office desk where I'd left it the previous afternoon.

Then I rushed to exercise class, skidding into the lot at the last minute, but, alas, no athletic shoes in the car. Between the moment I picked them up and the time I settled into the car, they vanished both from consciousness and arms.

When I arrived (late) to my dentist's office, I relayed the story of the missing shoes to the middle-aged receptionist.

"Oh," she said, "I've done that. They're on your kitchen counter."

And so they were.

Saturday, March 22, 2008

Baby boomers and Alzheimer's Disease

Here's hot-off-the-press bad news for baby boomers: 1 in 8 will develop Alzheimers' Disease. Lifetime risk for those of us BBs who are, have been, or will be 55 is 17% for women and 9% for men.

Women are more vulnerable to AD due to gender susceptibility and longevity. While men tend to die earlier and more abruptly, women tend to dwindle piecemeal with degenerative disease.
*2008 Alzheimer's Disease Facts and Figures

Friday, March 21, 2008

The FRAX Tool

Wondering how your bones will hold up over the next decade? The World Health Organization has created an algorithm based on certain clinical facts (age, nationality, personal and family fracture risk) and derived from data in four continents. You do need to know your DEXA scores for hip density.

Check out The FRAX Tool. I've got a 6.1% chance of taking out a vertebrae, wrist, hip, or shoulder in the next 10 years. If I was turning Japanese --same stats-- my fracture risk would drop to 3.7%.

Tuesday, March 18, 2008

Why am I here?

My Mom was having a bad day, but she knew exactly where she was. And it seemed as though she was not happy about it.

"Oh Judy," she sighed, "Why am I still here?"

"Well, Mom," I answered, launching into my standard litany. "You've had a stroke, and you weren't safe at home anymore."

"No, no," she replied, impatiently, "I mean, why am I still HERE?"

"Oh, I think I get it now, you mean why are you HERE?," and I indicated the world around us with a sweep of both hands.

She nodded.

"Well, Mom," I said with a sigh, "I guess you're still here [once again gesturing laterally to the surrounding world] because you're not yet THERE."

She watched me raise my hands up to indicate the sky above, paused thoughtfully, then burst out giggling.

Saturday, March 15, 2008


The quest to find the 'voice' of ovarian cancer --that silent killer that doesn't speak up in a symptomatic sort of way until it's spread beyond the ovaries-- continues. European women now have a new testing option with the release of the HE4 assay, a blood test which screens for this protein known to be elevated early in the course of ovarian cancer.

Researchers found that the results of the HE4 test when combined with the not-so-golden CA125 test (which thus far has been the gold standard for ovarian cancer screening) can be dropped into a mathematical equation that accurately predicts a woman's chances of having the disease.

The HE4 test is currently under FDA review in this country.

Thursday, March 13, 2008

Menopause Moments

Can't hold a thought. Period.

My forty-something patient and I chatted about her recent hysterectomy before we got started on the business of her annual exam. As we settled into her medical history, I ran through my usual questions about her energy level, sleep habits, diet, and exercise.

Moving on through the interview, I looked up and asked "So when was your last period?"

Wednesday, March 12, 2008

Falling and hip fractures

Dr. Mary Bouxsein, a biomechanical engineer at Harvard, defines a fall as a "sudden, unexpected event that results in a person coming to rest on a horizontal surface."

She and others have studied the dire consequences of such events to aging skeletons. While prevention of bone loss is a major focus of medical research on osteoporosis, equally important is the prevention of fractures in bones already thinned by the disease. Research has shown that a sideways fall is almost six times more likely to cause a fracture in an osteoporotic hip than pitching over in any another direction. Healthy adult volunteers falling in research labs have shown why.

Only two of six subjects were able to get their arm out in time to break the impact of the fall. For the others, hip impact occurred first, with almost all of the force delivered on a path directly through the bone. As expected, overweight fallers delivered a larger impact to their hip. Even though the fat pad overlying the hip bone absorbs some of the impact energy, it is probably not enough to prevent a fracture when a large but frail lady comes to rest on the floor.

"Trochanteric padding systems" (a girdle-like garment with padding over the hips) have been developed to decrease the destructive impact of sideways falls to fragile old ladies. One study, however, found that women were reluctant to wear them because of how they looked.

Tuesday, March 11, 2008

Abdominal Aortic Aneurysms

We even offer a special package price
of $149 (or less, depending on location)
when you select our Complete Wellness
Package which includes our stroke/carotid
artery, abdominal aortic aneurysm,
peripheral arterial disease, and
osteoporosis screenings.

--Life Line Screening Web-site

Several of you have brought in flyers from Life Line, an independent service offering reasonably priced screening tests direct to consumers, wondering whether or not you should sign up for the exams. While direct access to such testing is appealing, do we all really need to be screened for this set of four chronic and serious conditions? Consider abdominal aortic aneurysms, or AAAs.

AAAs are a chronic, progressive, degenerative disease of the aorta as it passes through the abdomen, carrying oxygenated blood from the heart to the organs and legs. Over time, gradual deterioration and expansion of the aortic wall can lead to weakening and a catastrophic rupture. This aortic breakdown is initiated by the same injury and inflammation that sets off atherosclerosis or hardening of the arterial walls in other vessels throughout the body.

Well shoot, you do not want an aortic blowout mucking up your nice spring day. If a simple screening test can detect the condition, why not? The United States Preventive Services Task Force (USPSTF) took on that very question, weighing the probability of finding the condition in selected populations against the costs and benefits of detection and operative repair.

They concluded that older men--ages 65-75--who ever smoked should undergo a screening test for an AAA. The experts concluded that ultrasonographers would have to probe the abdominal aortas of just 500 aging old guy smokers to find 1 aneurysm. The 1-year risk of AAA rupture is 1 in 10 if the aneurysm measures 5.5-7 centimeters, and 1 in 3 for bulging aortas stretched beyond 7 centimeters.

The USPSTF did not have an opinion one way or another about screening older men who never smoked. Finally, they graded AAA screens for older women as "D" or not routinely recommended unless she is a smoker with a family history of aortic aneurysms.

Sunday, March 09, 2008

What's a liver spot?

I recently spoke at a training session for the DermAnalysis scanner. This gizmo uses black light (UVA) to highlight areas of sun damage and dryness. The scanee sticks her head under a drape, screams with horror to discover her entire face lit up with blotchy purple and orange sun-ravaged areas, then jerks herself free of the machine seeking soothing explanations from the screener. While this UV scan cannot diagnose skin cancer, it certainly facilitates discussion of skin care.

Here's a brief lexicon of skin destruction:

Solar Lentigines: A fancy name for liver spots (aka horrid age spots) which have absolutely nothing to do with the liver whatsoever. They are, instead, the result of sun-deranged melanocytes overproducing the skin pigment called melanin. Some of these skin melanocytes just give up after years of tanning and quit producing melanin at all, resulting in white patches (see below).

There are a couple of remedies for an ugly lentigo, none of which include bleaching. A prescription product called Solage applied twice daily will fade these hummers. Melanocytes hate to be frozen, so liquid nitrogen will also work.

Idiopathic guttate hypomelanosis: A big name for tiny white spots on sun-damaged skin. Age plus sun equals death to certain touchy little groups of melanocytes. Nothing to be done about them.

Solar elastosis: This is basically at the root of this skin aging thing. Sunshine--right, the very sun you sought in college as you slathered on the baby oil and placed a reflector beneath your neck--causes breakage and clumping of the elastic fibers in the skin. As a result, skin sags and the superficial layers of the epidermis bunch up.

Cutis rhomboidalis: Talk about feeling bad about your neck! Think the deeply plowed neck skin of Midwestern farmers and ranchers. Crisscrossing furrows through thick yellowish skin. No cure for this, grow your hair long.

Poikiloderma of Civatte: I don't know who this Civatte fellow is, but this condition equals a combination of all of the above sun mess plus dilated capillaries on the anterior chest of women who faced up to the sun many times too often. No more decolletage for Suzanne Somers on those infomercials!

Seborrheic keratoses: These are big scary variegated growths that typically appear on the torsos of aging susceptibles (if you can picture these on your parents skin, you're on your way to growing your own). They have a 'stuck-on' warty appearance, and can grow to alarming proportions. Not to worry. Not dangerous from a skin cancer point of view, but distressing nonetheless. They can be surgically removed.

And here's the rest of the tour:

Crow's feet result from overuse of the orbicularis ocli muscles that activate when you crinkle your eyes during really big smiles. Furrowed brows result from chronic worry creasing your forehead. Marionette lines crease the skin from the angles of the lips to the jawline. Angular cheilitis results from really big marionette lines, perhaps coupled with loss of teeth collapsing cheeks further, resulting in folds at the lip angles that fill with saliva and residual toothpaste. This irritating ooze from mouth leads to red and painful inflammation.

Saturday, March 08, 2008

Vitamin D and immunity

Sometimes I read a research report so compelling I just have to get up and do something about it. Just now, that instant reaction included heading downstairs to pop my second vitamin D supplement of the day. Did you get the memo? If not, here's the scoop.

Simply put, influenza viruses hate sunshine. The seasonality --here in winter, gone in summer-- of flu epidemics has long been noted but only more recently understood. The reason, it turns out, that flu bugs hate sunshine is that sunshine on un-sunblocked skin during summer months causes production of vitamin D. D in turn acts on portions of human DNA to produce antimicrobial peptides which are worthy little proteins deadly to the influenza virus.

If the prevention of influenza infections were just a matter of producing 'herd immunity,' than populations in which a large number of individuals had been immunized should have fewer members die of flu. In fact, a study of Italian old folks showed that the death rate dropped not a whit over a 15 year time period during which immunization rates rose from 10% to 60%.

Once the vitamin D/influenza connection was made, other investigators herded together some postmenopausal women and hooked half the old gals up with extra vitamin D. Those in the group without supplements were three times more likely to fall ill with influenza compared to D other group. By the third year of their trial, a higher dose of supplemental D (2000 IU/day) "virtually eradicated all reports of colds or flu."

Virtually and eradicated are strong words. So strong, I went down and took my second 1000 IU D pill for the day. I need all the D I can get to get through the rest of this nasty flu season.

Tuesday, March 04, 2008

Wind, wound, water, and walk*

This is the little mnemonic that medical students use when searching for the source of a post-operative fever. It's coming in handy this day, years past med school, as I think through why a certain old lady might be running a temp near 102. I'll add colitis to the list as she's been on antibiotics for her arm wound (which is much improved, so that's not where the fever is coming from).

Antibiotics can cause a dangerous shift in the body's resident bacteria. While a little diarrhea might be a small price to pay for the treatment of a serious infection, one antibiotic-related bowel infection--Clostridium difficile-- is a bad actor that you do not want in your intestinal tract. The last time Mom did battle with that little hummer, she became septic (the bacteria was released into her bloodstream, causing a systemic infection) and nearly died.

You don't have to be a frail little old lady to get a c. diff infection. I've had two otherwise healthy adults get c. diff colitis after a course of oral antibiotics for no-big-deal infections. While neither one was seriously ill, they had some serious diarrhea for a long time and required yet another antibiotic to clear this microbe out of their colons. All the more reason to skip antibiotics if possible through the flu season.
*Wind = Respiratory infection or pulmonary embolus
Wound = Surgical site or any opening in the skin from injury or ulceration
Water = Urinary tract infection
Walk = Deep venous thrombosis or clot

Monday, March 03, 2008

HDL cholesterol supports the brain too

HDL cholesterol may slow the aging process, and not just with respect to the heart. The worthy little HDL protein plays a pivotal role in reverse cholesterol transport, toting the fatty goo out of the tissues--including blood vessel walls--and back to the liver for elimination from the body. Low levels are a common abnormality in patients destined to develop coronary artery disease, even when total cholesterol values are in the normal range. Researchers have now found a correlation between robust HDL levels and mental clarity in the oldest of the old.

Scientists at the Institute for Aging Research in New York City conducted a study of healthy, really old people (average age 99). They found that these remarkable centenarians maintained much higher HDL levels than expected for their age. HDL levels decline with the passage of time by approximately 5 points for every 8 years. According to this formula, the expected HDL level in this gasp of geezers should've been 20 but averaged 55.

Across the study group, HDL levels were directly related to scores on the Mini-Mental State Examination. The higher the HDL's, the more agile the aging brain. Investigators note that cholesterol plays a key role in maintaining connections between brain cells and processing beta amyloid protein, the tenacious gunk that gums up the neural works in Alzheimer's disease.