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?

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.

"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.

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.