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.

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.

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.

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.

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.

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.

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!
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(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.

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.

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.
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(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