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?