Big-time kyphosis

When some of my older female patients lie back on the exam table, their heads drop backward, necks extended, due to a forward curve in their thoracic spine between the shoulder blades. This hunchback thing is an exaggeration of the kyphosis or the gentle curve normally present in this area. It can result from weakness of the upper back muscles aggravated by poor posture but it becomes particularly prominent in women suffering from osteoporosis.

The lady in the above x-ray* has a helluva kyphosis based on osteoporosis. Her T score which compares her bone density to the ideally mineralized skeleton is -4.2 (normal range is greater than -1). This means that she has lost 42% of her bone mineral density and is severely osteoporotic. As a result, her normally block-shaped vertebral bones have collapsed anteriorly and become wedge-shaped due to compression fractures. She has lost height; her head and upper body have permanently sunk forward as her spine curled.

She no longer has room for her abdominal organs which have pooched out as her ribs sank into her pelvic bones (yes, that's bowel gas just below her chin--she is permanently gazing at her navel!). Worse yet, her thorax is severely shrunken, and her lungs can no longer fully inflate. She presented to the ER in respiratory failure as she could no longer exchange high CO2 exhaled air for high O2 inhaled air. She died during this hospital admission.

You do NOT want this collapsing spinal column thing. Lie on the floor--does your head flop backwards due to the forward curve of your upper spine? Are you uncomfortable without a pillow when lying flat on your back? Get your bone density checked. Find a physical trainer to nag you about your posture and work on your upper back strength. Take extra D and calcium!
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*Blechacz, B. Images in Clinical Medicine. NEJM 6/12/08.

The Teeming Team from Palliative Care

My friend was making some tough decisions. She was in the hospital for shortness of breath, and a lot of fluid had been drained from the area around her lungs earlier that afternoon. These effusions from her metastatic cancer would soon return; the question under consideration was what to do next.

Yet another knock on the hospital door heralded yet another helper with an agenda. No, not one helper, but rather a bevy of young, white-coated women bustled in.

"Hi," chirped one, "I'm Ms. Whatever from the Palliative Care Team. Your doctor asked us to come visit with you."

Oh heavens. This well-meaning crowd was about as welcome as a flock of Grim Reapers. Right time, right place, but WAY too many of them in the room, all eyes trained sympathetically on my friend lying in bed. The one next to me with Something, MD embroidered on her lapel (didn't have my reading glasses on) leaned forward, hands on knees in the sort of poise you'd use to peer down at a small child, and outlined the services the team could offer.

After a brief and strained conversation, E. sent them packing. Great idea, nice people, but they should crowd into a conference room and review their M.O.

Prostate Cancer Risk Screening

"Should I get a PSA test?" My patient was giving me a run for his money during his annual exam last week. We'd already discussed the pros and cons of undertaking treatment for blood pressure, and he'd asked for the evidence why one medication was preferable to another. He wanted to know if the data I presented was from studies sponsored by dirty drug company money. Finally, he threw out this challenge to conventional wisdom on prostate cancer screening, and a very good question it was.

Men anticipate prostate cancer screening with all the dread that women bring to Pap tests. Screening is generally limited to men over the age of 50 (unless there is a history of early prostate cancer in a father or brother) and consists of an exam of that part of the prostate that can be reached by a probing finger plus a blood test for prostate specific antigen or PSA.

The problem is that the PSA, while being the only cancer marker test currently available for screening purposes, is not specific. In other words, most men with an elevated PSA do not have cancer. The digital exam is even less specific as many aging men have enlarged prostates without harboring cancer. Other screening deficiencies in our current approach of one blood test and one finger exploration include:

• Most men with prostate cancer (85% in one study) detected by PSA screening could avoid therapy. Per another study, one would have to screen 1400 men and perform 50 prostatectomies to prevent one death from prostate cancer.
• There is no PSA level below which the risk of cancer is zero. The Prostate Cancer Prevention Trial (PCPT) found cancer in 6.6% of men with PSAs below .5 and 12.5% of those men had aggressive cancer.
  
• Other factors seem to affect PSA levels, e.g. obesity and statin use lower PSA.

So what's a guy to do? One study over nearly 9 years showed a 20% decreased risk of cancer death with PSA screening every 4 years vs. none at all. Another concluded that testing every 6 years with digital exams every 4 made no difference whatsoever. Dr. Eric Klein notes(1): "All cases of prostate cancer are clinically relevant in that they can cause anxiety or can lead to treatment-related morbidity." In other words, we are detecting a large number of sub-clinical tumors--i.e. no symptoms suggest a prostate cancer brewing--with our screening, many of which would never cause a problem. We know that 90% of men with low-grade prostate cancer choose treatment which can cause incontinence, impotency, or death.

Dr. Klein suggests one approach to screening that uses seven variables to predict a man's risk of currently having prostate cancer. This test can be found at PCPT risk calculator.
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1. Klein, EA. What's new in prostate cancer screening and prevention? Cleveland Clinic Journal of Medicine. Vol 76 August 2009 439-445.

Doc of Ages now on Twitter

I'm going to give this a try for all the little pearls I come across in medical magazines that can be delivered to you in 140 characters or less. No updates on where I am, what I ate for breakfast, or how much sleep I got, just the latest in medical knowledge from the cutting edge.

You can sign-up at twitter.com/docofages. All my blogs will continue to be published on a more or less regular basis.

Is Multitasking Bad for Your Brain?

This morning I was perusing an August issue of Science. My husband walked into the kitchen and switched the radio on to NPR's Car Guys, then began grousing about what idiots they were and what bad advice they gave. So there I am, reading, drinking coffee (I don't suppose that counts), listening to those Car Guys yuk it up, and degrousing the spouse (that's what you do when you acknowledge someone's rants with sympathetic murmurings of assent). Oddly enough, in one of those 'bloggable moments' that those of you who blog know so well, the magazine article I was reading was "Multitasking--Bad for the Brain?"(1).

A word or two first about multitasking--I don't know when the word was coined, but in this day and age of electronic devices, the skill ranks right up there with missing sleep to multitask as one of the characteristics of New Age success. The ability to text, talk on the phone, work on the computer, and troubleshoot simultaneously is the mark of a modern manager (and that, Jean C, is why we pay you the big bucks!). More than once I've cited 'inability to multitask' as one of the job requirements that a patient applying for disability can no longer perform.

I personally go into what I call overwhelm mode if called on to multitask too long. Bi-tasking I can do, fielding an urgent message say in the middle of an exam, or mixing pancake batter while talking on the phone. Well actually, the latter has proven problematic in the past. But layering calls from the ER, prescriptions, annual exams, work-ins, and a kid crisis in a single afternoon puts me over the top with agitation.

So here's what Stanford scientists found when they compared 19 heavy habitual media multitaskers with 22 persons who generally limit their electronic input. The subjects were tested for their ability to filter out irrelevant environmental information as well as "irrelevant representations in memory." In addition, all the volunteers were also tested for the ease with which they switched tasks. Those heavy duty multitaskers (IM'ing, skyping, texting, gum-chewing fools no doubt) were more distractible and less able to switch tasks midstreams than their colleagues who characteristically uni- or bi-tasked.

The obvious question that arises from this study: Do multitaskers scramble their brains in the multitasking or are they just a flighty, distractible bunch from the get-go who are attracted by nature to a 3-ring cognitive circus?

My reaction to my a.m. over-stimulus? I excused myself ASAP to go blog, taking my IPhone along so I could respond to a text that just came through from Jean C.
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(1) Ophir, E, et al. "Cognitive Control in Media Multitaskers." Proc Natl Acad Sci USA. 2009 Aug 24.

Verbal fluency exercises

Verbal fluency or the ability to find the right word at the right time in a timely fashion is one of those front brain skills that lags with age. Add dwindling hormone levels, social isolation, and/or a history of even a mild concussion, and you may end up as fumble-mouthed as an evening news anchor.

We know that reading, working crossword puzzles, and interacting with friends are all ways to support brain function and verbal fluency. To heck with all that, how 'bout still another way to waste time on the Internet? Try lumosity.com, a web-site full of games that do both--bolster your brain and while away time you don't have. In particular, have a go at Word Bubbles which not only tests your verbal fluency but your typing and spelling skills as well.

And thanks, or no thanks, to my niece Miranda for the loss of many an hour!