Doc of Ages

Of Dreams and Dendritic Cells

2011-10-04T13:11:00.002-06:00

"His dream was to use his discovery to cure cancer and infectious diseases like HIV and tuberculosis. It's a dream that's pretty close." Michel Nussenzweig on his fellow researcher Ralph Steinman.

When my mom was newly diagnosed with lung cancer, I brought her a bunch of "Conan the Barbarian" balloons with an encouraging note calling on her immune cell to rally to the job of eliminating the cancer (which she ultimately bested, living on another 18 years!). At the time, however, she was less than amused and huffily informed me that "There is nothing wrong with my white cells."

Immunotherapy, wherein a patient's own immune cells are primed to attack their invasive cancer, is a rapidly advancing area of cancer research. Due to a wide array of ploys with which cancer cells hide from the immune system coupled with various host deficiencies in mounting the appropriate defense, cancer therapy has for years centered instead on chemotherapy. These toxic chemicals are designed to be more lethal to the rapidly dividing cancer cells than on normal tissue. Unfortunately, normal often falls along with the malignant.

One of the giants among researchers in immunotherapy is Ralph Steinman who ironically died September 30th, three days before winning the Nobel Prize in medicine earlier this week. In a further twist of fate, he died of pancreatic cancer, living much longer than most unfortunate souls with this disease perhaps because he applied his own discovery to his personal case.

Dr. Steinman's contribution to this important research was the identification of a unique little player in the immune cascade that he dubbed a dendritic cell due to its tree-like branching configuration reminescent of the dendrites of neurons. The dendritic cell is one of the initial workhorses of the immune system, processing foreign material such as viruses and then presenting it to T cells which are activated in turn to attack the unwelcome invaders.

Dr. Steinman isolated his dendritic cells, exposed them to his pancreatic cancer cells, and thus instructed his T cells to recognize those bad boys as unwanted visitors. A former student, now a collaborator, had this to say, "We'll never know [whether it worked] ...but one thing is for sure: he was able to make T-cells specific for his cancer. It obviously didn't cure him, but it may have prolonged his life."

Walking across Virginia

2011-08-27T15:56:00.011-06:00

Wondering where I've been? Well, busy for one, very busy. For those of you who didn't get the mailing, we've moved our office. From our vintage little office building that was originally built by my pediatricians in 1949 to sleek revamped office digs on the old Children's Hospital medical campus. If you can get through on the phones and find the darned office (still a few glitches to work out!), I think you'll be pleased to see that Adele and I are business as usual under the auspices of Exempla Healthcare here in Denver.

In my spare time, however, I've been walking across Virginia. Well not really walking across Virginia which would doubtless be even hotter than Denver and logistically problematic. I'm talking traversing in a virtual sense. I urge my patients to find an exercise activity that engages their interest as well as their heart. Used to be Jazzercise for me, step aerobics too, but that was years and a lot of knee cartilage ago. Walking with a dog is a personal joy, but I've got no pooch on-site with whom to mosey. So instead, I'm walking solo across the United States with an eye on the West Coast by 2020.

Wanna' come along? Check out the TransAmerica Trail (aka Tools to keep you active) at http://exercise.lbl.gov/index.html. Sign me up as your partner--they'll put you on my map and me on yours at the same starting point. I'm walker number 65471 about to enter Kentucky but happy to join you back on the Virginia coast.

Sesame oil may be some kind of cure-all!

2011-03-06T19:08:00.008-07:00

This just in from my favorite naturopath, Dr. Jacob Schor. This news is particularly important for persons who are hypertensive, have high cholesterol, are diabetic, carry weight around their middle, or travel that overweight road to all of the above.

According to an article penned by Dr. Schor in the current issue of Natural Medicine Journal (1), just a spoonful of sesame oil (actually 2.4 tablespoonfuls/day) makes the blood pressure/cholesterol levels/blood sugar/waistline go down. He cites results from a group of scientists from India's Vinayaka Missions University about the remarkable results of daily sesame oil use in a group of 60 diabetics followed over 2 months. One third downed oil alone, one third used oil plus a diabetic medication called glyburide, and the remaining subjects took glyburide alone.

While those on drugs plus oil did best of all, the oil-alone group fared fairly well as well. The glucose-lowering effects of combo therapy were downright remarkable with blood sugar dropping by 36% and HbA1c (a value that reflects an averaged blood sugar over the prior three months) by 43%! All oil-users also had significant drops in total cholesterol, LDL-cholesterol, and triglycerides plus a bonus rise in HDL-cholesterol.

The Vinayaka group conducted a similar study on locals with high blood pressure who took one of two commonly used anti-hypertensive drugs--hydrochlorothiazide or atenolol. Over a study period of 45 days, the subjects used sesame oil for all their cooking needs and blood pressures dropped to normal. The next 45 days were spent sans sesame supplementation, and blood pressures rose to pre-study levels. Body weight, body mass index, and waistline measurements dropped as well.

I plan to recommend this strategy to my patients willing to give it a try; I'll let you know what results we get. I personally have used sesame oil each a.m. for almost two years in an ayurvedic quest for oral health(4). That morning spoonful theoretically draws out nasty toxins and is meant to be spit out post-pull. Perhaps thereafter, I should consider actually swallowing a swig for the rest of me.
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(1) http://www.naturalmedicinejournal.com/article_content.asp?article=113
(2) Sankar, D et al. Sesame oil exhibits synergistic effect with anti-diabetic medication in patients with type 2 diabetes mellitus. Clin Nutr. 2010 Dec 15. [Epub ahead of print]
(3) Sankar, D et al. Effect of sesame oil on diuretics or Beta-blockers in the modulation of blood pressure, anthropometry, lipid profile, and redox status. Yale J Biol Med. 2006 Mar;79(1):19-26.
(4) Asokan S. Oil pulling therapy. Indian J Dent Res 2008;19:169

Sarcopenia or why we install railings by toilets

2010-11-09T09:47:00.004-07:00

I attended a funeral last Friday. There was a fair amount of rising and falling to feet and to seats what with religious moments and a standing, whooping, foot-stomping ovation to Megan and her life well-lived. I've written before about funerals, and how I love a good one, but that is not the subject of this post.

My pew-mate was an older woman who carried more than a little extra weight and who struggled mightily to stand each time we were called upon to do so. In front of me sat a skinny woman, still older yet, who did not even attempt to get upright until it was time to leave the chapel. Two elderly friends of Megan, each losing physical ground in her own way, one to excess adiposity and osteoarthritis of knees and hips perhaps, the other to fraility and sarcopenia. The inability to rise from a seated position, however, be it in a kitchen chair, a living room recliner, or a toilet seat, is a big step on the road to dependence and demise.

Aging is filled with -penias as in osteopenia (loss of bone mass short of osteoporosis) and sarcopenia or loss of muscle mass. There are many factors that contribute to this age-related wasting away of muscles some of which not yet elucidated but not the least of which is inactivity brought on by injury, arthritis, and illness which in turn leads to weakness and fatigue which in turn fosters more inactivity.

In order to repair, regenerate, and develop muscles to propel ourselves up out of a chairs and off to the 'frig (or the gym!!), we depend on 'satellite' stem cells that reside on the surface of our muscle fibers. Reduced numbers of such cells coupled with their decreasing ability to do their job is the biological basis of sarcopenia. I've had patients seek out human growth hormone and human chorionic gonadotropin in order to boost muscle mass and reverse aging, but rats and researchers in Washington state and Israel have recently published findings that suggest a simpler, less expensive, more accessible way to get myogenic satellite cells. One word: Exercise!

Rodent models suggest nothing but bad news from aging satellite cells. Satellite cells are usually in a resting state in older animals but can be activated to repair and renew muscles after injury and illness. But satellite cells are more likely to generate fat (the lady next to me!) or fibrous connective tissue (the stringy, skinny lady in front of me!) than muscle fibers as they grow old. So what happens if rats work out instead of veg in front of the TV set?

The researchers confirmed that the older the rat, the fewer the satellite cells on their calf muscles. However, when the four-legged geezers were persuaded to hit the exercise wheel, this aging effect was corrected, and both males and females greatly increased the number of myogenic--muscle producing--cells. Better yet, this cellular change had a visible effect on the old coots with a favorable shift in their lean-to-fat content and on their level of "spontaneous locomotion." Svelte, toned, AND disinclined to sleep the day away in the wood shavings!

One of the ways I assess how my patients are faring is to greet them first in the waiting room. First of all, it's a good way to start the visit, but, in addition, I can watch them rise from their chairs and walk across the room and up two stairs to the hall. I am daily appalled by the way some of my long-time patients increasingly struggle with the task, even moreso by their seeming indifference or inattention to their inability to move with ease. Check out the way you spring from your pew, your toilet, your desk chair. Don't take "can't do it easily" for an answer.
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1) Shefer, G et al. Reduced Satellite Cell Numbers and Myogenic Capacity in Aging Can Be Alleviated by Endurance Exercise. www.plosone.org.

Swiss chard and lung cancer

2010-10-02T09:03:00.013-06:00

If R is you or more specifically your DNA in charge
of cell proliferation, the CH3 or methyl group is your
potential road to ruin.

In the spring of 2008, one of my patients came back from a vacation to Mexico with "pneumonia". But I didn't really think it was pneumonia--the shadow on her x-ray wasn't quite pneumonia-ish, and her symptoms of fatigue and a non-productive cough weren't exactly right either. Anyway, we optimistically tried a course of antibiotics without any change in that infiltrate, and, alas, it was lung cancer after all. Mother of two boys still at home and an ex-smoker for more than a decade, my patient died at home six short months later.

Sometimes rogue DNA--perhaps damaged by aging, smoke, or an errant sunbeam--just gets the best of you despite all that water and veggies and walking at dawn. Still, a person keeps trying to do what she can to avoid the brick wall of mortality, and a recent study in the journal Cancer Research (1) further supports the value of leafy greens. But before we discuss the goodness of greens, a word or two on gene promoter hypermethylation events which are nothing you want occurring in your DNA.

Genes are minute strips of DNA. During a typical 'business-as-usual' day in the life of a normal cell, they are activated by external and internal events and transcribed via RNA to produce worthy proteins that carry on normal activities that include damage repair and control of cell proliferation. If, however, one instructional molecule of the DNA gets permanently tangled up with a methyl group, the entire gene is silenced and its work remains undone. Worse yet, as that cell with its load of methylated DNA replicates itself because no gene product was there to tell it not to, all its offspring cells are also methylated. As a result, an out of control, methylated mass of cells continues to grow unchecked. Sounds like cancer, doesn't it?

So once hypermethylated, can you become demethylated? Such a demethylation process is the dream of scientists looking for chemopreventive strategies. As opposed to chemotherapy drugs which seek and destroy cancer cells, chemopreventive agents act to repair or prevent malignant change. Researchers from the University of New Mexico sorted through sputum from smokers (both current and ex-) seeing if certain dietary strategies were associated with lower levels of methylated genes in expectorated DNA.

Some 1,100 subjects dutifully hawked up their secretions and completed Harvard Food Frequency Questionnaires. As a result, the New Mexican docs were able to identify leafy greens (and we're not talking lettuce here), folate, and multivitamin use as three strategies that correlate with less methyl-generated mess. They proposed that further study might verify these and other agents as ways to reprogram our genome for life without cancer.

Now I'm all for this sort of research as a doctor and an ex-smoker. My problem is that a pile of steamed chard (or kale or greens) is an unappealing mess all its own. Any suggestions of different ways to prepare an appetizing, chemopreventive side dish of greens?
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1) Stidley, CA et al. Multivitamins, folate, and green vegetables protect against gene promoter methylation in the aerodigestive tract of smokers. Cancer Res. 2010 Jan 15;70(2):568-74.

Best personal trainer deal in Denver

2010-09-29T20:37:00.004-06:00

Please note the corrected dates for this program

I have struggled mightily with back pain from scoliosis and degenerative arthritis. Thanks to a program of core strengthening courtesy of two knowledgeable young women--one a Pilates instructor with a strong background in physical therapy and yoga, the other an athletic trainer with a gift for modifying her workouts for older, less flexible non-athletes--my spasms and debility are yesterday's news.

I've put a lot of time and money into this program figuring properly that any bottom line beats crippling pain and decreased mobility. I am pleased to announce now that my trainer Tanya Martelli (Dr. Sykes goes to her too!) has assembled a low cost solution for those of you displeased with your aging spines.

She will be conducting a three class workshop for five participants Oct. 8, 15, and 22 at our office from 4-5 p.m. The focus will be on posture and core power, and at the end of the sessions, each person will have a home program to continue progress made during the class. The cost is $45. If these times do not work for you, Tanya plans another three week session mid-day Tuesdays at the end of this series.

You do not need to be our patient to attend these classes. Interested? Contact Tanya at tlyaskoff@mac.com to sign-up or inquire about future classes. She just designed a home program for me that I took on a recent road trip to California--worked just perfectly to keep me upright and buff while away from home. She could do that for you too!

Rose Kelly

2010-08-01T13:29:00.003-06:00

Rosellen Kelly, 8/20/52-7/31/10

I lost my dear friend Rose yesterday to cancer. Mom, wife, friend extraordinaire, writer, artist, and Assistant Head of School at St. Anne's Episcopal here in Denver, she was a treasure to all who knew her. She collected friends like an endless strand of pearls--like the ones she wore at a time when our generation was mostly through with such traditional adornment.

Gracious, hilarious, and soothing, she told me that she viewed death as "just showing up for my next assignment. An angel in life, she has ample experience for her upcoming gig.

Window of Opportunity of Estrogen Therapy for Neuroprotection

2010-05-01T21:24:00.005-06:00

Those of you who find this topic one of interest should check out the newest post at my other blog: Menopausemoments.blogspot.com.

Fractures and Fosamax

2010-04-23T14:29:00.013-06:00

Dang, what was this 60-something year old lady(1) doing that resulted in her femur breaking like a branch across a gardener's knee? The unsettling answer? Nothing. She just felt a "giving away" sensation in her leg and then she gave way and went to ground. Of note, however, she had been taking medications for 17 years to prevent osteoporosis: first Fosamax and then Boniva.

Our bones are in a state of constant turnover. Breakdown of bone matrix by cells called osteoclasts is balanced by a corresponding build-up of bone mass undertaken by osteoblasts--a process that continually replaces old bone with new. In adults, bone formed equals bone broken down as osteoblasts fill areas along the bone surface previously resorbed by osteoclasts. Such dynamic restructuring in response to the forces of gravity and activity is essential to bone strength. In addition, this active bone metabolism repairs micro-traumas caused by everyday wear and tear as well as macro-traumas such as fractures.

As we grow older, we tend to breakdown faster than we build-up (well duh!). Ongoing osteoclastic activity is no longer countered in kind by reciprocal action from aging osteoblasts especially in women who are estrogen-deficient, inactive, on steroids, or deficient in calcium and vitamin D. Now bone resorbed by osteoclasts exceeds bone built by osteoblasts resulting in bones that are not only thinner but also architecturally unsound. As a result, vulnerable areas such as the hip, the vertebrae, and the bones of the forearms lose strength and fracture easily.

One strategy developed to combat this scenario is a class of drugs called bisphosphonates (Fosamax, Actonel, Boniva, Reclast, and others) which inhibit normal bone-remodeling through inhibition of osteoclasts. Since bone resorption triggers bone formation, these drugs are better suited to slowing loss rather than gaining mass. While population studies show decreased risk of fractures in persons using bisphosphonates, disturbing patient histories, such as that from the unfortunate lady pictured above, suggest that extended use of Fosamax and friends may result in bone fragility through the accumulation of microdamage in bones weakened by a loss of the normal reparative functions.

Texas researchers had a look at bone chips from persons who had spontaneous--i.e. no antecedent trauma--fractures while on Fosamax(2) most of whom had delayed or absent healing at the site of the break. Scary stuff on microscopic exam--many of the patients showed "markedly suppressed bone formation" with little or no osteoblastic activity and diminished mineralized bone. Even those patients on concurrent estrogen therapy demonstrated decreased bone formation. While Fosamax was the first bisphosphonate 'out of the gate' and thus most likely to be associated with fractures related to long-term use, scientists believe that this brittle bone thing may well be found with ongoing use of the other agents in this class.

Well yikes, is it time to boycott Boniva? Act not on Actonel? Consider first, this meta-analysis of several bisphosphonate trials.(3) These scientists from four different countries supported by Merck (Fosamax) and Novartis (Aredia, Zolmeta) analyzed data from three large studies looking for risk of fractures of the femoral shaft (considered atypical when compared with the more common fractures of the femoral head) as they were associated with use of bisphosphonates. Most reassuringly, they found such drug-related breaks to be rare, occurring at a combined rate of 2.3 per 10,000 patient-years. In other words, of 1,000 women using a bisphosphonate for 10 years, 2.3 would have an unexpected fracture of their thigh bone. There was no elevated risk of this type of fracture between those on Actonel and those on placebo, and a relative risk of 1.5 for women on Zolmeta (an IV bisphosponate most often used in serious situations such as in women with metastatic cancer where the drug slows down the spread of the tumor through the bones).

In an editorial that accompanies this study(4), Dr. Elizabeth Shane of Columbia University emphasizes that such atypical fractures are extremely rare, and particularly unlikely in persons on bisphosphanates. In fact, she cites studies that show, on average, that these femoral shaft fractures are more commonly caused by osteoporosis than the medications that treat the condition, and high adherence to this drug regimen more often decreases the risk of this type of bone breakage. She concludes: "many more commonand equally devastating hip fractures are prevented by bisphosphonatesthan are potentially caused by the drugs."

Several authors have suggested that women on bisphosphonates be given a drug holiday in order to allow for a time of normal bone remodeling. Bisphosphonates bind to bone and are slowly released by osteoclastic activity. Fosamax is present in the body long after its use is discontinued--one study found bone turnover suppressed for three years after five years of regular Fosamax use. There are no official guidelines to follow with respect to intermittent bisphosphonate use, but one year off does not seem to diminish the positive effects on fracture risk.

What should you do? Talk with your doctor about taking a drug holiday (no, not THAT kind of drug holiday) if you've been on bisphosphonates for more than five years.
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(1) X-ray and case history from:
Goddard MS, et al. Atraumatic Bilateral Femur Fracture in Long-Term Bisphosphonate Use. Orthopedics. 2009 Aug;32(8). pii: orthosupersite.com/view.asp?rID=41933. doi: 10.3928/01477447-20090624-27.
(2) Odvina, CV, et al. Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab. 2005 Mar;90(3):1294-301. Epub 2004 Dec 14.
(3) Black, DM, et al. Bisphosphonates and Fractures of the Subtrochanteric or Diaphyseal Femur. Published Online March 24, 2010 (DOI: 10.1056/NEJMe1003064).
(4) Shane, E. Evolving Data about Subtrochanteric Fractures and Bisphosphonates. Published at www.nejm.org March 24, 2010 (10.1056/NEJMe1003064)

The changing face of primary care

2010-04-09T15:04:00.002-06:00

My medical partner and I are facing big decisions about the future of our medical practice. I urge all of you--particularly our patients--to head over to Denver Doc Online and read about our dilemma and leave your thoughts behind.

Morton's Foot

2010-03-19T16:16:00.015-06:00

Dr. Dudley Morton practiced in the 1930's, first describing a number of foot ailments including Morton's foot (aka Morton's toe), and Morton's neuroma. Morton's foot is a common but dysfunctional variant of foot structure occurring in more than 25% of the population. By the time one hits middle-age, however, the instability caused by this condition can lead to pain and an inability to walk pain-free into the golden years.

Check out the sketch below from The Trigger Point Therapy Workbook for a look at Morton's Foot which is also known as short first metatarsal syndrome. The metatarsals are the longish bones beneath each toe, and the first metatarsal meets up with the big toe at a most critical juncture known as the 1st MTP (metatarsal phalangeal) joint which should be one of the primary weight-bearing areas of your foot.

If you've been issued a stumpy first metatarsal (arrow B), your weight is transferred to the 2nd MTP joint (arrow A) beneath your 2nd toe (arrow C). As a result, your weight can wobble inward towards the arch or outwards towards the little toe which has been likened to 'walking on ice skates'. The 2nd toe may extend beyond the big toe in persons with this Morton's business; while some call this long 2nd toe a sign of nobility. In my experience, it's a sign that you may give up walking for exercise.

Then look out, it's like a veritable aging house of cards cascading down your midline. The arches fall, a bunion may pop out, the ankles hyperpronate (see below), your calf muscles start working overtime to hold up your body,your knees knock together in the midline causing arthritis and collapse of your lateral knee joint,

you start to hate walking, gain weight, and plummet into old age way before your time.

So if that info knocked your socks off, check yourself for Morton's foot thusly:By pulling your toes downwards, you'll be able to see the locations where the metatarsals end and Morton's mayhem begins.

Got Morton's? I do. Custom-made orthotics and Pilates have changed my life. If you've been short-changed on your first metatarsal and are starting to hobble with pain, a trip to the podiatrist is definitely worthwhile. For more information, check out Mortonsfoot.com.

Milk thistle for liver protection

2010-03-09T19:57:00.004-07:00

I had a patient in yesterday whose medical records show a long history of elevated liver function tests. These enzymes, namely aspartate aminotransferase (ALT) and alanine transaminase (AST), are part of routine blood test panels often ordered to screen for disease. Normally present in liver cells, elevated levels in the blood can indicate disruption of the cells by inflammation or disease. Even minor elevations are taken seriously if they persist over time as progressive destruction of the liver from hepatitis or other disease can occur without major changes in the transaminase values.

Further testing indicated she might be suffering from auto-immune liver disease wherein a misguided immune response against one's own tissue can cause damage to the organ. She wondered what she could do to promote liver health while pursuing a definitive diagnosis with a specialist. I recommended milk thistle only to read the following today on the Consumer Lab web-site.

Consumer Lab is an independent organization that tests nutritional supplements for quality, assuring that these products are pure, contain what they claim, and are free of contamination. The nominal yearly subscription fee is well worthwhile if you are a fan, as am I, of supplements. One of their recent reviews covered milk thistle.

Only one brand was found on testing to contain the amount of active ingredient indicated on the label. Furthermore, the evidence that milk thistle changed the course of chronic liver disease caused by hepatitis or alcohol was weak. The research suggesting that the herbal preparation protects against liver toxicity from acetaminaphen and anti-seizure meds was stronger. The active ingredient in milk thistle--silibinin--has been the subject of recent cancer research and seems to have some promise as a chemotherapeutic agent.

I don't feel quite so enthusiastic about my recommendation now. If you're considering milk thistle supplements, have a look at the ConsumerLab site to choose the best brand.

Rheumatoid arthritis, disability, and dismay

2010-03-02T20:53:00.004-07:00

One of my favorite patients struggles mightily with the pain and disability of rheumatoid arthritis. Unfortunately, she got hooked on Oxycontin that she started taking for the pain of infected foot ulcers brought on by the immune-suppressive drugs she takes to control her disease.

Each time I see her, I'm dismayed with 1) how quickly life can unravel due to disease and disability, and 2) how difficult it is to be taken seriously when you take too many pain meds no matter how legitimate your need for same. I spent over an hour on the phone today with the patient and a pain specialist she consulted last month. The latter never even examined her when she came to his office seeking help with pain control and narcotics withdrawal. "I could have you committed," he told her, "for your illegal use of drugs. What on earth did he think he'd accomplish with nonsense like that except to drive her to tears (which he did).

So now she's fallen and sustained four compression fractures of vertebrae made thin from steroid use. The orthopedist she sees for degenerative disk disease never mentioned to her that her new, dreadful pain was due to fractures. I have no idea what my colleagues think they're doing here. But I do know if you're malnourished, angry, and you look older than you are due to the ravages of pain and illness, it's extraordinarily hard to be taken seriously.

Social genomics and loneliness

2009-11-17T11:37:00.005-07:00

The term social genomics is a new one to me. The fact that social factors influence health is not.

I wrote some time ago about the effects of self-described loneliness/social isolation has on the health of older adults. UCLA researchers examined the white cells of persons who were highest of the "high-lonely" vs. those "low-lonely" (socially connected) subjects.(1) A total of 209 genes showed different levels of expression between the two groups. Over 4 years of study, the lonely crowd over-expressed genes that resulted in inflammation and under-expressed those involved in antibody production against bacteria and viruses.

These DNA effects of social isolation were very specific to three groups of genes. The first group of affected genes are involved in the early phase of the immune response wherein the body revs up inflammation as a first response to injury or infection. I have written numerous times about the blessing/curse of inflammation insofar as appropriate levels are essential to a successful recovery from infection but too much (think cytokine storm in influenza pneumonia) or wrong place at the wrong time (say in an arterial wall that has cholesterol build-up) can be counter-productive or downright destructive.

The other two groups of immune genes that respond to the lonely soul's transformed internal environment are those that stimulate the production of interferon (a molecule that amplifies immune response against viruses) by lymphocytes and those that stimulate production of antibodies by B lymphocytes. The activity of both these types of genes is diminished in people who are less connected to friends and family.

The psychological literature abounds with studies in which socialization is correlated with susceptibility to viral illness. In another one of those 'who the heck volunteers for these things' type of study, researchers at Carnegie Mellon University assessed 193 subjects for PES (positive emotional style) vs. NES (negative emotional style of course) and then sprayed rhinoviruses/ common cold or influenza viruses up their noses to see who got sick.(2) Those NES-positive individuals, described as anxious, hostile, and depressed were 3 times as likely to succumb to the influx of nasal virus compared to all the PES prone Pollyanna types who were happy, lively, and calm.

Per Steve Cole, co-author of the study on white cells and loneliness: Research in social genomics has now clearly established that our interpersonal world exerts biologically significant effects on the molecular composition of the human body.(3) What remains to be seen is how attitude adjustments of the cognitive or pharmocological variety can affect how our DNA gets activated.
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1) Cole SW, et al. Social Regulation of Gene Expression in Human Leukocytes. Genome Biol. 2007;8(9):R189.
2) Cohen S, et al.Positive emotional style predicts resistance to illness after experimental exposure to rhinovirus or influenza a virus.Psychosom. Med. 2006 Nov-Dec;68(6):809-15. Epub 2006 Nov 13.
3) Cole SW. Social Regulation of Human Gene Expression. Current Dir. In Psych. Sci. 2009 Vol 18 No 3.

To Elaine Calzolari 12/30/50-11/8/09

2009-11-08T10:43:00.010-07:00

Astolat. Public art by Elaine Calzolari

My friend and sister-in-law Elaine Calzolari died early this morning. A sculptor whose innovative work with stone revolutionized the field, her favorite work was Astolat, named after the legendary home of the fair maiden Elaine of Arthurian legend.

It is my privilege to have shared her life and death along with her daughter Miranda Paley. We should all be so blessed to exit earth with such a brave and loving soul as Miranda at our side. Elaine's favorite poem was "Witnessing" by Gary Miranda, the perfect tribute to this mother/daughter team. Godspeed Elaine!

Witnessing

Beneath the leaves of a plant, that's named for milk
that bleeds milk, we search for chrysalides,
things that I've never seen, but whose name I like.
And I think as I look of all the things

you've taught me to name--larkspur, loose-
strife, sea lavender, plants called hens
and chickens, butter and eggs, your eyes
bright with such knowledge and solid as nouns.

Just so, you tell me now of creatures
who choose the underbelly of these leaves to make
wombs of, studded with gold, from which emerge
Monarchs that range the length of the Atlantic

in hordes--one more fact I must have missed
by skipping the fourth grade. And when, today
we find no trace of anything resembling this
miracle you mention, and I'm about to say

you made it up, you bend down, break a pod,
and blow unlikely butterflies in the sky's face-
not black and orange like Monarchs, but cloud-
thought white, or like the way I mark my place

when I read your eyes, which witnessing claim:
This is the world. Try to learn its name.
Witnessing.

Vitamin D and blood vessel health

2009-10-28T13:29:00.011-06:00

I'm sure you know by now that vitamin D is the new darling of the vitamin world. If you're not taking extra, where have you been? UK investigators(1) tested blood vessel health in type 2 diabetics by an indirect method called flow mediated vasodilation or FMV and added yet another reason to consider letting a little sunshine onto your pasty white skin. And if your skin is not white, all the more reason to make an extra effort to get extra D by sun or by supplement-- darker skin is known to be more resistant to the effects of UV radiation with respect to the production of viratmin D.

First a review of FMV. This rather simple test measures the ability of the brachial artery located in the elbow to dilate in response to increased flow. A pressure gauge measures the force of blood flowing through this upper extremity vessel. A blood pressure cuff is then placed on the subject's arm and pumped up high enough to stop blood flow to the arm below. When released, the surge of blood returning to the artery causes the vessel to expand, accommodating an increased flow to the (briefly) oxygen-starved tissues of the lower arm.

This dilation is the mark of a healthy vessel. People with diabetes and hypertension have blood vessels that don't respond normally when tested--and also, unfortunately, in real-life situations such as exercise. Researchers, therefore, use this test to evaluate certain interventions like medications, vitamins, or dietary strategies that tend to normalize the wacked-out FMVs of those with such chronic conditions.

So Dr. Sugden and his colleagues took a group of sun-starved, diabetic Scots in winter and gave them a single whopping dose of D--100,000 units--testing their FMVs before and 8 weeks after the bolus. All of these subjects had D levels <50 ng/ml prior to the trial, and the D supplement raised their levels on average by 15. Darned if that D didn't do the duty! FMV levels rose significantly at follow-up.

Have you D-cided to up your D yet?

_____
( 1)Sugden, JA et al. Vitamin D improves endothelial function in patients with Type 2 diabetes mellitus and low vitamin D levels. Diabet Med. 2008 Mar;25(3):320-5. Epub 2008 Feb 13.

Small thigh circumference and cardiac risk

2009-10-27T12:28:00.006-06:00

Here's a new take on body build and health! We are all familiar with the apple/pear thing in that those who carry their weight around the waist in an apple-ish silhouette are at greater risk of heart disease than those whose excess pounds hang on their hips. These Danish researchers took the measurements one level lower(1); here's what they found:

Professor Berit Heitmann and company from Copenhagen's Research Unit for Dietary Studies took tape measure to thigh on over 2800 legs still attached to as many Danes, then followed the group for 12+ years checking out incidence of heart disease and death. Pipe cleaner thighs that fell short of 60 cm. (23.6 in.) in circumference were an independent risk marker for both unfortunate endpoints.

So what's the problem with skinny thighs? Two of our biggest muscles are contained therein, namely the quadriceps and the hamstrings. A loss of muscle mass could be a marker for inactivity or chronic disease such as COPD that prevents exercise. In fact, a Canadian study found that loss of mid-thigh muscle mass as measured by CT scanning was a better predictor of mortality in chronic pulmonary patients than a low body mass (both indicative of the wasting associated with lung disease).(2) Less muscle mass is also known to predispose to insulin resistance and type 2 diabetes as demonstrated by the elevated fasting blood sugars and cases of diabetes that we unexpectedly see in scrawny old ladies.

So should we be measuring thighs along with waistlines, blood pressures, and pulse rates (and also asking about physical activity, sleep habits, diet histories and domestic violence in the leftover minutes of annual physicals)? Says Australian epidemiologist Dr. Ian Scott in an editorial accompanying the Danish study: "Will this association help clinicians predict risk in individual patients more accurately than they already do using readily accessible and validated risk calculators? The answer is — we do not know."

I, for one, shall pass for now.
_____
(1) Heitmann, BL et al. Thigh circumference and risk of heart disease and premature death: prospective cohort study. BMJ. 2009 Sep 3;339:b3292. doi: 10.1136/bmj.b3292.
(2) Marquis, K et al. Midthigh muscle cross-sectional area is a better predictor of mortality than body mass index in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2002 Sep 15;166(6):809-13.

Idiopathic erythema

2009-10-15T20:29:00.005-06:00

My friends used to worry that my father, a psychiatrist, was secretly diagnosing their psychopathology when they'd stop by the house. On average, one word--adolescence--was all that was needed to label our deviance from normal behavior during those formative years.

Sometimes, I like to play 'guess the diagnosis' when I'm out and about in public. During PTA meetings at my daughter's high school, I'd sit and wonder why another parent's face was so red (the meeting content, as you may guess, was simply riveting!). I never did figure it out, nor do I have the slightest idea what happened to the man in the years since last we met. I was disturbed, however, to come across an item in a medical journal that suggested that his diagnosis may not have been benign.

Idiopathic erythema is a fancy way of saying the skin is red and we don't know why. One of my fellow residents during training had allergic dermatitis (eczema) as a cause of his not-so-idiopathic erythema. Those patients who are red for unknown reasons tend to be male (73%) and older (average age 69 years in one study).

Out of 218 Singaporeans studied by dermatologists there, 18% were ultimately found to have cancer. Dr. Steven Thng and his colleagues concluded, "We recommend close follow-up with reevaluation for malignancy even if the intitial investigation had been negative."

I hope this fellow is doing well, ruddy but cancer-free. But I now have something new to think about when a patient complains "Boy is my face red!"

Vitamin D, influenza, and old ladies

2009-10-02T21:00:00.008-06:00

Many epidemiologists now believe that flu is seasonal because vitamin D levels fluctuate seasonally. Vitamin D is a potent immune modulator; individuals tend to have higher levels during summer months with higher exposure to UV radiation and, therefore, are less likely to contract the flu while sun-kissed.

Researchers followed the seasonal health adventures of 208 post-menopausal women over three years as correlated with their monitored intake of D.(1) The results, shown in the bar graph above, were as follows:

Those ladies in the placebo group (lightest bars) got cold and flu symptoms all year long, but especially in the winter.
The test subjects (intermediate shaded bars) who received 800 units/day of supplemental D were as likely to get sick in the summer as winter, but were far less likely to take to their beds than their D-ficient colleagues.
In the final year of the study, the test subjects were plied with 2000 units of D each day. Only one lady (as represented by the itty-bitty dark bar in summer) got sick while D-eeply dosed with the vitamin.

Presumably D same benefits accrue to old guys too.
_____
1)Aloia JF, Li-Ng M: Epidemic influenza and vitamin D. Epidemiol Infect 2007; 135: 1095–1096.

Big-time kyphosis

2009-09-26T19:53:00.009-06:00

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!
_____
*Blechacz, B. Images in Clinical Medicine. NEJM 6/12/08.

The Teeming Team from Palliative Care

2009-09-22T08:51:00.005-06:00

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

2009-09-19T09:04:00.005-06:00

"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.
_____
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

2009-09-15T11:01:00.004-06:00

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?

2009-09-05T14:18:00.009-06:00

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.
_____
(1) Ophir, E, et al. "Cognitive Control in Media Multitaskers." Proc Natl Acad Sci USA. 2009 Aug 24.

Verbal fluency exercises

2009-09-01T13:12:00.005-06:00

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!

Weekly H1N1 flu update

2009-07-21T15:53:00.004-06:00

As an internist and primary care provider, I expect to be on the front lines during the upcoming flu season...whatever it may bring. Here's my first weekly flu report; stay tuned for future updates concerning the H1N1 vaccine, the latest in H1N1 research, and ways that you, your family, your friends, and co-workers can stay healthy through the fall and beyond!

A few words about seasonal flu

Influenza viruses are identified by their surface proteins that allow the little buggers to 1) stick to the cells of your throat and 2) thrive and multiply in your airway. H is for hemagluttinin, a protein that hooks the virus up to you, and N is for neuraminidase, a protein that promotes the release of newly made flu virus particles from the infected cell to its uninfected neighbors.

The reason that flu is such an ongoing nightmare is that the virus remakes itself every year with novel H and N proteins so that many people, even those who have previously had flu, aren't immune to the new variety. Every year we try to anticipate what this slippery little devil is going to do with respect to H's and N's and then develop a shot to promote immunity in all vaccinated persons. We particularly target those who are very young, very old, or otherwise affected with a chronic disease which would make them more susceptible to a complicated and dangerous case of the flu.

What's all the fuss about H1N1?

This past spring (late in the flu season) a new strain of flu emerged--first identified in Mexico--with novel H and N proteins. The strain was first traced to pigs--new influenza strains often start in pigs--thus the original name 'swine flu'. This name was dropped after pigs were unfairly targeted as the infectious source of the disease, but now we know of course that you cannot get H1N1 flu from eating pork.

The scary things about this new flu were that 1) it showed up in the Northern Hemisphere at a time when flu should be winding down, and 2) it appeared to be particularly severe or lethal in healthy, young adults, a group generally not at risk for flu complications or death. We are concerned, of course, that this H1N1 flu could cause another worldwide, devastating pandemic like the outbreak of 1918 which was also caused by an H1N1 type of influenza. Bird flu,incidentally, is typed as H5N1.

Lots of research is being done on this new strain, but the findings of flu expert Dr. Peter Palese and his team at Mount Sinai School of Medicine in New York are reassuring. They agree with CDC data that estimate only 10% of household contacts of patients with H1N1 will become infected which suggests that this bad actor is not as tough or transmissible as we originally feared.

Tuna casserole deficiency or cardiac arrest?

2009-07-14T10:08:00.010-06:00

Manytuna Casserole
2 tuna-fish-can-sized cans of the cheapest tuna
1 package broad noodles
1 can condensed cream of mushroom soup
1 package of frozen green peas

Precook the peas. Precook some (not all) of the noodles. Mush together in the pot
you just cooked the peas in (after draining off some of the water): the peas, the tuna
fish, the cream of mushroom soup (just as it comes out of the can), and the following
seasonings: salt pepper paprika oregano and garlic salt
Beginning with the noodles, alternate in your casserole dish layers of cooked noodles
and mush-mixture, ending with mush-mixture. Sprinkle a little paprika on top for local
color. Bake at 350 degrees for 20 minutes or so (there being no cheese to melt in this recipe).

I was never deficient in tuna casserole after my mom sent me "The Impoverished Students' Book of Cookery, Drinkery, & Housekeepery." And a good thing too as medical research confirms that ample tuna casserole (or omega-3 fatty acids in any other form) is a good way to ward off death. Here's what researchers at the University of Washington found:

They gathered blood samples from 300 unfortunates who had pitched over mid-life from sudden cardiac arrest. They then minced up the red cell membranes from the dearly departed, analyzed them for omega-3 fatty acid content. This measurement of omega-3 fatty acids in red cells--specifically DHA and EPA--is called the omega-3 index and measures the levels of these worthy fats as a percentage of total fats in the cell membrane.

The omega-3 indices of the fallen were compared to those of a control group from persons of similar age who were still alive and well. This upstanding group--who doubtless loved tuna casserole or rare tuna steaks or anchovy pizza--were far more likely to own red cells with at least 5% omega-3 content.

A preventive cardiology group at the University of Munich crunched omega-3/risk of death numbers and came up with these compelling statistics for downing capsules even if they make your breath smell like a dead mackerel:

"A review of the literature, expanded by measurements of the omega-3 index, indicates that the risk of sudden cardiac death correlates inversely with the omega-3 index. For persons with an omega-3 index <4%,>8%.

So omega-3 fatty acids, specifically EPA and DHA (read the label on your fish oil supplement selections and choose the capsule with the highest content of these two components), have anti-atherosclerotic (prevents build-up of cholesterol plaque), and anti-arrhythmic (prevents your heart from beating too fast, too slow, or too irregularly) properties. Furthermore, that fishy oil in the red cell membranes makes them less likely to glump together in a clot and more likely to squish through narrow places.

What's your excuse for sneering at tuna casserole?

Cankles

2009-06-28T17:36:00.007-06:00

Not a pretty sight, and certainly not one you want to see below your knee on a trans-Atlantic flight. On average, it's a bad thing that airplane seats on such journeys are so close together that you can hardly reach your feet to pull off your shoes, but a good thing insofar as inspecting your ankles is difficult. But when I finally got my lower leg into viewing range on the leg of the trip from Madrid to Philadelphia, it was strictly Exhibit B for me!

This would be a good time to review venous return from the lower leg and all that might interfere with it during a summer flight. Consider blood and its journey from toe back to heart after its load of oxygen has been delivered to these nether regions. Each heartbeat sends a surge of blood through the elastic arteries which expand as the blood pushes by and then contract in a springy sort of way to amplify its forward progress. By the time the blood passes through the teeny weeny capillary bed back to the leg veins, however, it's a different story.

The veins which carry blood back to the heart are neither elastic nor springy. When the blood arrives in the venous system, that pulsing kick from the heart's action is much diminished. In the upright or seated position, gravity is tugging that old deoxygenated blood downwards. The veins have valves on their inner walls that open to partially prevent this gravitational backwash, and activation of the leg muscles helps to further squeeze venous blood in its upward course.

Think for a moment, then, about a middle-aged lady(MAL) stuck in a seat for 9 hours watching "Bride Wars" and "Marley and Me" and eating salty airline meals. Actually, the movie choices have nothing to do with our cankle tale here, but believe me, these were dismal ways to pass time. So the MAL has already walked too much through the hot Spanish sun with her venous system dilated from the heat and saggy with age. She's retaining water from the high salt food. Furthermore, as she sits motionless in steerage, two 90 degree turns in her leg veins (at the knees and the hips) further slow the flow.

Oh gad, methought, those are NOT my ankles (or more precisely, where are my ankles?). For those of you wondering when your ankle bones will re-emerge from the inflight edema, mine took two days and I've seen it take up to two weeks in some of my patients.

Limbrel--new option for osteoarthritis

2009-06-08T20:19:00.005-06:00

I wrote some time ago about licofelone, a new analgesic for osteoarthritis (OA) that was then in Phase III clinical trials. Not only does this new agent decrease pain and inflammation from OA without stomach irritation (a la ibuprofen, naproxen, etc.) or cardiovascular complications (a la Vioxx and Bextra), it also demonstrates potential in actually slowing down joint destruction. Alas, while new reports on its dual action efficacy--analgesia AND disease modification--continue to appear, I can find no information on a release date.

I was pleased, therefore, to learn today about a new drug for osteoarthritis--a medical food actually--from a patient. Limbrel is all phytochemicals which should delight the aging hippies in all of us that search for the natural in the drugs we take to keep old body hooked to mellowing soul. It's made from those two lovely plants pictured above: Scutellaria baicalensis and Acacia catechu.

So here's the scoop. Arachidonic acid(AA) is a polyunsaturated fat that's necessary to body functions when it is appropriately converted to chemicals that protect your stomach lining, dilate blood vessels, promote proper blood clotting, and repair tissues. Too much AA in the wrong place at the wrong time is a bad thing whether it's derived from cellular injury or diet (think twisting your ankle as you eat a Big Mac for a double load of AA). Per Dr. Barry Sears: "...if you inject arachidonic acid into... rabbits they are dead within three minutes. "

As you get older, injured, have an inherited predisposition to arthritis, and eat too much fatty red meat or egg yolks, all that piled up AA gets churned along by the COX-1, COX-2, and 5-LOX enzyme systems into a world of inflammatory molecules and reactive oxygen species which set off a process by which your cartilage is destroyed and your bone overgrows into treacherous spurs.

You can inhibit COX-1 by aspirin or NSAIDs or inhibit COX-2 by Celebrex, but unless you turn down your 5-LOX as well, the resultant imbalance creates other problems. Scientists have sorted through more than a thousand plant-derived molecules looking for flavonoids with favorable suppressive action on these inflammatory pathways. Apparently those pretty posies posing above won the competition, proving both safe and efficacious in decreasing the pain of osteoarthritis.

While licofelone has been shown to slow down the cartilage destruction that leads to permanent joint deformities in osteoarthritis, Limbrel makes no such claims. Whether this is due to a lack of research supporting this function, or simply that it doesn't work in that way is not clear. Limbrel, however, is available here and now whereas licofelone is still churning along on the slow train to FDA approval. I've requested samples from the company, and look forward to working with those of you with the gnarly hands and aching knees of osteoarthritis to see what we think about this one.

Patellofemoral pain, arthritis, and exercise

2009-05-30T14:44:00.004-06:00

First off, an explanation. What's Martha Raye with her toothsome bedentured smile doing in a post on aging knees? If you have patellofemoral arthritis, I think you can relate.

The patella (kneecap) sits in front of the lowest part of the femur (thighbone) at the knee joint. Patella slides over femur as we bend at the knee, and when all is young and working correctly, the cartilage-covered surface of one slides over the cartilage-covered surface of the other.

So with age, cartilage breakdown, misalignment, and saggy old quadriceps (large muscle on the front of the thigh in charge of getting us off chairs and toilets), the patella starts slamming into the front of the femur, and the cartilage frays, tears, and wears away down to bone. So as we squat, plie, rise up, and sit down, one bone grates on the other bone, and...just like Martha Raye fielding a seed between denture and gum...we wince with pain.

Well, that's me. Deep knee bends are yesterday's move, squats out of the question, and I channel Martha Raye during lunges. The first thing I told a personal trainer during a trial session is "I don't do lunges. Period." But she is not taking no lunges for an answer, noting as I have that flexing the weight-loaded knee to heave the rest of me up and down (assuming I'm not in a wheelchair) is what I must do for the rest of my life if I care to remain independent. Is this all about being under 30 and not appreciating how it feels to work-out on aging knees, or is she on to something?

She will feel smugly vindicated when I show her a Dutch study(1) that indicates exercise beats other strategies for relieving patellofemoral pain. The sports medicine practitioners at Erasmus University Medical Center in Rotterdam signed up 131 patients with up to twice that number of painful knees to undergo a 12 week supervised exercise program directed at quadriceps strengthening, flexibility, balance, and coordination or an equal number of weeks under 'usual care' from their physicians. The latter, I'm guessing, means this control group was told "You should do leg lifts and take Advil (or whatever the Dutch equivalent is) and get over it. Next."

On comparing the exercised group with those who motored on without supervision, the researchers found significant improvement in pain and function scores in the former not only at the end of 12 weeks but also on follow-up 12 months later. One can assume that diminished pain means improved alignment and quadriceps strength have improved the tendency of bone to grate on bone and, as a result of this supervised exercise program, wear-and-tear degeneration has been halted.

My trainer has cleverly disguised lunges as other exercises where I hop from bent leg to bent leg as she throws things at me (well, a ball actually), or stand on one bent leg while I do distracting maneuvers with weights in hand, and, well, I hate to admit it but my knees feel better.

So I guess I'll channel Erma Bombeck instead and let Martha Raye rest in peace.
_____
1. American College of Sports Medicine (ACSM) 56th Annual Meeting: Abstract 570. Presented May 27, 2009

I'll be doggone!

2009-05-27T22:15:00.004-06:00

I was scribbling away on my patient's chart during the initial part of her annual exam. As I wrote her latest information, she began to pant.

My first doctorly thoughts before I looked up: "Good heavens, she's in metabolic acidosis," "She has a sucking chest wound," and finally "She's lost her mind!"

As I turned my gaze towards my patient, I noted that she looked neither distressed nor hypoxic. And...the panting was coming from near her feet!

"What on earth is that noise?" I asked.

She leaned down sheepishly and unzipped her large bag. A small silky-haired dog popped out and made my day by sitting in my lap for the remainder of the interview.

A biological reprieve from life in a shoe

2009-05-08T14:29:00.005-06:00

There was an old woman
who lived in a shoe,
she had so many children
she didn't know what to do.
She gave them all broth
without any bread;
she whipped them all soundly
and put them to bed.
--Mother Goose

Have you ever considered that menopause may be a biological boon to get us out of such sticky shoe situations? Seriously though, what is Mother Nature's point with this mixed, menopausal blessing?

Craig Packer, a professor of ecology at the University of Michigan, considered the evolutionary advantage to animals of such programmed senescence, where the ovaries quit years before the rest of the body. He first looked for a 'granny effect', a survival advantage for those young animals with living grandmothers capable of assisting in their care. Baboon grandkids survived just as well whether grandma was dead or alive. Lion cubs only benefited from Grandma Lioness's attention if granny could nurse the little darlings because she herself remained fertile (heaven preserve us from that!).

So why don't the females of various species just keel over at menopause? Packer concluded that the answer could be found in ''prolonged maternal investment," the dependence of young mammals on the presence of a mother who's neither frail, shoe-bound, nor dead. Baby baboons need that mother's touch through their second birthday, and it is fortunate then that a baboon mom typically lives five years past her final birthing.

On the other hand, lion cubs are independent and good to go after just one year, so mama lionesses live less than two years past the end of ovarian function. Packer then assumed that human children need their moms until age ten (what kids has he been around??), and guessed that our maternal ancestors ideally would have lived until age sixty--ten years past the end of reproductive cycling--in order to see the last little darling out the door.

And now, with current advances in medical care and nutrition, we can anticipate successfully nurturing our children until they themselves are sixty!*
_____
*Or more. My 90 year old patient spent the first half of her annual exam appointment two weeks ago fretting over her 70 year old son who still walks from his house next door to hers each evening for her home cooking. Gad.

The oriented-in-space place

2009-05-08T14:15:00.004-06:00

Drawing a mental blank is a drawback of a busy day; being unable to draw a mental map of your current location is a red flag for trouble. While getting lost in your work rates high performance reviews, getting lost while driving maybe a sign of dementia.

Arriving safely at home at the end of our day requires the proper functioning of an oriented-in-space place in our brains located just behind and above the ear. This medial superior temporal area (MST) is charged with personal global positioning, providing our brain with continual updates on our current location in space.

Unfortunately, the MST is particularly vulnerable to the cellular destruction associated with Alzheimer's Disease(AD), leaving its victims unstuck in their once familiar world. This deficit has been dubbed 'motion blindness'; the the resultant inability to navigate, even through one's own home, leads to a tragic loss of independence.

Here's another scary consequence. While early AD victims may remember street names and the basic rules of the road, there are certain driving skills that lapse early in the course of the disease based on MST dysfunction. I remember an office visit where my elderly patient arrived slightly late for her appointment. She sat down in the chair with a sigh, then proceeded to recount her harrowing drive over during which, per her report, she sideswiped several cars on both sides of the narrow streets near my office while trying to guide her car down the middle of the road. She had no sense at all of where her car ended relative to those parked by the curb.

I don't know what was more disturbing--her zigzag navigation of a potentially lethal weapon or her relative indifference to destruction that she left in her path.

What's the scoop on the flu?

2009-04-28T13:06:00.005-06:00

Every year, the influenza virus reinvents itself. In the countryside and farms of Southeast Asia, this bad actor mixes up genetic material with its viral cousins, producing brand new strains that then spread throughout the world in the throats and lungs of international travelers. And every year in turn, epidemiologists try to anticipate the new flu variants in order to produce an effective vaccine in time for the next flu season.

But now, as all of you know, the pesky pathogen has performed a new sort of quick change trick. This latest viral transformation apparently occurred in the pig farms of Mexico, and the resultant strain strings together genetic material from human, swine, and avian sources into a novel hybrid to which none of us are immune. This 'swine flu' has produced serious illness in its country of origin, and now the whole world watches in nervous anticipation as it continues its spread.

Let's get the good news out right up front. First of all, flu is seasonal, and the season here is nearly over. While this new strain of flu may resurface next winter, its current run could well be brief. And scientists will have time to develop an effective vaccine before its next world tour. Secondly, the cases thus far identified in the US and abroad have generally been mild and self-limited.

And finally, this swine flu is sensitive to two standard anti-virals--Tamiflu and Relenza. Remember, however, that not only can influenza pull off genetic mixology to produce an entire new strain, it also can acquire the genes for immunity to these drugs. If enough of us twitch and take Tamiflu at the first sign of any viral illness, be it flu, croup, or the common cold, this acquired resistance will be a sure thing. So don't call your doctor for a 'just in case' prescription; Adele and I will say "NO!"

The flu is highly contagious; it's effectively spread by tiny respiratory droplets which remain suspended in air and settled on surfaces for some time after an unrestrained sneeze or cough. Good prevention practices include:

Cough or sneeze into your sleeve. Using your hands or a tissue to contain your explosion just makes more objects infectious.
Better yet, stay home with your secretions when ill, and don't expect affected employees or co-workers to crawl on in to work when they are unwell.
Wash your hands frequently, and don't touch your face or handle food after touching shared surfaces until you've washed up.
Practice good health habits to enhance your overall immunity and resistance.
Ask your doctor to check your vitamin D levels, and then discuss supplements with her/him to bring yours up to the ideal range. Influenza is increasingly considered a vitamin D deficiency disease!

For an amusing look at keeping your mucous to yourself, check out this video.

Of linens and proteins...*

2009-04-24T10:48:00.005-06:00

And stressful situations in closets and cells.

I've mentioned before that I suffer a weensy bit from disposophobia or the inability to part ways with stuff. Old towels are no exception. My linen closet bulged (past tense due to recent reform efforts) with tattered towels and sheets too short for current mattresses. As I dug deeper in search of bath accessories with the most residual fluff, the rifled remaining towels took up more and more space, threatening the hinges on the closet doors. I desperately needed an unfolded towel response (UTR).

Enter the towel-like equivalent of body clutter, namely unfolded proteins. Not only do your cells need to string the appropriate sequence of amino acids together to form proteins, but they also must pull a little proteinaceous origami trick to get them into the right spatial configuration for proper functioning. Unfolded proteins are the bane of an aging cell's existence--witness all that rumpled beta-amyloid protein that gums up old neurons in Alzheimer's disease.

Hurrah for evolution! Enter the unfolded protein response (UPR), nature's way of sensing a haphazard pile of proteins on the cellular floor. And if the UPR can't straighten up the protein closet--wadded proteins stacking ever higher--then the UPR just makes some sort of nasty enzyme that explodes that cell and its proteiny mess right then and there.

Alas, as Dr. Dale Bredesen of the Buck Institute for Age Research points out, the UPR is no different than a lot of other body responses to dysequilibrium: "The initial response is protective, but the late response is destructive." He and other neurobiologists are hoping to unlock the secrets of UPR in order to keep this organizing principle on our side.
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*Check out Menopause Moments for a review of a book with one theory how misfolded proteins may be the infectious basis for Alzheimer's Disease.

"The Power of Two"

2009-04-19T20:29:00.005-06:00

After my mother's craniotomy for a subdural hematoma several years ago, she made rapid progress and was transferred to the rehab unit. Unfortunately, shortly after playing several hands of bridge with visiting friends, she developed a fever and chills and was diagnosed with c. diff sepsis.

The hospitalist came right over, started IV fluids and antibiotics, and breezed on out. My friend Brenda, the unit's only RN, and I looked at one another.

"Are you okay with her staying here?" I asked.

"It's just me and 20 patients," she replied. "I don't think I have time to give her the care that she'll need."

Fortunately, I caught up with the doctor, and he agreed to transfer Mom to the ICU. A good thing too as bacterial sepsis is not a rehab floor matter. I wondered what would've happened if I hadn't been there at the time. And I wondered that again several days later when the specialist missed the fact that Mom was going in and out of atrial fibrillation on the ICU monitor. And I marveled how anyone survives a hospitalization without an advocate on hand.

We are fortunate, therefore, that Brian and Gerri Monaghan have written a moving account of their own journey through life-threatening illness and advocacy, "The Power of Two". Not only is this book a compelling, entertaining, and (at times) tear-jerking account of love and loyalty in sickness and in health, it is a step-by-step, tip-by-tip, how-to manual for all of us who will face a serious illness or care for someone in that situation. And, through my life roles as doctor, wife, daughter, mother, and friend, I can tell you that will absolutely be all of us.

I'd like to say that I'm going to keep this book on my shelf for my next advocacy adventure, but I plan to give it away to a friend who was diagnosed last week with cancer. With the Monaghans on their team, and this guidebook in hand, she and her family will be able to stand up and advocate for what they need.

In praise of Dr. Anthony Laporta

2009-04-14T17:41:00.005-06:00

My friend/patient did not look well. She came in on Friday of last week looking gray and tearful, still battling the abdominal pain that she'd called me about the previous week. Not only was she 7 pounds lighter than her usual weight, she had scary lymph nodes on the side of her neck.

One of those moments when I puzzle over what to do with my face as I launch into Dr. Scheduler, working to get her a CT scan and an appointment with a general surgeon for a biopsy. All ASAP! Within two hours, both appointments were made for the beginning of this week.

So here it is Tuesday p.m., and I've just gotten off the phone with Dr. Anthony Laporta whom I've never met and never spoken to before yesterday. My friend and I agree that this fellow is the best. He was on his cell phone, the sounds of his son's lacrosse game in the background. He had the the CT results to me within 2 hours of the Monday's scan. Post-op, per him: "I walked down to the lab to have a look at the slides from the biopsy." No unnecessary waiting for my pal--"My goal," per Laporta, "is to get things done as quickly as possible to minimize the time spent worrying about the unknown."

So tomorrow a.m., she will see the oncologist--on her way to an action plan within five days of her first appointment! I recommend Dr. Laporta with pleasure to all those facing the scary prospect of surgery.

Fretful and friendless raises risk of dementia

2009-03-24T20:38:00.001-06:00

Just untangling the conclusions of this Swedish study was a brain workout in its own right, a downright 'how much wood would a woodchuck chuck..." sort of puzzle:

Neither high neuroticism nor low extraversion alone was related to significantly higher incidence of dementia. However, among people with an inactive or socially isolated lifestyle, low neuroticism was associated with a decreased dementia risk (hazard ratio [HR] = 0.51, 95% confidence interval [CI] = 0.27-0.96). When compared to persons with high neuroticism and high extraversion, a decreased risk of dementia was detected in individuals with low neuroticism and high extraversion (HR = 0.51, 95% CI = 0.28-0.94), but not among persons with low neuroticism and low extraversion (HR = 0.95, 95% CI = 0.57-1.60), nor high neuroticism and low extraversion (HR = 0.97 95% CI = 0.57-1.65).(1)

Got it? So do we fret and socialize, stay home and calmly knit, or placidly go out drinking with our buddies? Don't freak out while you discuss this conundrum with your friends because, as you will see once you sort out the various possibilities here, being a Buddha of a buddy is your best bet for the brightest brain.
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Wang, HX, et al. Personality and lifestyle in relation to dementia incidence. Neurology. 2009 Jan 20;72(3):253-9.

Flector patch--the first NSAID patch for pain

2009-03-21T11:28:00.008-06:00

So what does a NSAID patch have to do with this piece of exercise equipment? Let me explain.

It's called a Trikke (as in trike for grown-ups). You use all your balance and leg strength to power this in a skating sort of fashion. Is this the appropriate gizmo for a middle-aged female? No, no, not me, I wouldn't be caught dead on this thing--probably would be dead if I tried. My intrepid medical partner Adele, however, has been seen 'skating' on a Trikke down Montview Blvd. here in Denver, and one day she met the pavement beside her trike, her hamstring muscle ripped from its pelvic attachment.* She healed to skate (and ride, and do Pilates, and lift weights again), but the scarred muscle is not as flexible as it used to be which in turn puts stress on her pyriformis muscle.

So last week she was running from exam room to exam room working her healing magic while occasionally clutching her piriformis muscle which was in spasm whilst whining softly with pain (check out where the pyriformis muscle is and you'll know what she was grabbing). The King Pharmaceuticals rep coincidentally showed up with info and samples of the Flector patch.

A word or two about diclofenac, the active ingredient in this medicated patch indicated for topical use for pain control of acute injuries such as strains, sprains, and contusions. Diclofenac, formerly known as Voltaren, is a dandy non-steroidal anti-inflammatory (NSAID) which reaches high concentrations in joint spaces. It's generic, cheap, works well, AND causes stomach inflammation with bleeding, possible liver toxicity, and can reduce blood flow to kidneys, particularly aging kidneys.

So, Novartis developed Voltaren Gel to smear on arthritic joints; used regularly it significantly decreases pain without bothering the stomach, the liver, or the kidneys. And now King Pharmaceuticals brings us diclofenac in patch form with very little systemic absorption--also safer for use particularly in older souls with acid gastritis and aging vascular systems.

Adele, being the sort of sport that she is and really distressed by her pain in the butt, slapped a patch on the offending area. Perhaps this was not the best Flector patch trial as it became quite wrinkled given the anatomy of the area and the wearer reported it was a little like having an ongoing wedgie. Nevertheless, Flector is a good idea (but a really stupid name) and I look forward to handing them out to persons with sprained ankles, shoulders, or back to see how they fare.
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*My bro' Reality Man uses one too, but so far he's remained upright in his exercise endeavors.

How do crossword puzzles help my brain?

2009-03-14T14:15:00.002-06:00

Check it out at Menopause Moments.

YogaToes revisited

2009-03-01T13:38:00.006-07:00

I've mentioned before that this product has relieved most of my foot pain coming from falling arches and mid-foot impingement syndrome (along with arch supports in the shoes). Just noticed a coupon code in Health Magazine for $15 off--go to YogaToes.com and enter coupon code H3X9.

Can NSAIDs prevent Alzheimer's Disease?

2009-02-27T19:56:00.005-07:00

Alzheimer's disease (AD) gums up the brainworks with tangled neurons and protein plaques. Much of the damage occurs, however, as a result of an inflammatory response to these changes. Scientists theorized that the regular use of anti-inflammatory drugs such as Advil, naproxen, or Celebrex (also known as non-steroidal inflammatory drugs or NSAIDs) could slow down or prevent this degenerative disease.

The Alzheimer's Disease Anti-inflammatory Prevention Trial(1) enrolled over 2,000 seniors aged 70 years and older and followed them through 7 years of life correlating the use of NSAIDs (naproxen 220 mg. twice daily, Celebrex 200 mg. twice daily, or a look-alike placebo with no anti-inflammatory properties at all). All participants had a family history of AD and were thus considered to be at increased risk for developing the disease.

Made no difference what the septuagenerarian subjects took--naproxen, Celebrex, or no drug at all--with respect to their subsequent tendency to drift towards dementia. In fact, there was 'weak evidence' for a detrimental effect of naproxen.

The problem, however, is that this really wasn't a preventive trial at all. By the time old folks enter their eighth decade, they may well already be on the road to AD. Chemopreventive studies--i.e. those research trials seeking substances that actually protect against the development of AD through a neuroprotective substance-- would need to be undertaken on younger subjects over a longer period of study, an approach that is prohibitively expensive. The studies that suggest that NSAIDs are indeed useful in AD prevention are largely observational and/or retrospective; large populations are quizzed as to their health habits and medication usage, and these reports are correlated with present or future health outcomes. And if you've ever quizzed an old person about their drug use now and in the past, you may well wonder as do I how accurate those self-reports really are.

While the jury's still out as to whether NSAIDs are useful against AD, there is evidence that they may lower the incidence of cancer, and they certainly are good for pain. On the other hand, a recent study(2) showed a strong link between their use in patients also on anti-depressants such as Prozac or Lexapro (aka SSRIs) and gastrointestinal bleeding. Those on this pharmaceutical duet were 4.8 times more likely to bleed from their upper GI tract.
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1. ADAPT Research Group. Cognitive Function Over Time in the ADAPT: Results of a Randomized, Controlled Trial of Naproxen and Celecoxib. Arch of Neur. 2008;65(7): 896-905.
2. deAbajo FJ, et al. Risk of upper GI tract bleeding associated with SSRI and Venlafaxine therapy: Interaction with NSAIDs and effect of Acid-suppressing agents. Arch of General Psychiatry. 2008;65(7):795-803.

Kefir and breast cancer

2009-02-24T20:21:00.006-07:00

(thanks to Dr. Jacob Schor once again for bringing yet another health topic to my attention; check out his web-site at denvernaturopathic.com to subscribe to his newsletter)

Human beings have a self-preservation mechanism in the gag reflex; when something unexpectedly unpleasant in taste or texture hits the mouth, the entire upper digestive system reacts quickly and violently to eject to the offender. The first time I learned about this survival mechanism, I had just taken a large mouthful of buttermilk with my childhood friend Jean's encouragement. She raved about how tasty it was when, in fact, it was vile. I laughed hard and gagged simultaneously, sending the buttermilk through my nose.

Decades later, I accepted a small jar of homemade kefir from my patient V who took a bottle of the worthy stuff to work every day along with a container of home-cooked stew. As she is absolutely one of the healthiest people I know and care for, I was eager to start a kefir habit of my own. But oh heavens, it's surprisingly tart and foul, worse than buttermilk, and I spit the stuff out. New research suggests, however, that it may be the latest and greatest chemopreventive agent against breast cancer. Maybe chocolate syrup can enhance the taste. Check this out:

Canadian nutritionists cultured human breast cells--both cancerous and not-- in the lab, then fed the little colonies extracts of kefir, yogurt, and plain old pasteurized milk in various concentrations and checked out who thrived and who died(1). Kefir depressed tumor cell growth in a dose dependent fashion--the more kefir present, the fewer the cells. A .63% kefir extract dose (now perhaps even I could handle that) decreased tumor cell numbers by 29% and the 2.5% formula felled those cancerous bad girls to 56% their pre-kefir numbers. The yogurt also suppressed tumor growth, but less vigorously than the kefir. And the milk stimulated both lines of breast cells--normal and malignant--at concentrations as low as .31%!

Do I want to wait for more info, more studies? I think not. I'm calling V tomorrow for her kefir recipe. After all, if I fully expect it to taste sour and slightly carbonated, I can overcome the urge to cough it out through my nose.
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(1) Chen, C et al. Kefir extracts suppress in vitro proliferation of estrogen-dependent human breast cancer cells but not normal mammary epithelial cells. J Med Food. 2007 Sep;10(3):416-22.

Updated colon cancer screening guidelines

2009-02-19T08:34:00.005-07:00

When I was an intern, we had a standard 'scut list' of tasks that no one loves but only an intern (or medical student if you were lucky enough to have one around) would do. Every admission, no matter what time they rolled through the ER door, needed a complete work-up by the time morning rounds began, and that work-up included a gram stain of that which they were coughing up if coughing was one of their presenting symptoms. This involved getting a phlegmy sample, teasing out spit from the real deal gunk within, then spreading the mess on a slide and processing it appropriately. Needless to say, it was gross.

What does that have to do with colon cancer screening? Well it's to let you know that I'm okay with digital rectal exams and testing stool samples thus obtained for blood because it's a walk in the park compared to the above. Nevertheless, I welcome the latest screening guidelines(1) from the United States Preventive Services Task Force (USPSTF) that do not include rectal finger probes for those brave souls who get their every 10-year colonoscopy exams.

Colonoscopies are the best cancer screening tests we have with respect to cancers ducked (as pre-cancerous polyps are removed) or cured (tiny cancers found before they spread). That said, they're expensive, time intensive, and not without rare but serious complications. Someday we'll have a better way, but meanwhile they are still on the A list for those over 50 at average risk. On the other hand, the USPSTF says that colon CT scans are not yet ready for prime time screening purposes. More info needed, they declared, to support its routine use because thus far, this easier and less expensive scanning technique produces too many 'false positives' (looks like a polyp but not a polyp just a hunk'a stool clinging to the colon wall).

For those who cannot stomach (or perhaps cannot colon) the thought of a colonoscopy, or just plain can't afford it, the panel supports yearly high-sensitivity fecal occult blood testing (FOBT) or every 5 year sigmoidoscopy with FOBT in between. Used to be that FOBT was about equivalent creepy to sputum gram smears--requiring that the testy testee fish around in the toilet water for their 'specimen,' then to use a junior-sized popsicle stick to apply it a little card, do this three days in a row, then mail the cards off to the MD office where a testy assistant had to open the crusty old card and test it for blood. Now, the MD or patient takes darling little grooved stick from a teensy tube, gently rubs it in the residual stool on the exam glove finger or a used piece of toilet paper (if doing test at home), and reinserts stick in tube. Testing is then carried out with a treated paper strip and no further person/fecal interaction is required.

Alright, that is a wee bit gross as well, but all this colon cancer seeking is important stuff for persons of age.
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1) Preventive Medicine 2009: The Annual Meeting of the American College of Preventive Medicine (ACPM). Session 30. Presented February 13, 2009.

Breast cancer and hormone therapy

2009-02-10T10:52:00.007-07:00

I believe that the most important influences driving our medical decision making process are our personal beliefs, both our worst fears and our fondest hopes. These belief systems are powered by our own medical histories, those of our family, the things that we read, and our personal experience. Sometimes my exam room is crowded to overflowing as Suzanne Somers argues with Dr. Susan Love in the corner as Dr. Andrew Weil tries to get a word in edgewise. Meanwhile my patient's mother and her best friend's cousin are lurking just behind her clamoring to add their opinions on the magazine articles spread out on the desk in front of us.

I would be foolish to discount these many voices; if they're important to my patient, they need to be a part of our discussion. I like to think my worst fears are highly informed ones, yet I am highly influenced by my family history of dementia and completely freaked out by the latest news on breast cancer and HRT in the latest issue of the NEJM(1). Here's the scoop:

The Women's Health Initiative randomized over 16,000 women to receive either combined postmenopausal hormone replacement therapy (Premarin plus Provera) or a look-alike placebo, then followed each group with regard to health outcomes, particularly the incidence of cardiovascular disease and breast cancer. The trial was abruptly halted in the summer of 2002 (what menopausal internist can forget that?) when it was clear that harm outweighed benefit with respect to heart attack, stroke, and breast cancer risk.

The study has come under attack for applying data obtained from a somewhat older group of women (average age 63) many of whom were overweight, hypertensive, diabetic, and smokers to a younger group of women just entering menopause and looking to improving their quality of life with HRT. Several studies, both trials concluded and some still underway suggest that, in fact, this latter group of 50-somethings may actually receive cardiovascular protection from the use of hormones particularly so-called bioidentical estrogen delivered in a non-oral fashion (such as via a skin patch).

I'm good with all that but note please that cardiovascular disease is not high on my to-worry list although I certainly recognize that many of my patients are at risk for same. And as losing my marbles is number one on my future frets, and estrogen is a top neuroprotective agent for aging female brains, I'm choosing to motor on with my HRT choices.

When the WHI data came out, some drug company or other provided me with graphics on this breast cancer thing. One thousand little grey female stick figures were lined up on the top of the page three of whom were colored orange. These unfortunate orange ladies were the number per year of new breast cancer victims in 1,000 post-menopausal ladies not on hormones. At the bottom of the page, another 1,000 skirted sticks queued up, 996 clad in grey and 4 in blue. You've got it: the blues were new cases of breast cancer per year in 1,000 post-menopausal hormone users. The absolute risk was huge; a 33% increase in breast cancer amongst hormone users but the relative risk small, namely one additional breast cancer per thousand users.

BUT...consider that 4th blue lady, her life turned upside down with biopsies, chemo, radiation, and a world of worry even though her chances of actually dying from that cancer are small. And if your worst fear is that cancer-induced world upheaval, then you will choose to discontinue therapy or never start it in the first place.

And now the doctors of the WHI bring us this new news to add to the evidence behind our worst fears, namely that the incidence of breast cancer which nearly doubled in the hormone users over the 5.6 years of the study decreased rapidly in the two years after the study coinciding with a marked drop in the use of combined hormones by the subjects. The busy slide at the top of this post illustrates this in the upsloping solid red line on the left which represents cancer incidence during the study and the soothing downward solid blue line on the right as fewer women got the bad news in the 2 years following the study's end. The black and white graph that follows is the interesting and contrasting data from a Scottish study that also notes the drop in hormone use over a similar time frame (the two plunging lines) but the more or less straight line at the top shows that Scottish women did not experience the drop in breast cancer rate with falling use of HRT.

Argh, what's an aging woman on hormones or contemplating their use to think? Estrogen is a growth-stimulating hormone, and thanks for the boost when it comes to bone, muscle, connective tissue, skin, vaginas, and brain. I love my brain power, I worry often about dementia, and I don't mind the youngish looking skin, so here's to hormones! But, breasts that aren't prepping to feed a developing babe don't like to be stimulated, and the more you goose your breast cells years after pregnancy is nothing but a distant memory, the more likely you are to stimulate a cancer. I don't want cancer, no not one bit, I know one woman who got cancer within 1 1/2 years of starting HRT, so to heck with hormones!

Well, Ms. Suzanne Somers staring out the cover of "The Sexy Years" like you just rolled out of a bed in which you were not alone, what is easy about this decision? Absolutely nothing. Per Dr. Morris Notelovitz, a venerable old menopausal researcher, every year a woman and her doctor should review her hormone therapy decision (and every other medical decision she makes per me!). If she is using HRT, why? If she is not using HRT, why not? What are the experts and your secretary's aunt saying? What do you believe is best for yourself?
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(1)Cheblowski, RT et al. Breast Cancer after Use of Estrogen plus Progestin in Postmenopausal Women. NEJM. Volume 360:573-587 Feb. 5, 2009.

Pilates, back pain, and Denver's old spines

2009-02-08T15:53:00.006-07:00

I see a lot of older women going to ground--their spines telescoping downward and often acquiring notable, painful curves in the journey south. Unfortunately, got one of those backbones myself. I've tried a lot of things to shore it up but none more useful than my lessons with Dana Dreifus, a wonderful Pilates instructor in central Denver. She has an incredible intuition for that which you need to balance and strengthen, and she's quick with adjustments to the standard postures in order to accomodate your ability and level of fitness.

But you don't have to be old and degenerating to enjoy Dana's careful attentions and enthusiasm. If you're new to Pilates or wish ongoing instruction, you could not do better than to call her at: 720-936-3667.

L-carnitine for your hair

2009-02-06T20:19:00.006-07:00

Those of you who follow my Menopause Moments blog might already be taking this stuff to boost your brain. So here's good news from TheDermBlog.com that this supplement may stimulate hair growth.

Hair follicles go through cycles wherein hair grows (anagen) and then falls out (telogen). Hair aging badly becomes thinner, finer, and more colorless with each cycle. Progesterone promotes glorious hair (think hair during pregnancy) and precipitous drops in this hormone cause hair loss (think hair after pregnancy or during menopause). Testosterone causes hair loss in a characteristic pattern (those thinning temples and shiny pink crowns of aging men and some women). Minoxidil or Rogaine improves circulation to hair follicles and sort of helps men and women hold onto their hair. So what does l-carnitine do?

When hair follicles were cultured in the lab (if they can grow 'em in a dish, why can't they grow 'em on our heads?) in the presence of l-carnitine, researchers at the University of Hamburg observed several positive things: the growth phase lasted longer, fewer hair matrix cells keeled over dead, and more matrix cells proliferated. At a molecular level, less TGFbeta2 factor, less TGF-beta II receptor protein, and falling levels of caspase 3 and 7 confirmed a more-growth-less-death environment for the hairy little cell community(1).

The German dermatologists summed it up thus: "l-carnitine, a frequently employed dietary supplement, may stimulate hair growth by increasing energy supply to the massively proliferating and energy-consuming anagen hair matrix." Whoa, I would like to use "massively proliferating" and "my hair" in the same sentence. How do you say "Please don't hate me because I have beautiful hair" in German?
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1. Foitzik, K et al. L-carnitine-L-tartrate promotes human hair growth in vitro. Exp Dermatol. 2007 Nov;16(11):936-45.

Moxxor

2009-01-31T11:04:00.007-07:00

From an e-mail I received this week:
I was wondering your thoughts on Moxxor. I pasted below an email I got from a friend who is helping promote it. Please let me know your thoughts.

Oh dear, another product about which I know nothing but upon which I am asked an opinion. The standard dilemma--do I write back and say "This is Dr. Paley's secretary. Thank you for your query but unfortunately the doctor is unable to answer individual e-mails." Or do I look it up and give it my best guess. Well that's what I did.

Moxxor is a supplement made of oil d'green-lipped mussels. The thought of eating bi-valves always brings to my mind "The Walrus and The Carpenter" poem from Alice in Wonderland; the first poem I ever memorized (one of three lifetime poems by rote for me) wherein a walrus and carpenter entice little oysters to scurry from their beds for a walk along the beach and ultimately eat them all(2).

Back to Moxxor, just letting you know I'm a little uncomfortable right up front with its origins. I am, however, very pro-omega-3-fatty acids, and Moxxor's green-lipped mussel variety is, per glowing Internet reports, a particularly fine one. GLM-omega-3's are purported to have potent anti-inflammatory properties. One fellow who actually met the guy who developed Moxxor (a toothy, widely grinning fisherman from New Zealand) took his first dose, worked out like mad at the gym that afternoon, then woke up the next day pain-free from his exercise session.

Now if you can wait long enough for the graphics to load (which I did not), mymoxxor.com tells you how you can become an independent distributor of the stuff. Right there that's enough to make me want to write back to this lady about what a silly scam it all is--just buy the 3 for 1 omega-3's at puritan.com. But I looked in on PubMed.gov and learned a thing or two about the health benefits of GLM's.

UK Scientists did a meta-analysis of studies treating osteoarthritis with GLM(1). They concluded "The data... suggests that GLM may be superior to placebo for the treatment of mild to moderate OA. As a credible biological mechanism exists for this treatment, further rigorous investigations are required to assess efficacy and optimal dosage." The credible mechanism is provided by numerous studies that show that GLM's have unique poly-unsaturated fatty acids with significant anti-inflammatory activity.

Whoa, I'm down for that; I've got a finger, two thumbs, a knee, and a foot in serious need for significant anti-inflammatory activity. Maybe I could become a Moxxor dealer and get out of primary care. I'll let you know if I ever get past the graphics delay and my bi-valve aversion to actually order this stuff.
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(1) Brien, S, et al. Systematic review of the nutritional supplement Perna Canaliculus (green-lipped mussel) in the treatment of osteoarthritis. QJM 2008 Mar;101(3):167-79.

(2) Here's the part that's put me off my Oysters Rockefeller:

*'But wait a bit,' the Oysters cried,
'Before we have our chat;
For some of us are out of breath,
And all of us are fat!'
'No hurry!' said the Carpenter.
They thanked him much for that.

'A loaf of bread,' the Walrus said,
'Is what we chiefly need:
Pepper and vinegar besides
Are very good indeed --
Now, if you're ready, Oysters dear,
We can begin to feed.'

'But not on us!' the Oysters cried,
Turning a little blue.
'After such kindness, that would be
A dismal thing to do!'
'The night is fine,' the Walrus said,
'Do you admire the view?'

'It was so kind of you to come!
And you are very nice!'
The Carpenter said nothing but
'Cut us another slice-
I wish you were not quite so deaf-
I've had to ask you twice!'

'It seems a shame,' the Walrus said,
'To play them such a trick.
After we've brought them out so far,
And made them trot so quick!'
The Carpenter said nothing but
'The butter's spread too thick!'

'I weep for you,'the Walrus said:
'I deeply sympathize.'
With sobs and tears he sorted out
Those of the largest size,
Holding his pocket-handkerchief
Before his streaming eyes.

'O Oysters,' said the Carpenter,
'You've had a pleasant run!
Shall we be trotting home again?'
But answer came there none --
And this was scarcely odd, because
They'd eaten every one.

Pedometer-based walking intervention

2009-01-21T19:27:00.002-07:00

I love these names--if I recommend pedometers, and I do, then I am conducting pedometer-based walking interventions. Visions of two wild-eyed pedometer experts swooping unannounced into your workplace, grabbing you one arm apiece, and carrying you out to the parking lot where they install a pedometer on your waistband and drag you screaming, half-walking/half-kicking around the parking lot until you hit 10,000 steps.

Anyway, scientists from the Dept. of Family Medicine conducted a meta-analysis of PBWI's which means that they not only searched six electronic databases for weight loss outcomes in nine different studies that compared the pedometered with the pedometerless to see who lost the most weight, but they also contacted real-life pedometer experts just in from field interventions to interpret the results. Their conclusion?

Pedometer-based walking programs result in a modest amount of weight loss. Longer programs lead to more weight loss than shorter programs.

I trust the experts were pleased.

Statins and infection control

2009-01-19T12:29:00.005-07:00

I have any number of patients who take statin drugs(1) to lower their cholesterol levels in order to reduce their risk of unwanted cardiovascular outcomes such as stroke or heart attack. I would prefer, in an ideal world, that these patients control their risk factors with healthy habits in diet, exercise, and weight control, but, alas, this is not a perfect world but rather one in which many lack time, will-power, and resources to make these changes in a timely fashion.

In addition to their ability to reduce cholesterol production and increase LDL clearance by the liver, these drugs are known to reduce inflammation in the body. Inflammation is a good thing as a first responder to infection or injury, but inflammation gone amok is part of the pathological process that increases tissue destruction in Alzheimer's disease, athersclerosis (hardening of the arteries), cancer, arthritis, and severe infections.

Danish and American researchers theorized that the anti-inflammatory effects of statins could improve outcomes for patients admitted to the hospital for pneumonia; those persons protected from over-exuberant inflammation by statins might be more likely to walk out of the hospital rather than being rolled out through a basement door on a gurney. They examined the hospital records for nearly 30,000 patients over 7 years looking for pre-admission statin use as correlated with the risk of sepsis and death associated with serious pulmonary infections. Indeed, those patients currently on statins had a 31% better chance of being alive 90 days after their pneumonia diagnosis compared with those in a statin-less state.

Wondering why? Dr. Kasturi Haldar of the Center for Rare and Neglected Diseases (I kid you not) informs us in an editorial in the same Archives issue that it's all about G proteins. Statins block the isoprenylation (whatever that is) of small G proteins. This decreased prenylation business protects against Alzheimer's disease because the beta-amyloid guck that gums of the brainworks in the disease depends on the breakdown of amyloid precursor protein, a process which in turn counts on prenylated G proteins.

In infections, little G proteins increase the inflammatory response which can fill the patient's airway with fluids and white cells instead of the air upon which we depend. G proteins might also promote the bacteria's ability to enter cells and prosper therein. As in Alzheimer's, as statins decrease the prenyl pool upon which G protein function depends, the decreased inflammatory response may reduce the inflammatory response.

So if you are ever called upon to weigh the decision of statins or not in your future health care plan, consider this side benefit of the use of these drugs.
_____
(1)Lipitor, Crestor, simvastatin, lovastatin, fluvastatin
(2) Thomsen, RW, et al. Preadmission Use of Statins and Outcomes After Hospitalization With Pneumonia. Arch Int Med Vol 168 (No.19), Oct. 27, 2008.

Skinceuticals C E Ferulic

2009-01-12T20:41:00.010-07:00

So what's Arlen Specter doing on my blog? Well, he's got those pouchy things going on on either side of his mouth. And that's my newest obsession--my little pouchy things where acne scars are coalescing with wrinkles. I googled Arlen Specterish pouchoid look and found TheDermBlog.com Well, actually not, I don't exactly remember what I googled but it was some combination of Vitamin C serum and aging skin. Topical vitamin C is known to stimulate collagen production, and collagen is the fibrous tissue that keeps your cheeks off your chin and your chin off your collar. And Dr. Benabio's excellent blog noted that this fern-derived antioxidant called ferulic, when combined with topical C, stablizes the latter and allows it to penetrate better into damaged skin. And he said someday soon, topical C plus ferulic would be available.

I am computer woman, see me google. Off to vitamin C AND ferulic arriving at Skinceuticals C E Ferulic Sample Size . What the heck, thinks I, it was on sale in December, so for $25, why not?

Fast forward to three weeks later, a patient told me today my skin looked great. "Good color," she said, "You look healthy!" Need I say more?

September, 2009 update: Still using CE Ferulic. A little goes a long way--one tiny sample body supplies nightly face application for over a month. Skin looking so good that my 20-something year old daughter noticed it and took one of my bottles for herself! Get your own CE Ferulic my dear!

Fat or not, the fit live longest!

2009-01-11T12:48:00.004-07:00

I mentioned in my previous post that exercise promotes immunity, just one more reason to dance as if your life depends on it. Exercise scientists set out to study the association between cardiorespiratory fitness, extra weight, and the predisposition to keel over dead in older adults. They enrolled 2600+ adults aged 60 or older in the Aerobics Center Longitudinal Study, poked, prodded, measured, and then watched their subjects' survival stats over 22 years. Here's what they found:

In conclusion, in this prospective study of adults 60 years or older, low fitness predicted higher risk of all-cause mortality after adjustment for potential confounding factors, including adiposity. Fit individuals had greater longevity than unfit individuals, regardless of their body composition or fat distribution...It may be possible to reduce all-cause death rates among older adults, including those who are obese, by promoting regular physical activity, such as brisk walking for 30 minutes or more on most days of the week which will keep most individuals out of the low-fitness category(1).

So here's what I hear: "I'm so discouraged. I've been working out for a month now and I haven't lost any weight." A couple of points: 1) Working out at the rate of 20 minutes on a treadmill 3 days per week is insufficient to promote fitness or weight loss, though theoretically it's better than nothing at all, and 2) If you are on the road to fitness with sufficient cardiovascular workouts, you are promoting good long-term health--and survival--whether or not you lose weight. All-cause mortality is just that, death from any cause whether it be heart attack, stroke, cancer, or sepsis from an overwhelming infection with some nasty, multi-drug resistant bacteria.

What's on your New Year's resolution agenda?
_____
(1) Sui, X, et al. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. JAMA 2007 Dec 5;298(21):2507-16.

ESBL E. coli

2009-01-09T18:38:00.011-07:00

My 60 year old patient needed help from two of us to walk from the waiting room into the exam room. Once there and lying down, her blood pressure was 78/40 and her pulse was 120. I was unable to check her 'postural' blood pressure (comparing values sitting to standing looking for a significant drop indicative of dehydration) as she kept losing her balance and her consciousness in the standing position. Long story short--once admitted to the hospital, her diagnosis was sepsis (invasion of bacteria into the bloodstream) from an overwhelming urinary tract infection caused by ESBL E. coli.

I'll admit, I hadn't heard of this bad boy before Ms. B. nearly died from her infection. Just looking at the culture & sensitivity report, however, was enough to make my heart sink. Cultures of her blood grew an E. coli species resistant to all but 2 antibiotics tested, and those two were 1) only availble by IV, and 2) did not even exist back when I was in training.
Beta-lactam antibiotics are named for a beta-lactam ring in their structure. They include penicillin whose discovery revolutionized the treatment of infectious disease, and cephalexin, the miracle drug discovered after many bacteria developed resistance to penicillins. Extended-spectrum beta-lactamase-producing E. coli (or ESBL E. coli) produce an enzyme (beta-lactamase) that destroys the beta-lactam chemical ring, rendering it useless against the little buggers.

ESBL E. coli has been a problem in Europe for awhile. Its 'extended spectrum' resistance (eats not just one but most beta-lactam antibiotics) is theorized to have developed due to the overuse of antibiotics in animals--particularly chickens--raised for food. More often found in health care institutions such as hospitals, ESBL E. coli is clearly now out in the community where my patient came into contact with it.

Ms. B. survived, barely. When she came in earlier this week with symptoms of weakness and urinary burning and frequency, we both thought...and feared...the same thing. The culture came back yesterday--ESBL E. coli. She cried and I shuddered, feeling like I was glimpsing our future in Ms. B.'s today.

Ms. B. did nothing wrong, nor do we know just what to do right to avoid such a super-infection. I'd suggest hand-washing, scrupulous handling of raw meat especially chicken, vitamin D, and hot, sweaty exercise as known, immune-enhancing strategies.

Red yeast rice revisited

2009-01-03T09:40:00.006-07:00

I sweat along with one of my fifty-something year old patients at weekly Jazzercise sessions. As a result, I know her elevated cholesterol levels have nothing to do with a lack of exercise. We have tried several statin strategies to lower her numbers. Alas, even using CoQ10 supplements, low alternate day dosing of Crestor, and statins less likely to enter muscle cells, all still result in unacceptable side effects for her. She has chosen to motor on without meds.

She recently told me that she was using red yeast rice supplements as a 'natural' way to lower her cholesterol. I asked her how she was feeling, did she have any muscle pain with the supplement? As a matter of fact, she replied, she did notice that. She was surprised to learn that insofar as taking a supplement made by the fermentation of rice with fungus was natural, a process through which Lovastatin is made, she was going natural. So she was actually taking low-dose Lovastatin in an unregulated sort of way, complete with a risk of toxic contamination by the metabolic byproducts of fungus feasting on rice!

If you are interested in supplements, and I certainly am, I recommend you invest $30 or so in an annual membership to consumerlab.com, where you can read reliable information on the science behind those OTC pills we take and the results of their testing various brands for content and contamination.

Conditioner for limp, pathetic hair

2009-01-01T19:40:00.007-07:00

No news to regular readers that my hair is a source of some angst to me. Progesterone cream helps to keep it on my head, but nothing was giving it that shine and manageability I sought. Conditioners, mousse, volumizer, sprays, gels...all gave me the dog-caught-in-a-rainstorm look. My neighbor/friend/hair consultant just sadly shakes her glowing bouncy locks as she trims my hair in about five minutes, says no product exists to improve this mane.

So, far be it for me to be a beauty consultant, but this tip is too good not to share. I was flipping through Health Magazine, checking "The best anti-aging secrets: Looking younger isn't all about serums, needles, and lasers. Here's 17 all natural moves." This is the same article that gave us the all natural move of chugging our coffee ASAP so as not to stain our aging yellowing teeth.

This was the #1 tip from Lisa Hedley, the founder and creative director of the Mayflower Inn & Spa:

Open Sesame (Oil): First thing every morning I massage organic sesame oil from the health food store all over my body. Working it in wakes me up and really gets my blood circulating. Plus the oil hydrates my skin, giving it a healthy glow. Then I jump in the shower--the oil naturally cleans away dead skin cells.

I thought that would be the sort of thing my daughter would enjoy--all that blood circulating and glowing in the morning. She said let's get real here, I'm not going to do that before I go to work. So I'm left with this bottle of sesame oil, and I'm sure as heck not going to smear it all over me pre-shower and risk falling in the tub and cracking my skull open. But...wait, I think, what if I massage it into my scalp, toss some coffee quickly past my pearly whites, then wash my hair? Couldn't hurt, maybe could leave a healthy hair glow?

Who'd'a thunk it? My hair is fabulous (in a relative sense)--soft, shiny, no frizz, no flyaway, no static. I'm sure it will be hard to keep my husband from running his fingers through it when and if he finally notices. Six bucks for 13 oz. of the organic stuff from King Soopers. I highly recommend it.

A lovely thought

2008-12-28T14:16:00.004-07:00

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.

What did Lotrel ACCOMPLISH?

2008-12-16T20:39:00.003-07:00

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.

Floppy Eyelid Syndrome

2008-12-13T13:48:00.006-07:00

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!

Medical advice from Whole Foods vitamin clerks

2008-12-10T23:45:00.005-07:00

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?

Ergonomic snow shovels

2008-12-07T19:03:00.008-07:00

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?

Exam room etiquette

2008-11-23T12:37:00.008-07:00

I'm currently reading Pursued by the Bear, a book by 70-something year old psychologist about his 8 year journey through the medical world in pursuit of treatment for 3 different kinds of cancer. Dr. Singer's book is both hilarious and insightful; I highly recommend it to you. A lot of the book explores the relationship between patients and doctors. Here's his take on exam room etiquette, and one of his only observations with which I take issue:

[The doctor] tells me to get dressed [and] leaves the room (you have noticed I am sure that doctors seem unable to tolerate you in the process of dressing or undressing? They don't have problems with you naked or very scantily clad, but the act of removing or putting on clothing seems to be too personal or obscene to be allowed in their presence. It's the action itself that seems off-putting to them. My theory is that in the act of dressing or undressing, your personhood, your humanity cannot be denied--you are someone doing something--I move, therefore I am. Naked you can be an object)...

I always meet my patients while they are dressed, invariably leave the room while they are undressing, attempt to examine them in a way that reveals only that part which I am currently inspecting, and always leave the room while they dress. While we are both dressed, I feel our 'equal partnership' status is intact. When they are undressed, I am very aware that this is an unusual and privileged interaction between two people, doctor and patient. While disrobing or re-robing, however, I feel like I have no business in the room, that, as Dr. Singer writes, the act is indeed 'too personal' though certainly not 'off-putting', and that to stay there would overstep the boundaries of our professional relationship. Once my patient is dressed, we once again enter our partnership agreement where I offer my knowledge and observations and ask my patient to consider with me the options for care.

Are you offended when your doctor scuttles out of the room after the exam is over? How do you feel about conducting the pre- or post-exam interview while still undressed and gowned?

Here's your iliac crest

2008-11-10T19:37:00.006-07:00

His-self: It was hard to find a picture of an iliac crest suitable for inclusion in a family-friendly blog, but at least this model left his Calvin Klein's on! It's that bone your thumb finds as you place your hands on your hips.

Waist circumference

2008-11-09T13:14:00.006-07:00

It's the new vital sign. Waisted fat (i.e. fat socked beneath the abdominal musculature and carried front and center like an unfolding pregnancy) is known to be a potent marker and cause of both cardiovascular and diabetic risk. While the ideal dimensions of a healthy waistline are in dispute, thus far 40 inches/102 cm. for men and 35 inches/88 cm. for women are cited as goal.

How to measure a waistline is a hot topic. In fact, the International Chair on Cardiometabolic Risk, an organization headquartered in Quebec City, established a sub-committee to review the existing medical literature on the subject and establish a waist circumference protocol. Let it never be said that we doctors don't take our tasks very seriously.

The expert panel reached two conclusions: 1) "It didn't matter" where you measured distended abdomens with respect to predicting mortality from diabetes, cardiovascular disease, or all other causes. If the silhouette looked apple-ish (think Tweedles Dee and Dum), that defined the problem, and the bigger the gut, the worse the risk. 2) They decided to establish a protocol nevertheless to put an end to the "mass confusion" that existed on the subject so that both providers and patients could measure midriffs and follow weight loss progress.

They concluded for purposes of simplicity that the top of the iliac crest (aka pelvic or hip bone located on the side of the body at roughly, well, the waistline!) was a good anatomic marker easily found by physicians and the public alike. And in a bit of good news, spokesman and sub-panel chair Dr. Robert Ross assures us that the bathroom scale may not be the first reporter of success in weight loss programs, but rather that waist circumference may fall in a reassuring and healthful sort of way before the pounds start to drop off.

Shingles shot

2008-10-27T20:24:00.004-06:00

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

2008-10-22T19:11:00.004-06:00

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

2008-10-16T18:51:00.003-06:00

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

2008-10-12T19:59:00.004-06:00

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

2008-10-10T22:07:00.007-06:00

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

2008-10-08T13:31:00.005-06:00

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

2008-10-06T19:49:00.007-06:00

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!
_____
(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

2008-10-05T16:24:00.007-06:00

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

2008-10-04T19:30:00.006-06:00

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.
_____
(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

Team players

2008-09-30T18:35:00.003-06:00

One of my good friends is in the hospital right now recovering from extensive abdominal surgery. She's doing beautifully, but, as expected after a 10 hour operation, the road back to health is slow and painful. Each morning, her 'surgical team' breezes through, asks her how she is feeling, then flitters out without really hearing the answer. Imagine their surprise when they announced that it was time to stop the IV pain meds, and she announced "I'M NOT READY!"

The surgical team scuttled out the door and discontinued the IV drip for pain.

One day later the 'psychiatry team' shows up. Team members are one unhappy-looking med student and one psychiatry resident. They ask permission to be there, permission to talk in front of me the visitor, but choose not a we're-all-just-human-here sort of opener such as "Geez, what a journey you've been on, how are you holding up?" Rather med student leads off with "Are you feeling a little anxious?" Hell yes, major surgery, slow discouraging recovery, still got chemo treatments left to go, what on earth do you expect... says my friend.

"Well," says Dr. Psych Resident, taking charge, "your team asked our team to come in and find out why you're anxious." I kid you not, and he said it with a straight face. He continues, "They wondered what the problem was."

The problem? That one team needs another team to find out why a post-operative patient in pain reacts strongly to a surgeon who won't listen to what she says.

Denosumab

2008-09-21T17:17:00.012-06:00

Current choices in therapy for osteoporosis are something short of satisfactory. Estrogen works well but many women are reluctant or unwilling to take it for long due to its association with increased risk for breast cancer when used over a period of years. The bisphosphonates-- Boniva, Actonel, Reclast, and Fosamax-- are a good, non-hormonal choice if you don't mind taking a pill on an empty stomach 1/2 hr. before eating in the a.m. then sitting bolt upright 'til breakfast so the drug won't cause acid reflux and heartburn. Evista works but may give you blood clots or hot flashes, and Forteo is a dandy boost for way low bone density if you're o.k. with a daily shot.

Thank heavens, a new choice is moving through phase 3 studies on its way to the old gal market (guys can get osteoporosis too, but their major problem now is that no one thinks to check them for it). This medication, denosumab, is a selective inhibitor of receptor activator of nuclear factor-B ligand (RANKL). No surprise that a ligand know as RANKL is the cause of our skeletal woes joining the ranks of other things that rankle in our golden years--thinning hair, receding gums, falling arches, and teen-aged boys.

Here's the scoop. RANKL is a protein made by osteoblasts or those cells in charge of making new bone cells. RANKL hooks up with RANK to activate the RANKL-RANK pathway which then activates osteoclasts or the cells that break down bone. This whole bone thing is a regular Ecclesiastesian cycle, all this building up and breaking down at the right time and right place. When your season turns to menopause, however, the balance shifts, and suddenly you're breaking down via osteoclasts more than you're building up via osteoblasts.

Enter denosumab, a human monoclonal antibody that grabs the RANKL before it can grab the RANK. In doing so, the drug acts like osteoprotegerin(OPG) which was the normal RANKL inhibitor back in the day when you didn't need to worry about the state of your bone density. Apparently, both estrogen and Evista increase levels of OPG whereas denosumab has a biological activity equivalent to it.

So what do you have to do to be on denosumab? Get up early, stand up straight, endure hot flashes, worry about your breasts? No, none of that. Denosumab is administered as a shot twice a year, a shot under the skin no less, not like one of those stingy tetanus jabs into your deltoid muscle. Here's what lead investigator Steven Cummings, MD had to say about that: "it's a whole lot easier . . . to give what is essentially [like a] flu shot."

Panic attacks and menopausal women

2008-09-11T19:51:00.005-06:00

The first time I had a panic attack, I assumed that my heart rhythm was abnormal, and that was why I felt like I would lose consciousness as I drove to Boulder. By the second panic attack, my educated guess was that a tumor was pressing on my trachea, and that was why I could not draw a deep breath and might have a seizure at the wheel. Needless to say, driving after my snowy day collision with a moving van became a bit of an ordeal. As a result of my experience, I know that panic attacks are not about an anxious fear that you might die but rather a strong bodily feeling that you will die.

I was interested, therefore, to read a study in last year's Archives of General Psychiatry about cardiovascular outcomes in postmenopausal women who suffer from panic attacks. Panic attacks are common among women in this age group (although mine occurred over a decade ago). Researchers collected data from nearly 3400 women who participated in the Women's Health Initiative Observational Study.* The women self-reported whether or not they'd experienced panic attacks over a 6-month period, then they were followed for the occurence of coronary heart disease (CHD), stroke, or death in the next 5 years.

A 6-month history of full-blown, real deal, I-can't-get-a-deep-breath or I'm-going-to-die sort of panic attacks was significantly correlated with both outcomes in a scary sort of way. The women demonstrated a 4.2 fold increased risk for CHD, a 3.08 increased risk for the combined outcome of CHD or stroke, and (yikes!) a 1.75 times increased risk that those subjects who ducked heart attack or stroke would die of any other thing.

No surprise, panic attacks are awful, and they simply are not good for you.
_____
*Participants in the WHIOS were those women who either were not eligible for the hormone portions of the WHI but agreed to provide investigators with other information about their lifestyles and health outcomes. This particular sub-study was the Myocardial Ischemia and Migrained Study.

Zetia and cancer

2008-09-05T19:45:00.008-06:00

So first we find out that maybe Zetia (ezitimibe) isn't all it's cracked up to be. In an earlier study of patients with familial hypercholesterolemia--as in big-time LDL-cholesterol elevations of 300 and beyond-- the addition of Zetia to Zocor, a combination also known as Vytorin, did not slow down progression of arterial disease as measured in the carotid artery. Worst case scenario, we thought, was that Zetia wasn't really much use, and perhaps, we theorized, these high LDL patients do not represent our typical everyday high cholesterol patients so why compare outcomes in the one to clinical courses in the other?

Until now. Just out this week in the New England Journal of Medicine are the results of the SEAS trial(1), as in Simvastatin and Ezetimibe in Aortic Stenosis. This study compares the use of Vytorin to placebo in old folks with narrowing of their aortic valves. Mattered not in these elderly valves whether the owners used Vytorin with respect to progression of the stenosis or cardiac disease in general. What mattered, however, mattered a lot in fact, is that the seniors randomized to active treatment were significantly more likely to get cancer and borderline more likely to die of it.

In this same issue of the NEJM, another group looked at cancer data from two other Zetia studies. After studying the combined data from these larger, ongoing trials, they concluded:

There was no overall excess of cancer (313 active-treatment vs. 326 control) and no significant excess at any particular site. Among patients assigned to ezetimibe, there were more, albeit not significantly more, deaths from cancer (97, vs. 72 in the control group; P=0.07)... The available results from these three trials do not provide credible evidence of any adverse effect of ezetimibe on rates of cancer.

Oh gad, now what to do? An accompanying editorial theorizes that Zetia might not only interfere with the absorption of cholesterol but also other molecules that affect the growth of cancer cells. And the doctors conclude: "Physicians and patients are unfortunately left for now with uncertainty about the efficacy and safety of the drug."

I think I'm done with Zetia.
_____
(1) Rossebø AB, Pedersen TR, Boman K, et al. Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis. N Engl J Med 2008;359. DOI: 10.1056/NEJMoa0804602.

Endothelium

2008-08-30T20:20:00.012-06:00

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

2008-08-19T14:55:00.012-06:00

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"

2008-08-16T16:31:00.007-06:00

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

2008-08-09T19:08:00.003-06:00

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.

Overactive bladders

2008-07-26T12:55:00.009-06:00

This posting is not really about twitchy aging bladders that can't hold their own against a simple cup of coffee without whining uncomfortably for attention, but rather about the effect those frequent signals to head for the head have on our already addled brains.

Here's how the bladder connects with brain. That 'gotta' go now' message is sent to Barrington's nucleus, the brain center in charge of bladder contraction and urination. But no simple reflex here; rather than just send back a simple command to let 'er rip or hold on a moment dear, Barrington's nucleus feels compelled to tell the locus ceruleus all about it. This is the area in our noggin in charge of arousal and attention. I guess it makes sense because someone's got get up, find the loo, and transport the bladder there to do its business.

So researchers in Pennsylvania asked a group of rats to participate in an experiment wherein their bladder outlets were surgically narrowed to mimic an obstructed or overactive bladder(1). While Barrington's nucleus showed decreasing activity in the obstructed rodents compared to a control group (which may explain why people with OAB leak without knowing it until it's too late), the obstructed group demonstrated a hyperactive locus ceruleus.

Because the locus ceruleus is connected to the cerebral cortex, an area in charge of thinking, mood, and memory, the Philadelphia investigators conjectured that this hyped up bladder thing ultimately could affect behavior in an adverse sort of way. Indeed, the poor blocked-up rats brain activity consistent with chronic hyperarousal as seen in persons feeling anxious or stressed. And when the rats with obstructed bladders slept, their brain activity showed theta waves associated with restless sleep.

Researchers concluded: "Overactive bladder as a result of partial obstruction is particularly prevalent in the elderly, a population that is also vulnerable to neurobehavioral deficits and sleep disturbances. The present findings suggest that this visceral dysfunction may contribute to neurobehavioral and sleep deficits in this population."

Of course, surgically obstructed male rats are one thing, and aging women with overactive bladders quite another, but OAB may be just another brick in the deteriorating wall of our aging brains.
_____
(1)Rickenbacher, E. et al. Impact of overactive bladder on the brain: Central sequelae of a visceral pathology. Proc Natl Acad Sci U S A. 2008 Jul 21. [Epub ahead of print]

Diastolic dysfunction

2008-07-14T17:58:00.007-06:00

The diagnosis of diastolic heart failure, unfortunately, is often missed by unwary physicians.
---heartdisease.about.com/od/livingwithheartfailure/a/diastolic_HF.htm

Before I say more than a few words about diastolic dysfunction, I want to note that I am mostly not unwary. Who'd want to go to an unwary physician anyway? I will admit, however, that I was a little unwary regarding the consequences of diastolic dysfunction, but I am no longer so. Here's the scoop.

If diastolic dysfunction is a new one to you, I'm here to tell you it was not part of my original medical education. When I learned about heart function gone awry, it was all about a delivery deficiency. In other words, a failing heart is unable to squeeze out sufficient blood with each beat. As a result, tissues receive less oxygenated blood, the lungs receive less blood to oxygenate, blood backs up as it waits for its turn to pass through the stressed-out heart, and the lungs, liver, and legs fill with fluid. All this is now known as systolic heart failure or a failure of the heart to adequately eject blood during contraction aka systole. What a messy fluid build-up and lack of blood flow results from systolic heart failure after heart attacks, viral infections, rhythm disturbances, or alcohol toxicity among other things.

So several years ago, I started seeing 'diastolic dysfunction' showing up on echocardiogram results. "What on earth," I asked my friends the cardiologists, what were they seeing on ultrasound examinations of the heart that qualified as an abnormality of the relaxation phase of the heartbeat.

Whereas systolic dysfunction is a delivery problem as noted above, I learned that diastolic dysfunction is an acceptance problem. Once blood is squeezed out during systole, the heart relaxes to accept a new load of blood in preparation for its next beat. The heart muscle slackens, the mitral valve opens, and blood rushes in to the big chamber known as the ventricle. Just to get that extra kick, the top chamber known as the atria squeezes a bit more in just before the ventricle begins to contract once again. If the ventricle is stiff, however, from years of working out against high blood pressure, diastole does not go so well. The ventricle is unable to accept as much blood.

Early on in diastolic troubles, that last atrial squeeze gets the heart volume up to normal. The patient motors on oblivious to the chaos brewing in his/her overworked heart (Naw, Doc, I don't check my blood pressure. I feel fine.) Then stiff becomes stiffer in a ventricular sense, and the heart no longer fills with enough blood to meet the demands of exercise. Fluid begins to back up in the lungs when the patient tries to mow the lawn or go for a walk. The volume overload in the lungs creates pulmonary hypertension which further accelerates the diastolically failing heart thing.

What brought this all to my mind? One of my patients, younger than me, came in with swollen legs. She's a skinny lady, so her edematous ankles were particularly alarming. She has an unfortunate history of hypertension, high cholesterol, smoking, and an inability to exercise for years due to a back injury. Her echocardiogram showed that her heart was pumping okay but she had serious diastolic dysfunction and severe pulmonary hypertension. As if this was not sufficient trouble, her chest x-ray shows one side of her diaphragm is paralyzed, so we are currently looking for a possible lung cancer high in her lungs squashing her phrenic nerve.

So that is why I: 1) ask my patients not to smoke, and 2) press them to keep after their pressure.

Family and fiber: Colorectal cancer risk

2008-07-05T15:31:00.006-06:00

I'm always recommending a screening colonoscopy to my patients 'of age,' after all, I had one, therefore, so can they. Here's the top two excuses (after 'I'm a chicken' and 'I'm embarrassed') that people give me for not undergoing this important screening test, and here's what I have to say to them:

1) No one in my family has colon cancer. While having a first degree relative (parent or sibling) with a history of colorectal cancer (CRC) increases risk 2-fold, 80% of persons who get CRC have no such family history.

2) I eat a high fiber diet. Boston doctors undertook a prospective study of nearly 89,000 women ages 34-59 in 1980.(1) They found no association between dietary fiber intake and the risk of CRC during 16 years of follow-up.

One might raise the question, as did Dr. Neil Raven(2), as to what really constitutes a high fiber diet. He responded to the above study in a letter to the editor wondering if the flaw in the study's design might not be that Boston women who say they eat high fiber aren't really as fiber-filled as they think. He cited information from Dr. Denis Burkitt, a physician who spent time in West Africa studying lifestyle and disease. Per Dr. Raven:

Burkitt began his lecture with a slide showing a stool of a typical Western, "civilized" person, a sausage-shaped thing, familiar to most of us, in a toilet bowl. His next slide was of a stool of a typical rural West African, which looked like a flat cow pie. Burkitt postulated that the West African's stool moved more quickly through the colon, giving carcinogens contained on its surface less time to be in contact with the mucosa — thus less time to induce carcinogenesis.

During the question-and-answer period, many questions from the audience concerned how one determined whether or not a diet was high in fiber in the sense Burkitt meant. Burkitt shook his head at all the salads, cereals, and breads offered as sources of fiber. He showed a slide of the staple cereal eaten by West Africans, which looked, in its wooden bowl, not too different from the stool that came out the other end. The only thing the study by Fuchs et al. proves is what anyone who heard Burkitt's lecture already knew: the American public has been sold a sugar-coated misconception.
_____
(1)Fuchs, CS et al. Dietary Fiber and the Risk of Colorectal Cancer and Adenoma in Women. NEJM Volume 340:169-176 January 21, 1999 Number 3.

(2)Raven, ND. Dietary Fiber and Colorectal Cancer. NEJM Volume 340:1924-1926 June 17, 1999 Number 24.

"The middle of my foot hurts"

2008-07-01T20:37:00.002-06:00

My old arch is falling down (click on image; watch it throb!)

"Have you ever heard of Liz Franks?" the octagnenarian asked me, waving her foot in the air.

"Yeah," I said slowly, "I've heard of it [her?!?]. My voice screamed 'haven't a clue,' but my patient proceeded with her story.

"The middle of my foot hurts sometimes when I walk. The PA at my podiatrist's office says it's a Lisfranc injury and it has something to do with a separation in the bones of the feet. He told me that's why my foot hurts and the top of it swells."

Ah, yes, Lisfranc's as in Lisfranc's fractures. And now I had the entire Lisfranc's file open in my brain and the sum total of its contents revealed in those three words.

I looked it up later on the Internet, and learned that Doc Lisfranc was a field surgeon in Napolean's army, and the joints named after him are in the midfoot where the long bones or metatarsals below the first and second toes meet the various bones under the ankle. Wang, whoever he is, has seriously injured his and won't be playing for the Yankees for awhile. On average, Lisfranc's injuries occur abruptly and dramatically in athletes or in those who've fallen from great heights or been injured in car accidents. Lisfranc joints can be subtly sprained in athletic endeavors.

In no case, per my search, do Lisfranc dislocations or fractures occur in little old ladies who now and again get pain whilst walking. Pain in the midfoot of the aged is either midfoot impingement syndrome or degenerative arthritis of the middle of the foot including, perhaps, the Lisfranc joints.

The midfoot is the highest point of the arch. As we age--and by we, I definitely include me--the arch sags or just plain goes to ground causing the bone ends to crash into each other in a painful, unsupported sort of way. As a result, with each weight-bearing step the bone ends grind together. This daily grind, over time, wears down the joints causing degenerative or osteo- arthritis.

While merely impinging on one another's space, this bone on bone action causes episodic pain with weight-bearing activities. Once arthritic, the pain is more consistent, and the entire top of the foot can be painful and swollen. As with all archless conditions, standing in bare feet aggravates the pain; I advise all my flatfoots--including myself--to immediately slip their aging feet into arch-supported clogs or sandals on rising in the morning. Good Feet has a lightweight orthotic perfect for wearing with open-toed shoes.

And, as you may know, I am also a great fan of YogaToes, the plastic toe separators, which pull the toes and their metatarsal bones out of each other's face and space.

Enduring love or just never letting go?

2008-06-29T13:14:00.007-06:00

When it is our time to grieve, we must live each day as it comes,
dealing with both the mundane routine of living and our inner struggle.
Grieving and living through the entire experience of bereavement will
change us, and if we do it well, the change will be for the better. We
know we are becoming whole when we can look to the future with some
readiness to engage once more.
--Carolyn Jaffe "All Kinds of Love: Experiencing Hospice"

Grief, of course, has been a part of my life and thoughts this past year, both during the final months of my mother's life and the time since she died in late March. I have been surprised at the ease with which I've made this transition since her death, realizing though that she and I had ample time to say good-bye and knowing that she was ready to exit when she did. Interesting research from UCLA(1) suggests that those who experience what is termed 'complicated grief'--defined as feelings of loss that are so overwhelming that the person is debilitated and unable to resume normal life--have characteristic patterns of brain function underlying this show-stopping state of mind.

Psychologists there studied a group of women who'd experienced the loss of a mother or sister in the previous five years. The subjects were classified as either complicated or noncomplicated grievers. Using functional MRI imaging (fMRI), a technique that can identify which parts of the brain are actively at work, the researchers found that all the women lit up their pain centers when they viewed either pictures of their loved ones or words related to loss. Neutral words or pictures of strangers did not elicit this response.

They were surprised, however, to discover that those women suffering from ongoing complicated grief also activated the nucleus accumbens area of the brain. This region is the neurological command center for experiences of pleasure and reward. While it is unclear why this occurred, lead researcher Dr. Mary-Frances O'Connor theorized that intense attachment in complicated grief activates reward centers in ways similar to that experienced by contact with the loved one before death occurred. Those with fMRIs lit up in reward centers all reported 'yearning' but there was no correlation with the time that had passed since the death.
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O'Connor, MF, Craving love? Enduring grief activates brain's reward center. Neuroimage 2008 May 10. [Epub ahead of print]

Just ashed my Mom...

2008-06-24T20:31:00.006-06:00

and she knew that this was a great final resting place. She started life in Leadville, Colorado, and arrived back there on June 21, 2008, her 88th birthday!

Aromatase inhibitors and body aches

2008-06-17T08:02:00.006-06:00

Many breast cancers behave enough like normal breast tissue that they are stimulated to grow in the presence of estrogen. While premenopausal women produce most of their circulating estrogen in their ovaries, the postmenopausal set converts androgens (male hormones) from their adrenal glands into estrogen via the aromatase enzyme.

For that reason, the risk of recurrence of estrogen receptor positive breast cancers can be reduced by either blocking cellular estrogen receptors with tamoxifen or preventing the production of estrogen with aromatase inhibitors. In fact, use of drugs such as exemestane (Aromasin) or letrozole (Femara) over 5 years has been shown to improve disease-free survival compared with 5 years of tamoxifen therapy.

Unfortunately, some women do not tolerate therapy with aromatase inhibitors due to joint pain. This discomfort may be due to the effects of lack of estrogen on tissues of the musculoskeletal system similar to the body aches experienced by some women as they enter menopause. Here's an excerpt from a March, 2008 issue of JAMA as one woman describes her experience with Aromasin:

As planned, I switched to taking exemestane [from tamoxifen]. But while taking it, I was feeling like I was a hundred years old. When I got up in the morning and opened my hands, all my joints would be sore and my arms hurt. All of my joints felt creaky. I started thinking, why should I stay on the exemestane for another 2 1/2 years? Why am I doing this to myself? So I called my doctor and asked him to switch me back to tamoxifen.

Of frogs, princes, shoes, and feet

2008-06-10T19:25:00.003-06:00

One of my favorite books whilst growing up was an illustrated version of Grimms' Fairy Tales. Contrary to popular belief, the princess in the tale of The Frog Prince was so sickened by the attentions of the slimy frog that she "...picked [him] up with her finger and thumb, carried him upstairs, and put him in a corner." When he came creeping up requesting a spot beside her in bed, "she felt beside herself with rage and, picking him up, she threw him with all her strength against the wall, crying 'Now will you be quiet, you horrid frog?'"

So what's this got to do with horrid feet? I've been vainly attempting to replace my broken down not-so-New-Balance exercise shoes. Alas, New Balance no longer makes that model, so I must've tried on a dozen pairs of other NB styles at DSW's Denver store. Thank heavens the help pays you no mind there, because I was close to heaving a shoe or a salespunk, which one mattered not, at the wall. I left with sturdy Easy Spirit slip-ons, but no go-fast shoes.

Today, I scored by stepping out of the NB box into Balance shoes (that's Balance with a backwards B that looks like d that rhymes with c that stands for made-in-China comfort). Danced my heart out at Jazzercise an hour later with no pain at all.

The moral of my story is don't settle for sore feet. Try rolfing, neurokinetics, orthotics, Yoga Toes, orthopedists, and kiss as many shoes as you need to so that your feet can carry your heart, brain, bones, and muscles intact to the finish line.

Lipotoxicity

2008-06-04T19:13:00.005-06:00

It starts with ectopic lipid deposition. Don't you just hate that--looking for fat in all the wrong places...and finding it? But we're not talking thighs, waists, and back ends here, but rather heart, muscles, liver, and pancreas.

Researchers theorize that our overconsumption of lipid-rich foods results in oversecretion of insulin. As a result, our livers produce too much sterol response element binding protein 1c (you might know it as SREBP-1c) which results in that organ gearing up to take those extra calories and turn them into fat molecules called triglycerides. Great gobs of these calorie-dense triglycerides then float through the bloodstream on their way to some storage depot where they will sit waiting for the coming famine that never comes. It's merely annoying to wear the extra fat in rolls about your waist, but it's downright toxic to stow them in your heart, muscles, liver, and pancreas.

Ectopic fat, i.e. triglycerides stored in all the wrong places, results in a world of metabolic trouble with a capital T that rhymes with D that stands for diabetes. Once in muscle cells, the fatty acids cause the muscle tissue (our biggest bodily consumer of sugar) to resist the actions of insulin, thus preventing the uptake of sugar out of the bloodstream and into these cells.

Fat stowed in pancreatic cells further amplifies this metabolic mess by killing off the very cells that make insulin. When the human body goes one Big Mac over the line, therefore, we not only eat fat but our liver makes more fat, our muscles become insulin resistant, and our pancreas are rendered less able to make more insulin.

Too much fat in, too much fat made, too much fat stowed in the wrong places. The lipotoxic effects of overeating, the lipocentric theory of diabetes. Two lessons: 1) Don't ignore the high triglyceride levels on lab panels--they're a huge red flag that you're on the way to diabetes, and 2) Don't discount the enormous value of any weight loss, even a little, with respect to preventing and treating diabetes.

Young@Heart

2008-06-01T21:07:00.005-06:00

Want to smile and feel good about growing older? This movie is about remarkable old people in a singing group. Remarkable not because they've aged without physical ailments but rather because they've aged with spirit and humor despite their infirmities. The documentary follows them through the initial rehearsals to their sold-out performance with interim stops for a show at a local prison, and several trips to hospitals.

I need to find a singing voice and a fifty-something musical director in 20 or so years so I too can be young@heart.

Sleep apnea and memory problems

2008-05-28T17:57:00.002-06:00

You snooze, you lose. Neurons, that is, in charge of memory function, lost when you go apneic (quit breathing) while sleeping. Check out the details at Menopause moments.

Highways, blood vessels, and indoor air

2008-05-27T12:36:00.004-06:00

A lot of research suggests that particles from outdoor air affect vascular function, especially at high doses. We wanted to see whether the concentration of airborne particles in a regular, normal home would be sufficient to cause similar effects, so we removed them, and indeed we found they had [adverse] effects.
---Dr. Steffen Loft, University of Aarhus, Denmark

The air here in central Denver hangs heavy in the winter and is downright visible in the summer. If ever I deluded myself in thinking that staying indoors protected me and mine from the crap in our air, Dr. Loft has proven otherwise.

Loft and company studied a delegation of Danes living near heavily trafficked roads(1). These old folks, ages 60 to 75, spent four consecutive days in their homes-- two breathing high-efficiency particle-air (HEPA) filtered air and two without. The filter removed 60% of the resident schmutz in their air and improved their flow-mediated dilation (FMD or FMV) by more than 8%. FMD is an indirect measure of the healthy function of blood vessels.

Is 8% a significant boost to vascular function? Again, per Dr. Loft: "...I believe people with overt, severe cardiovascular disease have a reduction in microvascular function in the region of 30% to 40%. I think this improvement is something like what you might expect from a well-working drug."
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(1)Brauner EV, et al. Indoor particles affect vascular function in the aged. An air filtration-based intervention study. Am J Respir Crit Care Med 2008. 177:419-425.

Yoga Toes vs. a Trip to the Orthopedist

2008-05-21T20:14:00.009-06:00

They both cost me roughly the same--about $45. The former got me two clear plastic toe separators with a lifetime guarantee against breakage. The latter got me 5 minutes of his time, plus assurances that 1) my flatfeet were the source of my pain (I knew that) and 2) my posterior tendon was not hopelessly and permanently stretched (I didn't know that, but hoped it was true).

Here's my conclusion after one month of Yoga Toe workouts (stick your toes into the Yoga Toes, lie down, watch TV). Spend your money on them and skip the copay for the overpriced specialist. Compare and contrast:

December, 2007, I walk 5 blocks to an antique/thrift store on Colfax Avenue. My feet hurt so much that I wonder if I'll be able to make it home. No cell phone along on my retail adventure, so no choice but to hobble home.

May, 2008, I visit the Black Hills of South Dakota and scramble up a steep slope for 25 minutes to take in the breathtaking view (and try as I might, I can't make the guys there on Mt. Rushmore come through). I skid down (on feet not back end) and walk briskly back down the path to the car. No pain at all.

Lovaza

2008-05-15T20:13:00.003-06:00

"And I'll need a script for Lovaza..."

Dang, one of those humbling moments. What on earth is Lovaza? Should I just ask or should I excuse myself for a moment on the pretext that I need a new prescription pad, then look it up quickly in the PDR? Well, by hook or by book, I found out what it was.

Lovaza is Omacor. Omacor, by any name, is a high potency omega-3 fatty acid supplement, but that particular name was entirely too similar to Amicar, a drug used to prevent or treat serious bleeding in hemophiliacs. Not that anyone would have trouble reading my writing, but if they should, that's a heckuva mistake to make.

I always ask my patients about the supplements they take during their annual exams. As a result, I know that most everyone is on to the fish oil fad instead of the previously top popular vites C & E. Research suggests that use of these oils can prevent sudden cardiac death(1), decrease risk of Alzheimer's disease(2), improve the mood(3), and lower triglycerides.

So why pay for fancy prescription strength Lovaza when you could do a 3 for 1 deal at Puritan.com(current sale price)? The two products have similar EPA and DHA content--one capsule of either the OTC or rx variety has roughly 1,000 mg of these worthy fatty acids which is the recommended dose for persons already diagnosed with coronary artery disease. Patients with elevated triglycerides (blood fats) should consider a daily dose of 4,000 mg.
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(1)Is it death or tuna casserole deficiency?
(2)Be the right sort of fat head
(3)Fishing for a good mood

Cough CPR

2008-05-14T20:03:00.002-06:00

If you're like me, you've received multiple copies of the e-mail that sings the praises of coughing your way out of cardiac arrest. The method remains controversial and has earned itself a place on "urban legend" web-sites. A Polish cardiologist, however, continues to investigate the method and would like to pull it out of the mythic category into everyday practice.

Sudden cardiac death caused by rhythm abnormalities of the heart which cut off circulation to the heart and brain takes out 300,000 Americans each year. Dr. Tadeusz Petelenz notes that patients have a 20-30 second prodromal period prior to pitching marked by dizziness, shortness of breath, nausea, sweating, and weakness. If properly trained, a quick thinking cardiac patient can launch into cough CPR, maintaining consciousness long enough to call for help.

Animal studies support the physiology behind this maneuver. Forceful rhythmic coughing causes an upswing in pressure through the chest cavity. With each cough, blood is squeezed out of the lungs, back through the heart, and into blood vessels serving important organs such as the brain. With each deep inspiration between coughs, blood zips back through the right heart chamber and into the lungs and the coronary circulation.

Over 100 of Dr. Petelenz's at-risk patients were taught cough CPR and successfully hacked their way out of nearly 300 prodromal events. They required medical assistance through 73 events during which they were unable to cough up their blood pressure. Doubtful colleagues at the Annual Congress of the European Society of Cardiology objected that there was no coughless control group, but who would want to be assigned to that bunch of deadbeats now that Dr. P. has fair evidence that it works? If I were a patient at high risk for sudden cardiac death, I'd rather cough than wait to see if this prodrome was the big one.

Carotid bruits

2008-05-11T12:07:00.004-06:00

We're always looking for an easy-to-use, 'crystal ball' of a test that will predict cardiovascular risk. Since we can't actually visualize the blood vessel walls, we use 'surrogate markers' that are more or less associated with unwanted future outcomes like stroke and heart attack.

The carotid arteries are well-placed for easy access as they head upwards through the neck on either side of trachea. Not only does atherosclerotic narrowing in these essential vessels increase risk for embolic stroke (where little bits of clot and cholesterol guck break off from the walls and block the blood supply to parts of the brain), the health of these vessels is a good predictor of overall vascular health.

Thickening of the carotid walls known as intimal-medial thickness or IMT is a known risk factor for heart attack and stroke. Although this can be measured without actually needling these big old arteries, and thank heavens for that, carotid ultrasound technology is not readily available in the average PCP's office. Advancing age, LDL-cholesterol levels, and diastolic blood pressure(1) are good current predictors of IMT thickening(2). These measurements can be used then as surrogate markers raising suspicion that a person rating high in all three areas might well have carotid artery disease.

The latest issue of The Lancet confirms that another test easily performed on aging persons during their annual physical provides additional cardiovascular risk assessment. Around the age of 50 or so, I begin to feel for normal pulsation in the carotid arteries (but not both at once as bilateral pressure on these vessels can induce fainting!) as well as listen with my stethoscope for the unwanted, rhythmic whish of a carotid bruit that occurs as the heart contracts and sends a surge of blood through narrowed old carotids.

Doctors from Walter Reed Medical Center analyzed data from thousands of carotid arteries and their attached humans with respect to risk of heart attack with or without death in follow-up. Those whose carotids hummed at outset were twice as likely to have a heart attack in the 2-7 years that followed, and had nearly thrice the risk of cardiovascular death.

So ask your doc to check up your neck at your next physical.
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(1)Diastolic pressure is the lower reading on blood pressure measurement which measures the amount of pressure in your blood vessels as your heart relaxes in preparation for the next beat. The upper or systolic number is the pressure generated as the heart contracts. Diastolic hypertension is also a known risk factor for abnormal thickening of the heart wall.
(2)Davis, PH, et al. Carotid Intimal-Medial Thickness Is Related to Cardiovascular Risk Factors Measured From Childhood Through Middle Age. Circulation. 2001;104:2815-2819.
(3)Pickett, CA, et al. Carotid bruits as a prognostic indicator of cardiovascular death and myocardial infarction: a meta-analysis. The Lancet. 2008; 371:1587-1594.

Methylfolate and depression

2008-05-06T18:48:00.010-06:00

...or how to B undepressed.

Folate is a B vitamin that occurs naturally in green leafy vegetables. It plays a host of important roles in the human body, and is so essential to the proper construction of the nervous system of a developing human that the FDA mandated in 1996 that its synthetic form--folic acid--be added to breads, flours, and other grain foods.

The trouble with folic acid supplementation or even naturally occurring dihydrofolate from food sources is that the body must convert them into the active form which is L-methylfolate (known as MTHF--yes, I thought of that word too the first time I read it). Some people are better MTHF producers than others. For purposes of our discussion, we will focus on the effects of MTHF deficiency and the fully developed brain.

The brain is tightly guarded by the 'blood-brain barrier.' Certain molecules can't pass through the blood vessel walls into brain tissue, and folate is one of them. MTHF, on the other hand, slips right in, and a right good thing it does because it is an important co-factor in producing the three most important neurotransmitters involved in mood regulation. If you're low on MTHF, studies suggest that you may subsequently run low on dopamine, norepinephrine, and serotonin. We're talking transmitters with a capital T that rhymes with D that stands for depression.

A host of research shows that supplementing methylfolate--thus skipping the necessary internal steps to activate folic acid--improves depression under a host of circumstances. This being an older person's health blog, let me illustrate with one study which supplied sad, old people with MTHF.

Researchers coaxed 20 elderly people who were not only Italian but also depressed to take 50 mg daily of MTHF rather than antidepressants. Four said the Italian equivalent of 'what's the use' and quit. The remaining subjects showed significant improvement in their depressive symptoms.

But you don't have to be old to enjoy the potential mood elevation of MTHF. A product called Deplin is now available by prescription and specifically indicated for use in patients having a less than stellar response to antidepressants. Theoretically, it might also be useful for persons with mild mood disorders not on other medications.

The basic science literature supporting the theory that MTHF improves brain function is large, but clinical research, except for the random Italian or so, is sketchy. Thus Deplin has been designated a 'medical food' which apparently does not have the stringent proof requirements of prescription drugs. Nevertheless, no adverse effects of MTHF supplementation have occurred, and a downloadable coupon at deplin.com makes this an affordable gamble of a therapy.

Menopause moments

2008-05-03T20:40:00.002-06:00

Milk in the cupboard, cornflakes in the 'frig. Women of 'a certain age' find these moments infinitely amusing...and definitely scary. Are we overwhelmed, inattentive, out of estrogen, or slipping down the road to dementia?

I invite you to check out my newish blog Menopause Moments. Share a momentary brain lapse that made you laugh, then read the latest research about what constitutes a menopause moment (aka senior moment), and what you can do to assure that yours will never become a permanent state of mind.

Unipedal standing

2008-05-02T18:51:00.005-06:00

Less scholarly, perhaps, to just call it standing on one foot. Unipedal or onefooted, these Japanese orthopedists wondered if a daily balancing act might make old people less prone to pitch to earth and break their hips(1).

During their six month study, they divvied a pack of old folks at high risk of falling into two groups. The test subjects stood on one foot, then the other, one minute per side for three sessions each day. The other group just stood their ground in the usual manner.

Dr. Sakamoto previously calculated the load-bearing effects of stork-like posturing on the femoral head(2) or that part of the hip bone connected to the pelvic bone. This area is susceptible to loss of bone density and fracture when an old person goes to ground. He concluded that unipedal standing placed a load equivalent to 2.75 times the body weight on the involved femoral head, and one minute of time spent doing so was the equivalent of 53 minutes of walking with respect to benefits to bone density.

Let's see, one minute per side x 3 sessions per day equals six minutes of balancing acts vs. 318 minutes of walking. Well, how would you rather spend your discretionary time?

Alas, either six months is not long enough to determine the benefits of unipedal standing on old Japanese fogies, or you can't fool Mother Nature. At the end, there was a sort of significant decrease in falls in the test group compared to controls, and only one hip fracture in both groups.

I don't know whether I'm going to do this or not. Maybe if I could wear my Yoga Toes while balancing and thus do all my weird self-trials at once.
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(1)Sakamoto, K et al. Effects of unipedal standing balance exercise on the prevention of falls and hip fracture among clinically defined high-risk elderly individuals: a randomized controlled trial. J Orthop Sci. 2006 Oct;11(5):467-72.
(2)Sakamoto, K. Effects of unipedal standing balance exercise on the prevention of falls and hip fracture. Clin Calcium. 2006 Dec;16(12):2027-32.

Thanks to Jacob Schor, ND and his always excellent newsletter for calling my attention to these articles. You can subscribe at denvernaturopathic.com.

Stowed St. Francis in snow

2008-05-01T19:46:00.005-06:00

Mom's St. Francis statue in his new home in Colorado Springs. Looks right at home, doesn't he? That snow is right here, right now, in not-so-sunny Colorado.

Photo courtesy of Tobi.