Aching feet in Denver, Colorado

As a primary care doc, I'm the 'first responder' to that which ails my patients. When any particular problem steps out of my areas of expertise, I refer. I present to you the difference between a helpful consultation and one that makes you wonder why we bothered.

Both patients presented to me with foot pain. Patient #1 had pain along her arch, worse first thing in the a.m. or after rising from a chair. I figured she had a falling arch and/or a chronic sprain in her midfoot, but she did not improve with arch supports. Podiatrist #1 sent me a letter that reiterated the history, diagnosed it as 'left foot pain,' but she did not have further recommendations for this patient's care.

Patient #2 had right heel pain that began after she increased her physical activity. I felt she had plantar fasciitis. She had tried stretching and OTC arch supports, so I sent her to Podiatrist #2 as this pain was seriously interfering with her daily activity as well as her ability to stay active. He diagnosed:

1. Fractured calcaneal exostosis
2. Chronic proximal resistant plantar fasciitis
3. Hyperpronation of the right foot
4. 2-3 mm. limb length discrepancy left longer than right

He recommended custom prescription orthotics, and spent some time with her discussing the deformity of her foot based on her fractured heel spur. He told her the pros and cons of extracorporeal shockwave therapy, and gave her literature on the procedure.

Now granted these two problems are different but which podiatrist do you think I will use in the future? His name is Joseph Mechanik, DPM of the Colorado Foot Institute, and I recommend his services to you. His evaluations are consistently thoughtful and careful.

Antipsychotics and the elderly

In my mom's final months at home, she had several days where she was profoundly delusional. On one occasion, she called a meeting with her 'board of directors.' They voted unanimously to fire J., the home caretaker. After the decision was made, Mom became very agitated, following J. around the apartment and insisting that she leave. By this time, Mom was very unsteady on her feet, and falling was a serious danger.

J. slipped into the bathroom and called me from her cell phone. I knew that once Mom slept, she would no longer remember the incident, but, until she did, the situation was untenable. She couldn't stay alone, she'd never calm down as long as J. stayed, and with one slip of the foot, she'd surely fall and break a hip.

This sort of dilemma is not uncommon in older adults with dementia. Per a recent study in the Archives of Internal Medicine(1), however, darned if you drug and darned if you don't. Mom was a danger to herself in her delusional state, but researchers from the University of Toronto found that the use of antipsychotic drugs during such episodes is associated with a significant risk of real harm.

They compared the incidence of any medical events serious enough to lead to hospitalization or death in elderly persons some of whom had been newly prescribed antipsychotic medications in the previous month. Those who received such drugs were over 3 times as likely to experience such untoward outcomes compared to the old folks who remained drug free. One could argue that the group who required antipsychotic intervention on average was sicker than the control group, but this risk rose 3.2 times with the newer 'atypical antipsychotics' like Resperidal and as much as 3.8-fold higher when older antipsychotic agents such as haldol were used.

The investigators concluded that these drugs should be 'used with caution even when short-term therapy is being prescribed.' Well, I guess so!
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(1)Rochon, PA, et al. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med. 2008 May 26;168(10):1090-6.

Licofelone and osteoarthritis

I noted in my last post that osteoarthritis may be a misnomer as many consider this form of joint breakdown to be non-inflammatory. If that is the case, than osteoarthrosis would be a better name for the degenerating backs, fingers, knees, and hips of those who are middle-aged and beyond.

Just a moment's research, however, has led me to believe I typed too soon--the cartilage breakdown associated with osteoarthritis (OA) is indeed inflammatory in origin; there just aren't any white cells in the joint fluid to prove it. OA-related joint destruction is generated by cytokines which are pro-inflammatory molecules that cause a cascade of destruction when produced by cells under siege.

Turns out there is actually a world of inflammatory trouble going on in those aching knees. An enzyme called 5-lipoxygenase is turning arachidonic acid (produced from high omega-6 foods such as fatty red meats and egg yolks) into leukotriene B4 which along with certain cytokines such as tumor necrosis factor mediates structural cartilage damage and the formation of bone spurs.

A drug called licofelone is now in Phase III clinical tests as a dual action agent for the treatment of OA. Not only does licofelone function as a COX inhibitor like aspirin, ibuprofen, and Celebrex, but it is also a LOX inhibitor that puts a lid on all this hyper lipoxygenase business in osteoarthritic joints. As such, it decreases the pain of OA and modifies the joint destruction (as in slows it down!!) so maybe your original issue knee joints will last as long as you do.

Spondylosis

This is a common observation made by radiologists reading MRI reports of the cervical or lumbar spine. I usually ignore it, but I realized recently that I didn't really know what it meant. So now I do, and soon you will too.

Spondyl- refers to the joints and bone of the vertebral column and -osis means abnormal. Now there's a fancy diagnostic term that really is a non-diagnosis. Do I need a several thousand dollar imaging test to tell an aging someone with back pain that they have an abnormal spine?

More specifically, however, spondylosis is applied to those age-related changes in your backbone that leave you stiff and sore. This is a wear-and-tear sort of phenomenon, that which I used to call osteoarthritis or degenerative arthritis. But now I know that -itis means inflammation and, on average, if you're old and degenerating, your collagen and tendons are breaking down in an -osis not -itis sort of way. Therefore, arthrosis(1), tendonosis(2), ligamentosis(3), and degenerative discs(4) leave your vertebrae spurred and misaligned (see x-ray above) and your spinal nerves pinched and complaining.

Spondylosis city here. What a drag it is getting old.
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(1) abnormal joints due to cartilage breakdown
(2) abnormal tendons due to collagen breakdown
(3) I'm not even sure that's a word, but if it is, can't you just feel those thickened and stretched old ligaments allowing one vertebra to slip slideways on the next one down?
(4) the spongy, springy collagenous shock absorbers that are no longer so spongy and springy

Team players

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

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

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.
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*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

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.
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(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

People should think more about their blood vessels. In particular, consider the single layer of cells known as the endothelium that line them. Roughly fried eggish in appearance, healthy endothelial cells maintain a Teflon like coating that allows for the smooth passage of blood. Under siege, however, say as they're scraped across asphalt when you fall off your bike, endothelial cells act like Velcro and raise little chemical flags that attract white cells and clotting factors to stick to their surfaces.

Unfortunately, certain factors in modern life cause this same Velcro response in your blood vessel lining. Doughnuts, french fries, cigarette smoke, air pollution, unflossed gumlines, and waisted fat (i.e. the metabolically active fat that clings to your midline) all send your endothelium into high-level alert.

'Use it' or 'lose it' definitely applies to your endothelium. The more pressure and friction exerted by the circulating blood during exercise, the more the cells flatten and align in the direction of blood flow, thus expanding the vessel and increasing the delivery of oxygenated blood. The most important factor that stimulates the release of endothelial relaxing factor is increased blood flow. When flow decreases on a regular sit-on-your-butt sort of basis, the cells increase their volume, lose their alignment, and heap up like cobblestones thus creating a bumpy, narrowed passage.

Blood vessels love:

• Normal blood pressure
• Exercise
• Mono-unsaturated fatty acids
• Omega-3 fatty acids
• Oatmeal
• Dark chocolate
• Grape juice
• Air filters
• Vitamins C & E

Blood vessels hate:

• Hypertension
• Inactivity
• Saturated and trans-fats
• Fast food
• Obesity
• Particulate matter in the air
• Periodontal disease

Your choice: cobblestones covered in Velcro or fried eggs coated in Teflon. What's in your blood vessels?

Fallen arches: Yet another strategy

Yes, I'm still fussing over my feet. So much so that my friend remarked to me recently as we moseyed along L.A.'s Huntington Beach, "Gosh you talk about your feet a lot." Well color me old and tedious carrying on about my fallen arches whilst walking on a glorious day by the Pacific Ocean. Actually, all I was saying at the moment was that wet sand was the perfect medium upon which to walk with aging feet.

Turns out this is all another instance of Joni Mitchell's lament:
"Don't it always seem to go
That you don't know what you've got till it's gone?"

Not that I didn't know the moment when my arches crashed painfully to earth. What I didn't know was that I'd totally lost contact with my abductor hallucis longus muscle until my neurokinetics therapist told me to contract it.

Bob Gaas: Move your big toe away from your other toes.

Me: (after staring out my toe awhile) Gad, no can do. I have no idea how to do that.

BG: Don't worry, just look at it awhile each day, your abductor hallucis longus muscle just hasn't been used in a long time.

Turns out that the AHL muscle forms the floor of the arch, and if you are so out of touch with it that you can't move your big toe towards the middle of your body, you haven't got a prayer of getting your arch back. Bob assures me that if I can get my AHL function back AND move it independently of both my extensor hallucis longus (EHL) and my tibialis anterior (TA), I will sort of get an arch back. More importantly, my feet won't hurt so much.

Talk about needing a life. My evening activity now as my spouse and I work on the New York Times crossword puzzle is to multitask by discretely feeling along the medial border of my foot beside the arch, searching for life in my AHL muscle. And I am pleased to report we, my AHL and I, are back in touch, big-time! My next stupid person trick is to learn how to move it without activating my EHL (that's the muscle and tendon that flexes your big toe up off the ground) and or my TA which pulls the whole ankle back.

Want to play along with your feet? Your tibialis anterior tendon can be found on the front of your ankle just in front of the inside ankle bone. Cock your foot up and watch it pop out. The EHL tendon is just to the outside (little toe side) of the TA tendon. Point your foot down, then pull your big toe up and that tendon bulges upward.

There's more for those of you who note, as do I, that the passing years are less than kind to your feet. Bob Gaas has agreed to host a group session on getting back in touch with your aging tootsies. Let me know if you're interested.

"Cause of death"

Death certificates are the final period at the end of a life sentence. I've filled out more than a few over the two-plus decades I've been in practice. The hardest part of this difficult job is the last section on the form, namely 'cause of death.'

Here's exactly what the State of Colorado requests:

Immediate cause [Enter only one cause per line for (a), (b), and (c).] Do not enter mode of dying (e.g. Cardiac or Respiratory Arrest) alone.
(a)__________________________________________
Due to or as a consequence of
(b)__________________________________________
Due to or as a consequence of
(c)__________________________________________


Generally, the funeral director is standing by the front desk, deathly impatient, waiting for me to fill this form out in a moment stolen between appointments. But I find it very hard to think this out in a hurry yet essential that I give it my full attention and best shot.

I'm not sure who signed my Mom's certificate. I can't read the writing, it may be the doctor who visited her on one or two occasions. I'm not objecting to the lack of visits as I made it clear in an officious sort of way that I would mostly handle things pertaining to my mother's health care. So I guess I can scarcely be offended that whoever filled the certificate out listed "End Stage Dementia of Alzheimer's type" as the cause of death. Period. No (b)'s or (c)'s about it.

Well, Mom did not have Alzheimer's type dementia at all but rather multi-stroke dementia, and she doubtless died of a pulmonary embolus or a cardiac arrhythmia. But what she really died of was an "I've had enough" attitude due to or as a consequence of immobility, loss of independence, pain, bronchitis, and one tiny stroke too many.

I was interested, therefore, to read a column in a June issue of JAMA about the Genug Syndrome. Dr. Jennifer Soyke of Eugene, Oregon, writing in a regular JAMA feature called 'A Piece of My Mind', talks about the at-home death of one of her elderly patients. When she discussed the question of the actual cause of death with her patient's loved ones, they decided the lady had died of genug syndrome (genug is Yiddish--and German--for "Enough already!"). They did not want her life and her peaceful death summed up as a medical diagnosis. So Dr. Soyke ended up listing cause of death on the certificate as 'respiratory arrest secondary to genug syndrome.'

Now that's some kind of medical chutzpah. And speaks eloquently of a life well done.

How to take a blood pressure reading

Blood pressure reading does not seem to be done correctly in any medical clinic. And yet, the single most important thing physicians do in their medical life is take an accurate blood pressure measurement.
--Clarence Grim, MD, Medical College of Wisconsin

Well this is Grim news indeed for those of us who've been at this for decades. Per Grim(1), a proper blood pressure assessment is nuanced and time-consuming, an unwelcome proclamation in a world where appointment time in your average PCP's office (that would be mine) is limited and largely unreimbursed.

So here's the scoop. Ms. Patient needs to be sitting in a chair, back supported, feet flat on ground for 5 minutes before the exam, her arm on a table such that the center of the BP cuff, which needs to be the proper size relative to the circumference of her arm, is at heart level. Then, get this!, I'm to take readings in both arms (do I have to let her rest between measurements for another five?), and I can't chat as I measure. That's my downfall, I'm usually grilling her about her day, her job, her kids, her opinion of the Rockies (watch that pressure soar), when what I really need to do is just shut up and pump the cuff.

Research suggests that our worst failing as BP measuring health professionals is that rest thing, we don't let the patient rest. Here's what Joseph Izzo, MD, hypertension researcher extraordinaire has to say about that: "The problem is that physicians cannot afford financially to take the time to properly measure blood pressure--they aren't compensated."

And I would add that none of my patients spend their day at rest, so oughtn't we be measuring their pressures in real world, on-the-go conditions, when time constraints and tonight's preseason performance by the Broncos is driving their hearts and their minds?
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Mitka, M. Many Physician Practices Fall Short on Accurate Blood Pressure Measurement. JAMA, June 25, 2008-Vol 299, No. 24.

Overactive bladders

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.
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(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

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

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.
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(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"

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?

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...

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

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

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

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

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

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

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

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

"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

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

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

...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

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

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

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.

Stiff feet and Yoga Toes

Twenty-six bones in the feet, and all 26 of my Mom's moved as one. Zero flexibility in her old feet, and I'm here to tell you that was no small part of her mobility challenges.

As so many aging children of elderly parents do, I kept close watch on the physical changes my parents endured through the years with an eye towards my future. And I decided as I followed Mom down many a hallway, I do NOT want wood for feet.

No surprise that my arches had already fallen, they did so painfully about 8 years ago. As I researched this stiff foot thing, I discovered the too many toes sign and posterior tibial tendon dysfunction. I went to an orthopedic specialist in feet who assured me that while I had the first, I did not have the second. That's all I got from him for my $45 copay, but a little reassurance is always helpful. For quite a bit more, I bought Good Feet arch supports which resulted in 2 of the most painful months of walking I've ever experienced.

But now, color me green with 'range-of-motion' envy. I had a patient in recently with the most flexible forefeet I've ever seen. She could wave bye-bye with those toes in great sweeping motions so freely mobile her digits. And her secret? "Oh no," says she, "I didn't always have such clever feet. I owe it all to Yoga Toes.


Shoot, I had to get me a pair of those Yoga Toes. The picture on Amazon is inscrutable--they're actually clear plastic toe separators (and no longer available on Amazon!). When I put them on at work, my medical assistant declared them the very thing for painting your nails without smudging them.

Will they restore range of motion to my tired dogs? I'll keep you posted.

Leftover life: Stowed!

Mom's condo is empty at long last. Two station wagon loadfuls, and a final truck's trip for the couch to another family's living room with the same color decor as Mom's.

I just spoke with a young woman from Craigslist who is delighted with the 1950's style Smith Corona manual typewriter and rapturous over the prospect of the vintage black Singer sewing machine. All of Mom's life lovingly tucked away in hearts and homes.

I sometimes wondered if I'd lost my mind (or perhaps would lose it) handling each and everything with care as to the perfect disposition. Now I know it was the best way to honor her life and say good-bye.

Hemorrhoids and spicy foods

Are you a PLWH? Chances are good that you are as about 50% of adult persons are indeed living with hemorrhoids. Does the thought of spicy in (like, say, red hot chili peppers) leading to hot out (now I don't have to explain that, do I?) make your hemorrhoids cringe? Rest easy and indulge; research* indicates your hemorrhoids are not a risk from your spicy excesses.

Italian researchers, about 50% of whom doubtless had hemorrhoids, randomized 50 adults with big-time 'rhoids to receive two blue capsules at two different meals either packed with red hot chili pepper powder or placebo powder with no kick at all. They prepared the real deal capsules with the amount of spice needed to achieve "spicy enough" status (as defined by the Association of Teachers of Italian Cuisine) if the contents had been added to a normal dish rather than the colons of the test subjects.

One week, half the group popped hot and the other half downed not. The following week, the capsule allocation was reversed. On a visual scale of 0 to 10 (can you picture the visuals here?), the subjects were asked to rate the situation down under with respect to bleeding, swelling, itching, and burning before and after.

The results? Spice in is not a problem at the end of the line.
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*Altomare DF, et al. Red hot chili pepper and hemorrhoids: the explosion of a myth: results of a prospective, randomized, placebo-controlled, crossover trial. Dis Colon Rectum. 2006 Jul;49(7):1018-23.

When can you stop having mammograms?

I mentioned in a previous post that the American Cancer Society identified age 70 as the end of the line for low risk women to get Paps. Ducking the date with the speculum (the first of which, incidentally, was fashioned out of a pewter spoon) is one of those age DOES have its privileges things.

What about ending the annual encounter with the mammogram machine? European investigators presented the results of two large studies at last week's 6th European Breast Cancer Conference that address the ideal interval and cut-off age for older women and breast cancer screening.

In 1998, The Netherlands extended the national breast cancer-screening program to women up to age 75 from the previous age limit of 70. Investigators tracked the incidence of death from breast cancer in women ages 75-79 during the time period 2003-2006, five years after the expanded screening offering began. Compared with a ten year period beginning in the mid '80s, the breast cancer mortality for this age group dropped nearly 30%. Clearly, mammograms done on women in their late 70s were picking up breast cancers that would have otherwise proved lethal if not detected.

Researchers on the UK Breast Screening Frequency Trial randomized 100,000 women ages 50-62 to receive mammograms either annually or every 3 years. The two groups were followed over 13 years, and the risk of breast cancer death was virtually the same whether the women were annually squashed in the mammo machine or submitted to the test once per 3 years.

One of the reasons, investigators theorized, that women over 70 benefitted from screening is that their breast tissue was less dense, and thus mammograms were easier to read and more accurate at detecting early cancers. Senior researcher Jacques Fracheboud noted, however, that "it is not necessarily an argument for continuing screening beyond 75 because many tumors found at this stage are slow growing and may never reach the stage of causing a problem."

Breast density is a consideration for the somewhat younger group as well. Those women ages 50-62 with dense breasts--i.e. hard to image with mammograms--may well be doing themselves a disservice to embrace the every 3 year embrace of the mammogram plates. Before you decide that this interval is for you, or before you chuck the test at 75, check with your doctor to see if these decisions are appropriate in your case.

Leftover life to stow, Part II

I posted some time ago about the difficult but important task of shutting down a life. At that time, my Mom was still alive, newly in the nursing home, and I was taking the first few passes through her beloved condo. The best experiences then were giving away her plants, her craft supplies, and her books to people who were so excited to receive these bits of her life into theirs.

So now I'm down to the hard stuff, all the things that I'd look at and think ohnotnow, maybelater. Later is here. A wonderful friend joined me today, a woman long on organization and free of the emotional baggage that I bring to the task. Whenever I dithered and gave her the ohnotnow on a vase or a piece of art, she'd gently bring me to the ohyeahnow place.

So everything is sorted, stacked, and ready for transport. Some advertised on Craigslist, some ready for the art or natural history museum, a stack for me, a stack for my brother, one for charity, and one for the wonderful friend who spent the day holding my hand and honoring my Mom's leftover stuff.

Make friends and sleep

If you can't sleep, connect with an endearing community of insomniacs. There's bound to be such a chat room somewhere on the Internet. And if a great night's snooze leaves you little time to bond with friends over dinner, don't lie awake worrying that your health will suffer. Matters not whether you're sleeping or networking, researchers have proven that either activity will enhance your health.

Previous research has shown that poor sleep raises body levels of an inflammatory molecule called interleukin-6 (IL-6). On the other hand, another study found that old guys who hung out with their buddies had less IL-6 than the isolated curmudgeons. IL-6 levels are directly correlated with an increased risk of cardiovascular disease.*

Dr. Elliot Friedman and colleagues asked 135 aging Wisconsin women about their relationships with their friends and their beds. They then correlated those results with blood levels of IL-6. Those women who enjoyed both early evenings with others AND late evenings with covers had almost no IL-6 noted compared to their sleepless, disconnected colleagues. Fortunately, either good friends or great sleep was also enough to reduce IL-6 to "virtually undetectable" levels.
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*Cardiologists at the University of Pittsburgh reported in the November, 2005 issue of the American Heart Journal that women at risk for heart disease with the highest levels of two or more inflammatory markers (C-reactive protein, IL-6, or serum amyloid A) were more than four times as likely to die during their 5 year study compared with similar women who had no such laboratory signs of increased inflammation.

Estring and breast cancer

"If you run out of estrogen," a menopausal expert once told me, "you WILL dry up." As in symptomatic-genital-shrink-and-shorten sort of dry up. Yet many women are uncomfortable about the use of estrogen, particularly as it is associated with a slightly increased risk of breast cancer. For those of you passing up hormones or for those of you with a personal history of breast cancer, here's some important information.

Estring is a product that delivers estradiol locally right into the appropriate female passage via a silastic ring which is left in place for 3 months. During this time, the ring releases 2 mg of estradiol which is the equivalent of 1-2 days' worth of full-dose, oral estrogen therapy.

Menopause experts Drs. Nicole Brooks and Andrew Kaunitz note that they prescribe this treatment to a number of patients in their practices who are breast cancer survivors due to the ultra-low levels of estrogen that are absorbed via this route. Estradiol tablets--sold as Vagifem--are also effective in improving vaginal symptoms, but estrogen absorption into the general circulation is higher with their use compared to that with the ring. Some women complain of breast tenderness with the use of Vagifem. Estrogen creams produce the highest systemic levels of estrogen of all the local treatments and are sort of gooey.

While the estrogen absorption of Estring is ultra-low, the price is ultra-high.

When can you quit having Pap tests?

Age has its privileges. Per the American Cancer Society, no more Paps needed:

1. When you're over 70 AND
2. You've had no abnormal tests in 10 years AND
3. You've no new risk factors for cervical cancer such as a new partner.

An Aged Athlete

From a simpler time, when old was old, and physically fit was not (old that is):

An old-time champion pedestrian, whose record 30 or 40 years ago aroused the country, has recently at the age of nearly 70 performed the feat of walking from Philadelphia to New York, a distance of 96 miles, in a little over 23 hours and finished the task in excellent physical condition. This is a good example of the fact that the physical organization of man need not necessarily go to pieces before the allotted three score and ten, when, according to some, the system is worn out and useless. Of course, this man is an exceoptional case, but he shows what the possibilities are, and probably a great man other individuals of as great age could do likewise.

----JAMA, June 23, 1906

Sympathy cards

Cards, notes, calls, these expressions of sympathy are simply the best. Whether they share a wonderful memory or just say "Sorry to hear about your loss," they are a source of enormous comfort. I won't let another passing of a friend's loved one pass without sending my thoughts along.

Fall prevention

My friend Anita has suggested a mantra for growing older (nofallingnofallingnofalling). Having spent more than a little time trailing after an extraordinarily shaky old lady, I do not believe that this mantra has the proper rhythm to keep an old person upright. I found that singing "The Hokey Pokey" with gentle taps to the appropriate foot had just the rhythm for easy ambulation.

Dr. Frederick Carrick of the Carrick Institute searched for music to stay upright by, registering one clinical trail with the NIH under the title "Fall Prevention in a Geriatric Nursing Home Setting Using the Music of Nolwenn Leroy."* Who then is Nolwenn Leroy?

She is a 25 year old French pop star who's shuffle along music can be found at Nolwenn Sings for the Unsteady. While Dr. Carrick found her tuneskys superior to other musicians including Mozart for modulating the gait of walkers walking with walkers, I don't get it. I'd sooner do the Hokey Pokey myself.
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*"Music to stand bolt upright to."

Just lost that post-colonscopy glow!

There's nothing, or very little, like the pleasure of viewing one's colonoscopy in retrospect. Most immediately, there's that leftover Versed glow, but in a more lasting sense, there's that 'just for now the colon's clean' (in more ways than one) feeling. That is until I read this item from JAMA* summarized in the March 28 edition of Science.

According to a study of 1800 veterans screened for colorectal cancer via colonscopy, nearly 10% of them had 'morphologically subtle flat lesions.' As in not-heaped-up, icky looking polyps but boring-flattish plaques. Subtle but dangerous plaques that don't leap up into the colonoscopist's line of sight in a 'whoa that doesn't look good; let's biopsy that sucker' sort of way. And when this particular group of investigators did biopsy these areas, the tissue was five times as likely as polyps to show cancerous features.

Well, dang, now don't I feel underscreened! But another group of researchers are hot on the trail of these flat colonic plaques. They've found that if you spray the colon's inner surface with a certain kind of little protein that likes to bind to premalignant colonic tissue, and if you make that peptide glow in the dark by hooking it up with fluorescein, then you can snag those hummers 81% of the time.

And you may enjoy viewing your post-procedure movements under black light!
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*J Am Med Assoc. 299, 1027(2008)

I cry too much...

(or Better Mourning through Chemistry)

I cry easily and often. Certainly over the morning comics--who doesn't? For Better or Worse and Funky Winkerbean rival any soap opera or Greek tragedy for tear jerk potential. I cry when small children sing more or less in unison, I cry when other people cry, and, most distressingly, I cry when I'm mad.

Now don't get me wrong, there's nothing wrong with crying (cut to "It's alright to cry" from Marlo Thomas's "Free to Be You and Me" album which, incidentally, is a song that also makes me cry). But sometimes, crying gets in the way of effectively doing that which you want to do. Years ago, I wrote a eulogy for my Dad's memorial service, and I couldn't get through one word of it due to tears so my good friend Janice read it for me.

Last week, I threw a marvelous memorial service for my Mom, complete with a sing-along hootenanny of old favorites like "Down in the Valley" and "You are My Sunshine." I wanted to sing along and, more than anything, I wanted to speak my good-bye piece to Mom and tell her friends about the wonderful times she and I shared even up until the last week of her life.

Prior to the service, I took a little bit of Paxil (an older antidepressant/anti-anxiety drug) and a little bit of propranolol (a beta-blocker that stops some of the adrenalin outflow from the sympathethic nervous system that sets off the heart-pounding, shaky body feeling like when you battle a saber-toothed tiger or say good-bye to your mother). I wasn't tranquilized, I was still awash in emotion, but I was NOT awash in tears. I sang my songs (and I am not generally one to sing in front of a crowd) and I said my piece. It was wonderful.

I cried like mad the next day.

"What do you do when your small toe hurts?"

I am always interested in the google searches that bring readers to my blog. This question has brought more than one along. The answer, of course, is nearly always "Wear wider shoes."

Godspeed Evelyn Paley

Goodbye, my lady love,
Farewell, my turtle dove,
You are the idol and darling of my heart,
But someday you will come back to me,
And love me tenderly,
So goodbye my lady love, goodbye!

Born 6/21/20, died 3/27/08

Menopause moment

Moment, shmoment, this turned into a day long lapse.

After looking frantically about for my cellphone, I called it to see if I could hear the ring somewhere in the house. No sooner did I hang up but my home phone rang, my office manager calling to say my MIA phone was ringing on my office desk where I'd left it the previous afternoon.

Then I rushed to exercise class, skidding into the lot at the last minute, but, alas, no athletic shoes in the car. Between the moment I picked them up and the time I settled into the car, they vanished both from consciousness and arms.

When I arrived (late) to my dentist's office, I relayed the story of the missing shoes to the middle-aged receptionist.

"Oh," she said, "I've done that. They're on your kitchen counter."

And so they were.

Baby boomers and Alzheimer's Disease

Here's hot-off-the-press bad news for baby boomers: 1 in 8 will develop Alzheimers' Disease. Lifetime risk for those of us BBs who are, have been, or will be 55 is 17% for women and 9% for men.

Women are more vulnerable to AD due to gender susceptibility and longevity. While men tend to die earlier and more abruptly, women tend to dwindle piecemeal with degenerative disease.
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*2008 Alzheimer's Disease Facts and Figures

The FRAX Tool

Wondering how your bones will hold up over the next decade? The World Health Organization has created an algorithm based on certain clinical facts (age, nationality, personal and family fracture risk) and derived from data in four continents. You do need to know your DEXA scores for hip density.

Check out The FRAX Tool. I've got a 6.1% chance of taking out a vertebrae, wrist, hip, or shoulder in the next 10 years. If I was turning Japanese --same stats-- my fracture risk would drop to 3.7%.

Why am I here?

My Mom was having a bad day, but she knew exactly where she was. And it seemed as though she was not happy about it.

"Oh Judy," she sighed, "Why am I still here?"

"Well, Mom," I answered, launching into my standard litany. "You've had a stroke, and you weren't safe at home anymore."

"No, no," she replied, impatiently, "I mean, why am I still HERE?"

"Oh, I think I get it now, you mean why are you HERE?," and I indicated the world around us with a sweep of both hands.

She nodded.

"Well, Mom," I said with a sigh, "I guess you're still here [once again gesturing laterally to the surrounding world] because you're not yet THERE."

She watched me raise my hands up to indicate the sky above, paused thoughtfully, then burst out giggling.

HE4

The quest to find the 'voice' of ovarian cancer --that silent killer that doesn't speak up in a symptomatic sort of way until it's spread beyond the ovaries-- continues. European women now have a new testing option with the release of the HE4 assay, a blood test which screens for this protein known to be elevated early in the course of ovarian cancer.

Researchers found that the results of the HE4 test when combined with the not-so-golden CA125 test (which thus far has been the gold standard for ovarian cancer screening) can be dropped into a mathematical equation that accurately predicts a woman's chances of having the disease.

The HE4 test is currently under FDA review in this country.

Menopause Moments

Can't hold a thought. Period.

My forty-something patient and I chatted about her recent hysterectomy before we got started on the business of her annual exam. As we settled into her medical history, I ran through my usual questions about her energy level, sleep habits, diet, and exercise.

Moving on through the interview, I looked up and asked "So when was your last period?"

Falling and hip fractures

Dr. Mary Bouxsein, a biomechanical engineer at Harvard, defines a fall as a "sudden, unexpected event that results in a person coming to rest on a horizontal surface."

She and others have studied the dire consequences of such events to aging skeletons. While prevention of bone loss is a major focus of medical research on osteoporosis, equally important is the prevention of fractures in bones already thinned by the disease. Research has shown that a sideways fall is almost six times more likely to cause a fracture in an osteoporotic hip than pitching over in any another direction. Healthy adult volunteers falling in research labs have shown why.

Only two of six subjects were able to get their arm out in time to break the impact of the fall. For the others, hip impact occurred first, with almost all of the force delivered on a path directly through the bone. As expected, overweight fallers delivered a larger impact to their hip. Even though the fat pad overlying the hip bone absorbs some of the impact energy, it is probably not enough to prevent a fracture when a large but frail lady comes to rest on the floor.

"Trochanteric padding systems" (a girdle-like garment with padding over the hips) have been developed to decrease the destructive impact of sideways falls to fragile old ladies. One study, however, found that women were reluctant to wear them because of how they looked.

Abdominal Aortic Aneurysms

We even offer a special package price
of $149 (or less, depending on location)
when you select our Complete Wellness
Package which includes our stroke/carotid
artery, abdominal aortic aneurysm,
peripheral arterial disease, and
osteoporosis screenings.

--Life Line Screening Web-site

Several of you have brought in flyers from Life Line, an independent service offering reasonably priced screening tests direct to consumers, wondering whether or not you should sign up for the exams. While direct access to such testing is appealing, do we all really need to be screened for this set of four chronic and serious conditions? Consider abdominal aortic aneurysms, or AAAs.

AAAs are a chronic, progressive, degenerative disease of the aorta as it passes through the abdomen, carrying oxygenated blood from the heart to the organs and legs. Over time, gradual deterioration and expansion of the aortic wall can lead to weakening and a catastrophic rupture. This aortic breakdown is initiated by the same injury and inflammation that sets off atherosclerosis or hardening of the arterial walls in other vessels throughout the body.

Well shoot, you do not want an aortic blowout mucking up your nice spring day. If a simple screening test can detect the condition, why not? The United States Preventive Services Task Force (USPSTF) took on that very question, weighing the probability of finding the condition in selected populations against the costs and benefits of detection and operative repair.

They concluded that older men--ages 65-75--who ever smoked should undergo a screening test for an AAA. The experts concluded that ultrasonographers would have to probe the abdominal aortas of just 500 aging old guy smokers to find 1 aneurysm. The 1-year risk of AAA rupture is 1 in 10 if the aneurysm measures 5.5-7 centimeters, and 1 in 3 for bulging aortas stretched beyond 7 centimeters.

The USPSTF did not have an opinion one way or another about screening older men who never smoked. Finally, they graded AAA screens for older women as "D" or not routinely recommended unless she is a smoker with a family history of aortic aneurysms.

What's a liver spot?

I recently spoke at a training session for the DermAnalysis scanner. This gizmo uses black light (UVA) to highlight areas of sun damage and dryness. The scanee sticks her head under a drape, screams with horror to discover her entire face lit up with blotchy purple and orange sun-ravaged areas, then jerks herself free of the machine seeking soothing explanations from the screener. While this UV scan cannot diagnose skin cancer, it certainly facilitates discussion of skin care.

Here's a brief lexicon of skin destruction:

Solar Lentigines: A fancy name for liver spots (aka horrid age spots) which have absolutely nothing to do with the liver whatsoever. They are, instead, the result of sun-deranged melanocytes overproducing the skin pigment called melanin. Some of these skin melanocytes just give up after years of tanning and quit producing melanin at all, resulting in white patches (see below).

There are a couple of remedies for an ugly lentigo, none of which include bleaching. A prescription product called Solage applied twice daily will fade these hummers. Melanocytes hate to be frozen, so liquid nitrogen will also work.

Idiopathic guttate hypomelanosis: A big name for tiny white spots on sun-damaged skin. Age plus sun equals death to certain touchy little groups of melanocytes. Nothing to be done about them.

Solar elastosis: This is basically at the root of this skin aging thing. Sunshine--right, the very sun you sought in college as you slathered on the baby oil and placed a reflector beneath your neck--causes breakage and clumping of the elastic fibers in the skin. As a result, skin sags and the superficial layers of the epidermis bunch up.

Cutis rhomboidalis: Talk about feeling bad about your neck! Think the deeply plowed neck skin of Midwestern farmers and ranchers. Crisscrossing furrows through thick yellowish skin. No cure for this, grow your hair long.

Poikiloderma of Civatte: I don't know who this Civatte fellow is, but this condition equals a combination of all of the above sun mess plus dilated capillaries on the anterior chest of women who faced up to the sun many times too often. No more decolletage for Suzanne Somers on those infomercials!

Seborrheic keratoses: These are big scary variegated growths that typically appear on the torsos of aging susceptibles (if you can picture these on your parents skin, you're on your way to growing your own). They have a 'stuck-on' warty appearance, and can grow to alarming proportions. Not to worry. Not dangerous from a skin cancer point of view, but distressing nonetheless. They can be surgically removed.

And here's the rest of the tour:

Crow's feet result from overuse of the orbicularis ocli muscles that activate when you crinkle your eyes during really big smiles. Furrowed brows result from chronic worry creasing your forehead. Marionette lines crease the skin from the angles of the lips to the jawline. Angular cheilitis results from really big marionette lines, perhaps coupled with loss of teeth collapsing cheeks further, resulting in folds at the lip angles that fill with saliva and residual toothpaste. This irritating ooze from mouth leads to red and painful inflammation.

Vitamin D and immunity

Sometimes I read a research report so compelling I just have to get up and do something about it. Just now, that instant reaction included heading downstairs to pop my second vitamin D supplement of the day. Did you get the memo? If not, here's the scoop.

Simply put, influenza viruses hate sunshine. The seasonality --here in winter, gone in summer-- of flu epidemics has long been noted but only more recently understood. The reason, it turns out, that flu bugs hate sunshine is that sunshine on un-sunblocked skin during summer months causes production of vitamin D. D in turn acts on portions of human DNA to produce antimicrobial peptides which are worthy little proteins deadly to the influenza virus.

If the prevention of influenza infections were just a matter of producing 'herd immunity,' than populations in which a large number of individuals had been immunized should have fewer members die of flu. In fact, a study of Italian old folks showed that the death rate dropped not a whit over a 15 year time period during which immunization rates rose from 10% to 60%.

Once the vitamin D/influenza connection was made, other investigators herded together some postmenopausal women and hooked half the old gals up with extra vitamin D. Those in the group without supplements were three times more likely to fall ill with influenza compared to D other group. By the third year of their trial, a higher dose of supplemental D (2000 IU/day) "virtually eradicated all reports of colds or flu."

Virtually and eradicated are strong words. So strong, I went down and took my second 1000 IU D pill for the day. I need all the D I can get to get through the rest of this nasty flu season.

Wind, wound, water, and walk*

This is the little mnemonic that medical students use when searching for the source of a post-operative fever. It's coming in handy this day, years past med school, as I think through why a certain old lady might be running a temp near 102. I'll add colitis to the list as she's been on antibiotics for her arm wound (which is much improved, so that's not where the fever is coming from).

Antibiotics can cause a dangerous shift in the body's resident bacteria. While a little diarrhea might be a small price to pay for the treatment of a serious infection, one antibiotic-related bowel infection--Clostridium difficile-- is a bad actor that you do not want in your intestinal tract. The last time Mom did battle with that little hummer, she became septic (the bacteria was released into her bloodstream, causing a systemic infection) and nearly died.

You don't have to be a frail little old lady to get a c. diff infection. I've had two otherwise healthy adults get c. diff colitis after a course of oral antibiotics for no-big-deal infections. While neither one was seriously ill, they had some serious diarrhea for a long time and required yet another antibiotic to clear this microbe out of their colons. All the more reason to skip antibiotics if possible through the flu season.
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*Wind = Respiratory infection or pulmonary embolus
Wound = Surgical site or any opening in the skin from injury or ulceration
Water = Urinary tract infection
Walk = Deep venous thrombosis or clot

HDL cholesterol supports the brain too

HDL cholesterol may slow the aging process, and not just with respect to the heart. The worthy little HDL protein plays a pivotal role in reverse cholesterol transport, toting the fatty goo out of the tissues--including blood vessel walls--and back to the liver for elimination from the body. Low levels are a common abnormality in patients destined to develop coronary artery disease, even when total cholesterol values are in the normal range. Researchers have now found a correlation between robust HDL levels and mental clarity in the oldest of the old.

Scientists at the Institute for Aging Research in New York City conducted a study of healthy, really old people (average age 99). They found that these remarkable centenarians maintained much higher HDL levels than expected for their age. HDL levels decline with the passage of time by approximately 5 points for every 8 years. According to this formula, the expected HDL level in this gasp of geezers should've been 20 but averaged 55.

Across the study group, HDL levels were directly related to scores on the Mini-Mental State Examination. The higher the HDL's, the more agile the aging brain. Investigators note that cholesterol plays a key role in maintaining connections between brain cells and processing beta amyloid protein, the tenacious gunk that gums up the neural works in Alzheimer's disease.