A lovely thought

My patient Tricia asked about my Mom. When I told her she had died some months previous, and about how she had had enough and had been ready to die, Tricia smiled and said: Ah, a life concluded, not interrupted.

What did Lotrel ACCOMPLISH?

Blood pressure is a 'surrogate marker.' This vital sign is easily obtained at home, at the grocery, and in the doctor's office, and the success with which any antihypertensive medication lowers the BP is correlated with the final desirable outcome of blood pressure therapy, namely decreasing the risk of heart attack, stroke, and death by cardiovascular disease. In order to best accomplish our goal of avoiding those pesky outcomes, large studies have been undertaken to see which BP meds work best.

The Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension or ACCOMPLISH trial compared the effects of two combination therapies on cardiovascular events in thousands of hypertensive patients over the age of 55. These subjects were already hypertensive, many were on more than two medications, and only a third of them or so had their blood pressure within the therapeutic goal of less than 140/90. All of them had some sort of health trouble which significantly increased their risk of future problems, including a history of stroke, heart attack, diabetes, enlarged heart, decreased blood flow to their legs, or kidney disease.

They discontinued their current meds; half began Lotrel which is a combination of Lotensin (aka benazepril) and Norvasc (aka amlodopine) and the other half started benazepril plus a water pill known as hydrochlorothiazide (HCTZ). HCTZ has been considered first-line therapy for high blood pressure.

But ACCOMPLISH became one of those 'stop the study' studies by the end of three years. In other words, the benefits of the Lotrel combo were so compelling with respect to preventing unwanted cardiovascular death and disease--decreasing risk of same by 20% compared to conventional therapy--that the researchers called off the trial in order that everyone might benefit from the now proven superior approach.

So take that HCTZ at least when it comes to treating a high risk population. Here's what Dr. Franz Messerli had to say:

This landmark study unequivocally relegates hydrochlorothiazide from first-line to third-line therapy at least in a patient population with similar demographic and clinical features as in ACCOMPLISH. The issue is not to be taken lightly, since hydrochlorothiazide remains one of the most commonly prescribed antihypertensive drugs. Every year more than 100 million prescriptions of hydrochlorothiazide are written in the US. Almost half of those prescriptions are written for hydrochlorothiazide alone.

Some persons don't tolerate Lotrel very well, suffering a cough from the Lotensin part or swelling from the amlodopine component. Lotrel is available in some strengths as a generic, though it is thus far one of those pricey generics.

Floppy Eyelid Syndrome

You're probably thinking well shoot, I've already got that. You may well have saggy eyelid syndrome--you know, look in the mirror, gently shove the skin below your eyebrows off your upper lids and poof, the young, wide-eyed ingenue reappears. But this is FLOPPY Eyelid Syndrome, first described in 1981 by two researchers checking out the lids on middle-aged obese men. Associated with sleep apnea, this lizardish look not only includes the saggy lidded thing but also redness and irritation in the no-longer-so whites of the eyes.

We know that sleep apnea can seriously affect the heart (right-sided failure) and brain (increased risk of small vessel disease and 'mini' strokes). But why the eyes? Some investigators feel the cause is mechanical stress--i.e. smashing and stretching the eye against pillow--which is supported by the fact that one-sided sleepers often get one-sided F.E.S. Others wonder if alternating ischemia (not enough oxygenated blood) followed by reperfusion (flood of oxygen-rich blood when the apnea ceases) results in tissue inflammation. Studies of floppy lids (what happened to the sleeper upon which these lids resided!?!) showed an inflammatory injury reaction consistent with both stress and ischemia as seen in other tissue types.

Not only does F.E.S. limit the field of vision (while providing, perhaps, some sun protection in a visor sort of way), but the redness and irritation along with that iguana image may necessitate a surgical lid lift, one that the insurance company would be willing to fund!

Medical advice from Whole Foods vitamin clerks

I wonder what their credentials are. And what's in adrenal extracts anyway? Whose adrenals are dried and powdered within, and could they be just offal?

Ergonomic snow shovels

Wendy did a recent blogo-riff on snow shovels. Must be a Canadian thing as Jean had a thing or two to say on the subject last winter. More than likely it's a consideration for those of us middle-aged and beyond, and it just popped on my radar screen and lumbar spine this past week here in Denver.

Ergonomics is the study of people at work, and the science of fitting equipment and work place to worker to optimize performance and minimize injury. "Your online guide to ergonomic snow shovel" says it all:

The gardens, or lawns are covered with snows and the road is also covered with snow that piles up to any feet. The snowfall creates a lot of inconvenience and we wish that the days of snowfall are numbered...The act of removing snow is also back breaking work and many people go to the doctor to rid themselves of the ailment they have got on them during snow shoveling. The snow shovel is an important tool and it becomes very important during the days of snow. ...There is a lot of research going into the making of these snow shovels and the result is different types of snow shovels.

Well, I got a back pain on me when I used our new snow shovel on the first snow this season. My husband, noting that plastic rimmed shovels break easily, bought a metal-edged scoop. Cold metal on wet concrete is an ergonomic no-no. The characteristics of an ergonomically correct snow shovel have been described in exacting terms: plastic blade, 16 1/2" x 14 1/2" with a 42" adjustable shaft for a short person such as I've become, no steel-reinforced edges (note to husband!), and an angular shaft. And ergonomically correct snow shovel reviews are fun to read:

With a shovel like this, the user can thankfully proclaim "Who needs a snowblower?" Of course, snowblowers might make the job of clearing snow easier, but they are expensive, noisy, smelly, and can cause numbness in the hands. The ergonomic shovel will allow the operator to breathe clean air and experience healthy physical exercise. The chances for injury will be reduced as will the snow in the driveways and on the sidewalks of America.

But oh Wendy and Jean, wouldn't you wuv a SnoWovel Wheeled Snow Shovel as pictured above?

Exam room etiquette

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

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

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

Comment from a 65 year old nurse who came in today with a painful case of shingles on her abdomen:

I could kick myself for not getting the shingles shot.

This after spending 4 and 1/2 hours in the ER two days ago with the pain that preceded the outbreak. She got a CT scan, an ultrasound, many exams, and a raft of bloodwork looking for other causes for the pain.

While people are getting more and more familiar with the patchy, one-sided, blistered skin associated with an outbreak of shingles, many patients don't realize that severe pain is often the first sign of the disease and can predate the rash by several days.

For more information on shingles, see The shingles shot.

Estriol and wrinkles

Estriol is the darling of the natural hormone set. A weak little estrogen, it is, in fact, a metabolic byproduct of the normal breakdown of the body's two stronger circulating estrogens, estrone and estradiol. Enormous quantities are necessary to preserve bone mass, but itty bitty bits dabbed on your aging visage may improve the quality of your skin.

A .3% topical cream, available by prescription from compounding pharmacies, was applied daily to the wrinkled surfaces of a group of perimenopausal ladies. Not only did skin elasticity and firmness improve after six months of use, but also wrinkle depth and pore size decreased. Skin biopsy specimens (now how much did they pay these ladies for that?) showed increased numbers of collagen fibers. Serum hormone levels did not change and there was no evidence of any systemic hormone effects, suggesting that topical estriol is safe for use in women unable to use full-dose estrogen replacement therapy.

Working memory and menopause moments

Wondering why you're wandering around the house in pursuit of who can remember what? Check out Working memory and menopause moments.

Cipro side effects

Chances are good that if you go to an urgent care center for treatment of a urinary tract infection, you will end up with a prescription for Cipro. This fluoroquinolone antibiotic is also commonly used for intestinal infections, and its cousin Levaquin is a favorite choice for the treatment of pneumonia. Some of my patients request these antibiotics by name as their use was particularly effective for some previous bacterial infection.

Powerful medications are a good thing when battling serious infections, but you should know that the fluoroquinolones now have a 'black box warning' per the FDA. This cautionary material is rimmed by a bold black square in the PDR and on the product insert. This particular alert was issued 7/8/08 and reads in part:

Fluoroquinolones are associated with an increased risk of tendinitis and tendon rupture. This risk is further increased in those over age 60, in kidney, heart, and lung transplant recipients, and with use of concomitant steroid therapy. Physicians should advise patients, at the first sign of tendon pain, swelling, or inflammation, to stop taking the fluoroquinolone, to avoid exercise and use of the affected area, and to promptly contact their doctor about changing to a non-fluoroquinolone antimicrobial drug.

The achilles tendon is particularly susceptible to this inflammatory weakening, and, per a physical therapist I know, the loss of tendon strength and substance associated with drug-induced tendinitis is particularly devastating and hard to reverse.

So while fluoroquinolones, when indicated, are effective drugs and potentially life-saving, their routine use in uncomplicated urinary infections is unwise. Ask your doctor about using other choices in cystitis or bladder infections, and ask him/her to consider ordering a culture of your urine sample to confirm that your infection is susceptible to the antibiotic prescribed.

Post-operative pain management

My medical partner and I are routinely aggravated by the following situation. Our patients are admitted for surgery, say a knee replacement or an appendectomy. They are released from the hospital on meds for pain with instructions to call us for follow-up and refills. We think the prescribing surgeon ought to stick with the program. Now I'm rethinking this strategy.

My friend E. who is now 2+ weeks post-op extensive abdominal surgery for cancer has been on high dose pain meds and anti-anxiety drugs. Her surgeon abruptly decreased the former and discontinued the latter two days ago, then added ibuprofen and Tylenol in place of the dropped narcotic doses. E. sailed through Thursday, feeling so wonderful that she went with her cousin up Trail Ridge Road, a spectacular mountain road which tops 11,000 feet in spots. The trip was a treat, but she began to feel shaky on the way home and had a full-blown panic attack early Friday morning. Queasy, breathless, and in pain, she called me over to help.

So what was going on? Was she queasy from pain, withdrawal, or ibuprofen? Was she anxious from a lack of anxiety meds, withdrawal from tranquilizers, increasing pain, or the fear that she'd have another panic attack? Was she in pain from doing too much too soon, undertreated post-operative healing, withdrawal cramps, or from ibuprofen-induced colitis? Or all of the above?

Perhaps a top-notch cancer surgeon, which I believe her oncologist to be, has no more business adjusting meds than an internist such as myself has performing cancer surgery.

Aching feet in Denver, Colorado

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

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

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

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

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

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

Antipsychotics and the elderly

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

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

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

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

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

Licofelone and osteoarthritis

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

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

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

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

Spondylosis

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

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

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

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

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.