What's the scoop on the flu?

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

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

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

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

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

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

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

Of linens and proteins...*

And stressful situations in closets and cells.

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

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

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

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

"The Power of Two"

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

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

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

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

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

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

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

In praise of Dr. Anthony Laporta

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

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

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

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

Fretful and friendless raises risk of dementia

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

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

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

Flector patch--the first NSAID patch for pain

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

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

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

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

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

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

How do crossword puzzles help my brain?

Check it out at Menopause Moments.

YogaToes revisited

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

Can NSAIDs prevent Alzheimer's Disease?

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

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

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

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

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

Kefir and breast cancer

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

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

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

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

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

Updated colon cancer screening guidelines

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

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

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

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

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

Breast cancer and hormone therapy

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

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

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

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

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

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

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

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

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

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

Pilates, back pain, and Denver's old spines

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

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

L-carnitine for your hair

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

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

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

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

Moxxor

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Pedometer-based walking intervention

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

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

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

I trust the experts were pleased.

Statins and infection control

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

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

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

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

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

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

Skinceuticals C E Ferulic

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

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

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

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

Fat or not, the fit live longest!

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

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

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

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

ESBL E. coli

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

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

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

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

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