Big-time kyphosis

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

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

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

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

The Teeming Team from Palliative Care

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

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

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

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

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

Prostate Cancer Risk Screening

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

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

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

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

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

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

Doc of Ages now on Twitter

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

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

Is Multitasking Bad for Your Brain?

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

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

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

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

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

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

Verbal fluency exercises

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

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

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

Weekly H1N1 flu update

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

A few words about seasonal flu

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

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

What's all the fuss about H1N1?

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

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

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

Tuna casserole deficiency or cardiac arrest?

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

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

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

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

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

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

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

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

What's your excuse for sneering at tuna casserole?

Cankles

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

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

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

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

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

Limbrel--new option for osteoarthritis

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

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

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

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

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

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

Patellofemoral pain, arthritis, and exercise

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

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

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

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

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

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

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

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

I'll be doggone!

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

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

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

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

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

A biological reprieve from life in a shoe

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

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

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

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

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

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

The oriented-in-space place

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

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

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

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

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

What's the scoop on the flu?

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.