Back away from the computer, ma'am!

Received from a patient today:

"I am still having a very upset stomach and some episodes of diarrhea (3 to 4 a day now). They are happening after each email now instead of just in the evening."

Elderberry juice and H1N1 flu

I posted some time ago about a potential influenza complication known as a cytokine storm. While this violent immunological over-reaction is known to occur with H5N1 or 'bird flu,' it has not proven to be a problem thus far with this current epidemic. In fact, the adults (I see few teens and no children) in my practice, while not enjoying their bouts of 2009 A(H1N1) flu, are finding the one week course more a matter of misery than serious disease.

I only just got my H1N1 shot last week--the Denver Public Health Dept. did not feel that internists were a high risk group! As I've been seeing cases of this flu for months, I started taking elderberry juice concentrate about a month ago. An article published in July of this year(1) used spectrometry to determine which elderberry molecules bound to the influenza particles thus inhibiting their ability to penetrate and infect host cells. Two compounds were identified that, in fairly low concentrations, stopped the little flu buggers dead in their tracks. In fact, their ability to inhibit H1N1 infections in lab conditions compared favorably to that of Tamiflu.

I ordered my elderberry concentrate from wyldewoodcellars.com. Per my favorite naturopath Dr. Jacob Schor, I take 1 tablespoonful in water each morning. I won't kid you, I don't love it, but it's palatable and better mixed with OJ.
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1. Roschek, B. et al. Elderberry flavonoids bind to and prevent H1N1 infection in vitro. Phytochemistry 2009 Jul;70(10):1255-61. Epub 2009 Aug 12.

Oil pulling testimonial

I've written before about oil pulling, an ayurvedic practice that involves swishing a mouthful of oil around in the mouth for 10-20 minutes first thing in the a.m. One web-site proclaims that "regular application of this treatment by reversing [this natural bodily intrusive element evinced by the microflora] so that wellness is the dominant state of the human body is likely to increase the average human lifespan to approximately 150 years, double the present life expectancy."

Well I don't know about that, I don't even get what this authority is talking about. A small study from India(1) concluded, however, that oil-pulling daily for 10 minutes caused a significant decrease in oral Streptococcus mutans (the bacteria that promotes tooth decay) within 1 week of starting the practice.

I recently visited my dental hygienist for a check-up and cleaning. I have practiced daily oil pulling with sesame oil for 5 of the 7 months since my last visit with her. The conclusion? Less stain despite daily coffee, no difference in plaque, very healthy gums, and--best-of-all for me--no sensitivity in the lower teeth to her merciless probing. She was so impressed by the sparkle of my front teeth (so shiny, per her, "they look like glass") that she plans to recommend the practice to others.
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1. Asokan, S et al. Effect of oil pulling on Streptococcus mutans count in plaque and saliva using Dentocult SM Strip mutans test: A randomized, controlled, triple-blind study. J Indian Society of Pedodontics and Preventive Dentistry 2008. Vol 26, Issue 1, pgs 12-17.

Hydrosal, Drysol, and hyperhidrosis

I can now wear tops TWICE and can wear regular shoes. DrySol, you're the best!
--Comment from satisfied user on drugs.com

I had the mixed pleasure of dining at Red Robin recently. Always a pleasure to not cook dinner and not clean up afterwards, but the burger was just so-so. I was briefly alarmed to note as the host seated us that he had enormous sweat rings below his armpits, but then I realized that some misguided RR fashion designer had put darker panels of red material down the sides of the staff's red t-shirts.

Some people, of course, do suffer from axillary hyperhidrosis or excessively sweaty pits. And they suffer terribly, choosing clothing colors less likely to broadcast their problem, keeping their arms close to their bodies. Never raising their hands because they're sure it would be an embarrassing mistake.

Enter Drysol, one of medicine's best kept secrets. Part of the problem, my problem anyway, is the don't ask/don't tell mentality of hyperhidrosis. If I don't ask, patients mostly don't tell me that they suffer from sweaty pits, hair, hands, or feet. Last month, however, I had a patient ask for Drysol by name--he'd heard about it from his nephew. And now he says "It's changed my life."

Those are strong words indeed, praise I most often hear applied to antidepressants, anti-anxiety, and anti-acne medication. Drysol or aluminum chloride hexahydrate is strong stuff. It doesn't always work, and it stings like crazy if applied to wet or newly shaved skin, but when applied with care according to the directions, many hyperhidrotics lose their drip.

Hyperhidrosis is a disorder of sudomotor nerves or those nerves that hook up to and activate sweat glands in response to heat or emotion. While thermoregulation (keeping body temperature in a healthy range) is controlled by the hypothalamus deep and central in the brain, sweaty response to emotion is under the control of the anterior cingulate cortex behind the rational frontal brain and heavily connected to our fear-directing amygdala.

A new preparation of aluminum chloride hexahydrate has been released called Hydrasal which is in a salicyclic acid gel formulation rather than pure alcohol. Small studies recently released at the March meeting of the American Academy of Dermatologists show this product is better tolerated than the Drysol preparation and is also useful in patients who are undergoing Botox injections for hyperhidrosis with incomplete relief of excessive sweating.

Bacterial contamination from toilet flushing

I recently completed a long car trip, and thus spent more than a moment in public restrooms. Once in the stall, purse and road atlas in hand, I faced each time the dilemma of where to stow my gear whilst completing my business. Some facilities have elegant shelves to hold these items, others a hook on the door, some no place at all but the more or less unsavory floor. Imagine then how floored I was to read this item in the latest issue of Health Magazine(1):

"Don't put your purse on the bathroom floor; E coli in spray droplets following a flush may land on it. Hang it in the stall, and clean it inside and out weekly with a disinfecting spray or wipe."

Flushed with doubt, I wondered if this was all some sensationalist piece of journalistic nonsense designed to sell magazines and Wireless Wipes. But alas, check this out and think it over the next time you set your bag on the only dry spot on the tiled floor of a public can:

Microbiologists in the UK (2) contaminated "the sidewalls and bowl water of a domestic toilet to mimic the effects of soiling after an episode of acute diarrhoea." In other words, they dumped a gelatinous turdoid sort of matter containing fecal pathogens into the toilet bowl. Cultures of the bowl water and porcelain surfaces confirmed that significant colonies of the little darlings were clinging for dear life therein. They then flushed, and subsequent testing of the toilet AND the surrounding air confirmed that the bacteria had diminished in numbers in the actual toilet (thank heavens) but that a significant number of them had been jettisoned into the air on aerosol droplets of toilet water.

Dr. Barker and company concluded: "Many individuals may be unaware of the risk of air-borne dissemination of microbes when flushing the toilet and the consequent surface contamination that may spread infection within the household, via direct surface-to-hand-to mouth contact. Some enteric viruses could persist in the air after toilet flushing and infection may be acquired after inhalation and swallowing."

Think about it. Your toothbrushes sit how far from your toilet? My bathroom cup is inches away from mine. Do you close the cover before flushing? All this dainty hand washing, was it before or after you picked up your purse from the bathroom floor?

Yech.
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1) Health. November, 2009. p. 20.
2) Barker, J, Jones, MV. The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet. J Appl Microbiol. 2005;99(2):339-47.

Diagnoses at Denny's

I've mentioned before that I tend to diagnose the passers-by that I see around town and on the road. I was eating breakfast at the Denny's in Moab, Utah this past week when a middle-aged couple lumbered to their seats.

They were both quite wide in the middle, carrying way too much visceral fat packed around their waistlines. Doubtless two cases of metabolic syndrome, a high risk constellation of central obesity plus two of the following: high blood pressure, low HDL cholesterol, diabetes or elevated fasting blood sugar, and elevated triglycerides. Of course, I have no idea about their lab findings, but he no sooner sat down but he pulled out a ziplock baggy jammed with pill bottles.

He was unnaturally red in the face contrasting with his pale arms and legs sticking out from t-shirt and shorts. Sunburn? Shoot, that's a med. student's diagnosis. Idiopathic erythema? Rosacea? Polycythemia vera? His legs, however, had none of the swelling or skin changes associated with venous insufficiency which is a good sign, but his calves and thighs were scrawny which may be a bad sign per a recent report that a low thigh circumference is associated with a higher risk for heart disease!

As they sat, unaware of my clinical musings, she leaned forward, grinning, and said something to him in a low voice. His face immediately crinkled with amusement and softened with affection.

My final diagnosis? They were in love!

Fun with the flu

My patient no sooner sat down when she grabbed a Kleenex, said "Hold on!" and quickly turned away, coughing wetly into the tissue.

"Oh gad," I thought unhappily, "She's going to show it to me."

At that moment, my patient dabbed delicately at her lips, looked over her shoulder, and said, "Don't worry, I'm not going to show it to you."

We both burst out laughing.

C. difficile and diarrhea

Clostridium difficile (C. diff) is one of many reasons to stay out of the hospital. This bacteria is not a normal inhabitant of the human gut, but once it gets a toe-hold therein, it invades the colon wall, produces toxins, and causes serious illness with bloody diarrhea. Long classified as a nosocomial infection (acquired as a result of being under hospital care for another medical problem), C. diff is now showing up as a community-acquired infection.

The classic patient profile for C. diff sufferers is someone who is old, rather ill, and receiving heavy duty antibiotics such as clindamycin, cephalosporins (which are routinely given before surgical procedures), and fluoroquinolones such as Cipro and Levaquin. Several times a year, I see a patient who has none of those characteristics but has big-time diarrhea due to C. diff. Here's disconcerting news about possible sources of community acquired C. diff.

1. Meat in Tucson: Researchers there sampled both raw and "ready-to-eat" meat from supermarkets. 42% of the product tested was positive for toxigenic c. diff.(1)
2. Ready-to-eat salads in Scotland: 7.5% of these "healthy choices" harbored virulent c. diff.(2)
3. Meat in Canada: 20% prevalence, and more common in winter.(3)

Denver infectious disease specialist Dr. Mary Bessesen theorizes: "I suspect that animals carry it in their gut and on their skin when they arrive at the packing house." She goes on to note that no one knows for sure whether C. diff in the commercial meat supply causes human disease but "what we have thus far is suggestive only--not proof--but it is concerning."

Yuck.
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1) Songer, JG et al. Emerg Infect Dis. 2009 May;15(5):819-21.
2) Bakri, MM et al. Emerg Infect Dis. 2009 May;15(5):817-8.
3) Rodriquez-Palacios A. et al. Emerg Infect Dis. 2009 May;15(5):802-5.
4) Vujia, DJ et al. Emerg Infect Dis. 2009 Jan;15(1):69-71.

"Using the daylight"

Wise words from a century ago(1):

When illumination was poor, people went to bed shortly after nightfall and arose at daybreak. As illumination has become better, they have gone to bed later and later, especially in the cities; and the hour of rising has grown later until, in the summer at least, many persons sleep as much during daylight as in the dark.

This is of course unfortunate. Sleep is never so restful--at least for most persons--during the hours of light as when it is dark. Everyone knows this from personal experience. The old saw was that two hours of sleep before midnight were worth twice that amount afterward; and while this might not be literally true, the truth in it is that if sufficient sleep is to be obtained after midnight, then much of it must be secured after darkness has ceased. Everywhere one hears the complaint that people are becoming more nervous and are losing the power to rest thoroughly. Undoubtedly, some of this--probably much more than we suspect--is due to the fact that so much of sleep in city life where the increase in nervousness is particularly noticeable must under present conditions be obtained during hours of daylight.

The article goes on to make a case for the establishment of daylight savings time. So now we have daylight savings time, and people are still going to bed too late but now they're also getting up too early, getting insufficient sleep whether it's dark or light. And ever more, they're also becoming more nervous and are losing the power to rest thoroughly.

You cannot flick off bright lights, computers, or TVs and just pop into bed expecting to fall directly to sleep. A case could be made for turning down the wattage in preparation for bed, perhaps reading with just an Itty Bitty Book Light turned onto the page instead of a table lamp flashing our brains. Less Ambien and more common sense.
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1)The Journal A.M.A., July 31, 1909, liii, 383, 387.

Influenza, antibiotics, and procalcitonin

Sure, I know what procalcitonin is, namely that which is not yet but will be calcitonin or the hormone produced by the thyroid which shuts off bone breakdown. Salmon calcitonin (Miacalcin) nasal spray used to be the only drug available for treatment of osteoporosis before Sally Field and other aging baby boomers elevated this condition to a status worthy of new and better compounds.

So what's this got to do with antibiotics? Nothing that we knew about back when I was in med school, I can assure you of that. An article and editorial in a September issue of JAMA(1), therefore, was quite an eye-opener on just how important it is to continue on with continuing medical education.

First, a word or two about lower respiratory tract infections (LTRI) and antibiotic use, a subject that impacts my patients and my decision-making processes every day, especially as swinish flu slams the Denver area. Why do I closet myself several times an hour with some miserable coughing wretch at great personal risk to my own lower respiratory tract? To distinguish ordinary, show-stopping/week-ruining influenza from its many complications, particularly secondary bacterial bronchitis and pneumonia. Often it's me (don't want to overprescribe antibiotics to avoid complications to the patient and antibiotic resistance to the public) vs. them (No time for this! Need antibiotics! Big test/presentation/trip/wedding coming up! Need antibiotics!).

I check out: how sick are they, how long have they been sick, are they having trouble breathing, is their O2 level low, how do their lungs sound, what color are their secretions. Knowing all the while that they feel miserably sick, any days with flu are too many days, their airways are swollen so of course they feel short of breath, and, of course, their secretions are doubtless gross because flu-sloughed cells in the airway plus gobs of white cells will make that which they hack out green.

Surely there must be a better formula other than my experience + intuition + observations. Enter procalcitonin(PCT), and it's not just for regulating calcium anymore. While the thyroid C-cells make PCT and turn it into calcitonin depending on the biochemical need to drop calcium levels in the blood, all sorts of other tissues release PCT when the body is fighting bacterial attack. Under normal conditions, PCT is barely detectable in the blood but levels can soar 100,000-fold with widespread sepsis as bacteria invade the bloodstream.

So here we have a wonderful demonstration of theragnostics (another concept that's new to me) wherein a diagnostic test--say PCT levels--identifies patients likely to be helped by a certain therapy, and then targeted drug therapy is given--e.g.antibiotics--based on those results. And I, with my expensive cognitive skills, am cut out of the equation thus making therapy not only more scientific and less intuitive, but also more accessible and affordable!

Now of course this is not yet anything you'll find in a Walgreen's TakeCare Clinic (until perhaps a handheld PCT-O-Meter is developed) but the possibilities are exciting. Not only could we know just when to treat acute bronchitis or pneumonia with antibiotics because PCT levels indicate a bacterial source, we could use this test in other puzzling situations such as whether or not artificial joints are infected or a patient with worsening chronic lung disease has an infectious complication.
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1) Schuetz, P et al. Effect of Procalcitonin-Based Guidelines vs Standard Guidelines on Antibiotic Use in Lower Respiratory Tract Infections. JAMA Sept. 9, 2009 Vol 302, No. 10 1059-1066.

Emotion and Memory

My friend got lost years ago while on a cross-country skiing trip. The morning paper and the evening news reported search efforts in daily, discouraging detail. Time passed, and the possibility that my friend and her skiing partners lived on became less and less likely. One day, however, while driving home with the car radio on, a breaking-news bulletin announced that they had been found, alive and well if a bit frost-nipped on fingers and toes. I had to pull over and get a grip on my teary emotions.

I can tell you the exact spot I pulled over, the weather, and where I had been. This all quite remarkable as, on average, I've a big picture sort of mind while the details leak before storage in long-term brain files (no surprise this to my husband). My friend later told me that everyone invariably related the minutiae of the moment in which they'd heard of her rescue--this after I'd supplied her with my experience as if it were the most fascinating tale.

So what's with this emotional boost to memory? If you were alive at the time, you can doubtless remember where you were when Kennedy was shot or the moon landing occurred. Likewise for the World Trade Center tragedy and perhaps Princess Diana's death.

Japanese neuroscientists studied emotion and memory in patients with Alzheimer's Disease (AD) following the devastating Kobe earthquake of 1995.(1) They performed brain MRIs on all the subjects, then checked out who remembered the earthquake and who remembered the MRI. The patients were much more likely to remember the quake, suggesting that intense emotions reinforced the memory.

The researchers went on to correlate the ability to remember the temblor with the residual size of the subjects' hippocampus (the brain's memory center) and amygdala (emotional center). Victims of AD are known to suffer from brain shrinkage. Those who retained the emotional memory of waking up to a significant earthquake were much more likely to have a normal-sized amygdala no matter the size of their hippocampus, and, likewise, those with impaired emotional event memory had more intense amygdalar damage.
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1)Kazui, H. Emotion and memory. Four studies of the emotional memory in Alzheimer's disease. Japanese Journal of Neuropsychology. VOL.18;NO.3;PAGE.150-156(2002).

Can Prednisone make me feel crazy?

If you've ever taken it, you already know the answer is an emphatic YES!! Here's a visual from my friend and artist Rose Kelly about her trip to the "Prednizone" while undergoing chemo.

Advanced glycation end products

That which is truly tasty, like make the hair stand up on your neck and shiver over the full delicious tastiness of it all, may prematurely age your blood vessels, your nerves, your kidneys, and your joints.

These advanced glycation end products or AGE are the end-products of reactions that bond sugar to protein in the absence of water. Think sugar steaks (too bad you won't want to try one at Bastien's Steak House on Colfax after reading this), the brown sugar/Jack Daniels crust on baked ham, browned cookies, the caramelized surface of creme brulee. So let's just say you avoid AGE in foods, and I'm not necessarily saying you should because, after all, life is meant to be enjoyed, well turns out you can glycate your own darn sugar once its ingested or produced. And fructose (that which sweetens your bottled drinks) is very prone to glycation.

So AGE along with ALE (that would be advanced lipoperoxidation end products or metabolized fat) are very proinflammatory molecules. AGE hooks up with specific cellular receptors called RAGE and the combo acts as a 'master switch' that activates nuclear factor kappaB(1) and creates high levels of dysfuntional proteins among other things. The sort of dysfunctional proteins that gum up your brain, your peripheral nerves, and your arteries.

Well we're all going to rust and glycate and peroxidate eventually, and we may as well do it with the satisfied smile of the occasional gourmand. But, as in all things, a little is good but a lot is not, and if you want to keep your cells functional, some things are best done in moderation or not at all.
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1) NF-kB is a good thing if you happen to be injured or infected as it amplifies the immune response but a bad thing if you happen to drink Coke and eat browned chocolate chip cookies on a regular basis.

New Diagnoses, New Behavior

Can't look for what you might find
Once more you're running around in circles just to prove
You knew the answers all the while
Can't figure why no matter what you say or do
Things stay the same you will remain
Day late a dollar short
Day late a dollar short
--The Acro-Brats(1)

There's nothing like a new diagnosis of diabetes to get a patient's attention. Suddenly, all those discussions about diet, exercise, weight loss, soda consumption, etc. make sense. Well better late than never (perhaps The A-B's have a song about that too) but there's also the day late dollar short thing too because this is a condition that you are far better off without.

Yale scientists actually set out to prove what I already knew from years of consultations with the newly diagnosed. They checked out data from the Health and Retirement Study panel on over 20,000 people who were overweight or smokers.(2) The odds of weight loss or smoking cessation were hugely increased among individuals newly diagnosed with serious illnesses such as diabetes, smoking, heart disease, or COPD. Those who'd just learned they had heart disease were 5 times more likely to throw away the smokes than persons just counseled to do so just because it was the right thing to do, and new diabetics sent their BMI's plunging compared to the merely overweight.

Can't figure why no matter what I say or do
Things stay the same patients will remain
Day late a dollar short
Day late a dollar short

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(1) I actually listened to this song on You-Tube. Definitely not my thing--the metallic thrum made my amygdala cringe-- but I appreciate the edgy frustration expressed by the Acro-Brats. I feel it myself, everyday, in exam room encounters.
(2) Keenan, PS. Smoking and weight change after new health diagnoses in older adults. Arch Intern Med. 2009 Feb 9;169(3):237-42.

Too close for comfort?

I recently attended my 40th high school reunion. I talked for awhile with one old friend I hadn't seen in years. But I was distracted during the entire conversation by her preferred conversational distance which was close, darned close! Not a breath problem--hers was fine and apparently mine was too--just my problem with her 'in my face' proximity. A new study may indicate why, and it implicates my overactive amygdala.

I've mentioned before that the amygdala, an almond-sized region at the base of the brain, is nerve cell center for coordinating response to threat. If yours is on overdrive like mine, you may over-respond to horror movies, scary books, and phones ringing in the night.

Neuroscientists had the opportunity to study the biological underpinnings of personal space in a patient known as SM. She had a genetic disorder that took out her amygdala, and as a result, she could not recognize fearful facial expressions in others, and was very outgoing and far more trusting than average. And she cozied up in conversational situations such that she--Ms. Red above--let an experimenter get twice as close to her as the other Ms. Blues did without expressing any discomfort in the situation. (1)

Scientists went on to study preferred conversational distance with functional MRI scanning.(2) They socked away average persons with intact amygdalae in the machine, then got closer and closer to the subjects, measuring their brains for activity. When they invaded that person's comfort zone, the amygdala lit up with activity.

"Our findings support the idea that the amygdala functions as the brakes in social interactions, If you take away the amygdala, it seems like you are less tuned to ... social [behaviors] that can cause discomfort," says neuroscientist Richard Davidson of the University of Wisconsin.(1)
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1) ScienceNOW Daily News, August 31, 2009
2) Kennedy DP et al. Personal Space Regulation by the Human Amygdala. Nat Neurosci 2009 Aug 30.