How do you spell relief?

Relief is defined as ≥ 3 spontaneous bowel movements (SBMs) per week.
Promotional slogan, amitiza.com

Don't get me wrong, I'm not making light of the importance of SBMs. Bad bowel days may not be as obvious a setback as bad hair days, but they are, nevertheless, real show-stoppers. I do wonder though how much these drug companies spend on marketing and name selection, and whether or not these are dollars well-spent.

Ad campaigns aside, a new solution to a chronic lack of SBMs is always welcome. Amitiza joins Zelnorm in a tight little market clogged with far more patients than solutions. As opposed to Zelnorm, however, Amitiza does not work on the nerve supply to the gut, but rather on plumping up those stools with more water.

Amitiza, also known by its generic name lubiprostone, is a selective type 2 chloride channel activator. What do active chloride channels mean to you? More intestinal secretions, accelerated movement of digesting food remnants through the small intestines and colon, and, best of all, 1.9 more SBMs each week.

How good is that? I don't know yet, but the drug company is trolling out food and information on Amitiza for me this summer. Now who else but doctors would be willing to discuss this sort of thing over lunch?

All I have to do is mention the word 'diarrhea' to my son at the dinner table to make him push away his plate. (Just trying to fill the fam in on my exciting day at the office.) While the reluctant teen is working as our office 'file technician' this summer, I don't suppose he'll attend this particular luncheon, even for the free food.

Chantix revisited

I asked the Pfizer rep today what was up with this name Chantix (see below if you haven't a clue what Chantix is). She said the original name was supposed to be Champix, but that sounded too much like Chapstick.

Good choice to change--you do not want a smoking cessation drug with a name like a prize-winning feminine hygiene product.

Dressing like a doctor

I am dreadfully tired of travel knit. So I went off to Cherry Creek Mall in search of a new look and found a lacey white blouse of the kind that looks so great on young models. Just the thing to team up with a '80s broomstick skirt from the depths of my closet.

Dear heaven, what was I thinking? I put the whole look together this a.m.--like the leading lady in a senior production of "The Sound of Music." Who wants to see a healer who resembles Heidi on Geritol? Nice neck, doctor...a little crepey perhaps.

Just returned the blouse to Anthropologie and took the skirt to Goodwill.

Amitiza

Good drug, dumb name? Watch here for more information.

Chantix

What an inscrutable name for a smoking cessation treatment!

Clinical trials indicate that Chantix (varenicline) is better than Wellbutrin (Zyban, buproprion) for parting smokers from smokes. Despite a weensy bit of nausea, Chantix users threw away their cigarettes AND did not dig them back out of the trash significantly more often than the trial participants on Wellbutrin.

I've mentioned previously that nicotine binds to certain receptors in the brain where it sets off a rewarding release of dopamine. Chantix also gloms onto these alpha4beta2 receptors--better than nicotine--causing a little dopamine surge but not a big reinforcing one. As a result, nicotine withdrawal symptoms are squashed, but the smoker becomes accustomed over 12 weeks of therapy to life without those cigarette highs.

As The National Commission on Prevention Priorities has tapped tobacco-use counseling as one of my top three health-promoting strategies in patient care, let's hope this little hummer of a drug delivers on its promise.

Dianosed in a fingerstick!

Don't miss the upcoming June issue of Vintagefemail about a new test for ovarian cancer.

Doctors for Adults

This catchy little slogan from the American College of Physicians (ACP) reminds you that you just have to love internists. Perhaps you didn't ever give that a thought. Consider then:

"They are specially trained to solve puzzling diagnostic problems and can handle severe chronic illnesses and situations where several different illnesses may strike at the same time." Direct from doctorsforadults, this stirring language confirms that primary care providers such as myself, trained in internal medicine, are 'whole picture' kind of docs, diagnosticians who take the extra time to consider your entire health situation.

So now how good is that? Well, unfortunately, general internists are leaving the field in droves, and the proportion of third-year internal medicine residents choosing internal medicine careers has dropped to 1 in 4.

Dr. Donna Sweet of the ACP Board of Regents warns, "Unless steps are taken now, there will not be enough general internists to take care of an aging population with growing incidences of chronic diseases." Perhaps Dr. Sweet is a weensy bit biased from her chair position on the ACP Board of Regents, but she's got more to say: "Without general internal medicine, the health care system can become and will become increasingly fragmented, overspecialized, and inefficient, leading to poorer quality care at even higher costs than we have today."

On the heels of all this bad news from the ACP, the Centers for Medicare and Medicaid Serices are considering moves to make primary care for aging adults an even less attractive practice choice than ever. They are proposing a 4.6% pay cut for 2007. Dr. Larry Fields of the American Academy of Family Physicians is blunter than Dr. Sweet when he notes that many more physicians may stop taking new Medicare patients or may even close their practices. In short, says Dr. Field, "When the overhead is greater than the payment there won't be any access."

Digestive Diseases Week 2006 has sadly come to a close. If you missed it, this yearly gathering of gastroenterologists met last week in Los Angeles.

One presentation by St. Louis investigators from Washington University confirmed previous research that type 2 diabetics are at a higher risk for colon polyps of the precancerous variety. Dr. Jill Elwing reported that adult diabetics, specifically women, were found to have a 2- to 3- fold increased risk of lower intestinal tumors. She concluded: "The most clinically significant impact of this finding is that diabetics should undergo colon-cancer screening because of their increased risk for colon polyps."

We're continuing to run Saturday a.m. colon screenings for women at the Rose Endoscopy Clinic. Check out colonoscopies do not knock your socks off, then call my office to schedule yours.

The National Commission on Prevention Priorities has spoken.

I've long realized that the only really important thing I do with my stethoscope is take a blood pressure. Beyond that, my time is best spent discussing health habits and lifestyle changes during annual exams with respect to improving future outlooks for my patients.

The NCPP agrees. They've ranked preventive services according to their worth in "clinically preventable burden and cost-effectiveness." In other words, what can I as a primary care physician do for you that best results in serious troubles prevented per dollar spent to do so.

Their conclusion? The top 3 servces are: 1)Discussing aspirin use with adults at high-risk for cardiovascular disease, 2) immunizing children, 3) tobacco-use screening and intervention. In another look at their data, they also selected high-ranking services that were not being utilized at a very high rate, including tobacco counseling, screening adults over 50 for colorectal cancer, and immunizing adults over 65 with the pneumonia vaccine.

In other words, hang up the stethoscope. It's a good thing too; as some of you may know I often have trouble finding mine where I last left it.

"These changes were independent of diet and exercise."
--Dr. Alexandra Einerhand,
Loders Croklaan, Wormerveer,
The Netherlands

'These changes' were a significant drop in body fat mass, as in 5.6% over six months. In this Dutch research study of 105 overweight adults, the women lost their lipid load in the abdomen and legs while the men just whittled their waistlines.

Now how good does this sound? No diet, no exercise, all these lucky volunteers had to do was down 3.4 gm. daily of conjugated linoleic acid (CLA).

CLA are normal dietary fats found in animals that graze and their milk. A brief search on Google suggests that 3 grams per day of linoleic acid would cost around $90/month. Fortunately, per Wikipedia, "Kangaroo meat may have the highest concentration of CLA when compared with other foods."

Ketek vs. the liver
Over a week into my recent illness, I finally gave in and started antibiotics. I felt awful from a secondary sinus infection and, like so many of you, I didn't "have time to be sick." Who does? I've seen at least ten patients this week with urgent needs to get well, including pending trips, visits from out-of-town guests, elderly relatives who need help but don't need to catch the illness, and upcoming high school graduations.

So it's especially disturbing to me that the very antibiotic that turned my corner with no side effects is now under fire from the FDA for reports of liver failure. Now how bad is that...liver failure?!? I'd rather have sinusitis than liver failure. There are only twelve reports of this side effect amongst many, many satisfied Ketek-takers such as myself. Still that's twelve people who wish they'd muddled through whatever infection they didn't have time for, and four of them aren't wishing anything anymore as they died.

This is just a reminder to me and you that these are potent medications that we're asking for in the middle of our busy lives.

LIFO.

My brother the MBA introduced me to this accounting concept. Last in, first out in a business sense means that the last units added to inventory are recorded as the first units sold. LIFO in a medical sense means that when I ask patients how that new drug is working out for them, they often answer "What new drug." And when I inquire about the fledgling exercise program that we talked about on a previous visit, they'll deny the conversation ever happened.

I'm definitely feeling a bit LIFO about my vitamins. As some of you know, I take quite a handful each day. The last in--turmeric--was the capsule that sent my stomach over the edge. For three days straight, I'd feel so nauseous after dinner that I assumed (who wouldn't?) that I was getting hepatitis. Finally I realized that my inner lump of supplements was the source of my distress. Not that a turmeric pill is nauseating, but it was just one pill over the tolerance line for me.

My friend Jean from France sent me a news item this week that an NIH panel has reported that Americans may be taking too many vitamins. I think they mean me.

Don't, however, give up on those calcium and vitamin D supplements. The recent report out of a sub-study from the Women's Health Initiative concluded that calcium and D are necessary to prevent postmenopausal bone loss but they may not be sufficient as the only strategy for bone protection. Somehow reports in the media took the evidence and concluded that calcium was no longer recommended.

In fact, Walter Willet MD, Harvard's nutritional guru suggests that most healthy adults should take 1,000 units of D each day. He commented, "This is a conservative amount, and higher intakes may prove better." So 500 mg. calcium and 400 units of D twice daily will stay in my vitamin pile. FILO.

A yummier, more informative drug dinner

Now ordinarily I don't attend two of these in a year. Three in one week is at least two too many, and not just because restaurants do not serve their usual fare to drug-sponsored groups.

The Avandia event was interesting though the food inscrutable. As a result of the information presented, I convinced one man with congestive heart failure and diabetes to register ASAP for Medicare Part D in order to afford this worthy drug that can actually reverse atherosclerosis AND improve diabetic control.

The Acomplia event was dull, the food appalling. I guess when the centerpiece drug du jour is designed to control risk of diabetes, heart disease, and obesity, the accompanying dinner must be sugar-free, low-fat, and fish-filled. As in dried up salmon with a side dish of undercooked asparagus wrapped in some nasty fishy flesh complete with scales intact, thinly topped in dry, whole wheat, tasteless dough. Disgusting. The speakers were just plain dull, as is the promise of Acomplia. It remains in FDA limbo without any particular promise of approval in the near future.

The grand finale dinner was at Cherry Creek's Mirepoix who delivered a dinner worthy of their best paying customers. Glaxo Smith Kline presented an informative dinner program that had almost nothing to do with their drug Advair. As a result of last night's dinner, I know:

1. Women are more susceptible than men to lung damage from cigarettes.
2. Chronic lung disease is the fourth most common cause of death in the US, and soon will be the third leading cause of death worldwide.
3. Women now surpass men with respect to incidence of chronic lung disease.
4. All smokers over 45, symptomatic with cigarette-related troubles such as cough or shortness of breath or not, should be screened with spirometry, a simple test administered in the office that measures lung function.
5. A significant number of asymptomatic smokers have a measurable decrease in their lung function.
6. Persons with asthma who reach for their rescue inhalers more than twice weekly risk suffering irreversible remodeling of their airways if they don't use a disease modifiying therapy.

And now I'm going to eat home for awhile and get my up-to-date information from medical journals.

Colonoscopies do not knock your socks off


Screening for colon cancer brings out the best in footwear. Participants in the recent Women's Colonoscopy Day sported smiles and excellent socks.



Frances with nurse Kay



Judy Paley and Dr. Lisa Schatz screen seven women at the first Saturday morning screening extravaganza at Rose Medical Center in Denver.



A portrait of Helen plus socks




Elizabeth waits for her turn





Debra Butrabaugh of the Rose Endoscopy Center handed each participant a rose as they walked out the door.

All declared: "No big deal!

Quadriceps and Mother's Day

I've got thighs and moms on the mind today for a couple of reasons. Not the least of which is that aging women such as myself increasingly see Mom in the mirror. We appreciate inheriting her wisdom, but are dismayed perhaps to see those tiny mom-like spider veins on our thighs now as well.

More important, however, is the task of keeping the quadriceps muscles strong. These muscles on the front of our thighs not only keep our legs fit for shorts--oh right, the veins already ended my short shorts career--but they hoist us out of our chairs, keeping us independent.

Furthermore, strong quads keep our knees in alignment, making them less likely to degenerate into arthritis. I'm off now to pick up Mom for a Mother's Day brunch--she no longer drives due to weak quads and knee arthritis. But first, a step aerobics class for the quads.

Check out holding up the joint for more info.

Eat & Learn

Grow sage and grow fat is more like it. I attended one drug company sponsored luncheon today on Avandia, a medication not only useful for diabetes, but also proven to REVERSE cholesterol plaques in arteries. The chicken dish, wrapped in tough as leather prosciutto, served with long strands of kale (or chard maybe) and funny little rectangular chunks of crunchy unidentified yellow stuff was dreadful. The information was fascinating, convincing me that Avandia is worth the extra copay for anyone battling high triglycerides and diabetes.

So tonight I'm off to yet another dirty drug money dinner, this one on Acomplia.. At last, the anti-fat, anti-smoking wonder drug is coming out. I'll let you know what I find out

Here's three bits of hopeful news about bird flu:

1) H5N1, the influenza strain raging through bird world, has never caused a human epidemic.

2) French researchers have completed a phase I trial with a vaccine made from inactivated flu virus which infected humans in Vietnam in 2004. The immunization was well-tolerated and resulted in a good antibody response in volunteer injectees.

3) H5N1 prefers to attach to cells with surface receptor molecules known as sialic acid-alpha-2,3 Gal. How would we even know what kind of news that is? Because Rotterdam researchers assure us that cells with this receptor exist deep within the lungs, which makes the avian flu virus less easily spread from one human to the next via a cough or a sneeze.

Here, however, is the bad news:

1) The virus, while not loving those upper airway cells, definitely has a taste for the lower airway. "The virus readily attached to and proliferated within the bronchioles and alveoli." This attack plan "may contribute to the severity of the pulmonary lesion," the Dutch specialists concluded from their studies.

2) While the same authors point out that it would take a series of mutations to interest the H5N1 in the upper airway, they remind us that "recombination is the real concern on everyone's mind."

Comfort food

Did your mother serve you ginger ale when you were sick? Mine did, so I, in turn, poured it for my children when they were home with an illness. Years later, both admitted that they hated gingerale. They loved, however, the Cream of Wheat, that I trolled out when they had a sore throat or stomach ache.

What is Cream of Wheat anyway? How did they take perfectly wholesome grain and make it white? And why is it so hard to clean the pot post-cooking? Nutritious or not, Cream of Wheat equals a mother's...or daughter's love. I made a creamy white bowl for my mom today as she was down and dizzy with something or other. Beats drugs!

Speaking of ailing mothers, she makes a good case for maintaining one's quadriceps while aging. More on that later.

Ladies' Day at the GI lab

I don't suppose one could ever call a colonoscopy fun. But there are ways to make it more pleasant. I'm just one free hour short of posting pictures from last Saturday's screening where seven women got that little bit of screening unpleasantness behind them.

Check back in a day or two.

A Hair-raising story

Have you seen this lady...in your mirror? I certainly have looked at a personal version since I started this plunge into menopause.

Granted, there are more important body parts to worry about through midlife and beyond: brain, heart, liver, breasts. And there are far more important things to do than count how many hairs have bailed off the scalp during the morning shampoo. I know I'm not the only one who's done that; one patient, an elegant woman in her 60s with short, beautifully styled gray hair brought in a baggy with way too much of that hair in it to demonstrated her a.m. loss.

My best hair days were during pregnancy, my hair thick, long, and glossy. My worst hair days were last year in the opening months of menopause. The difference? Estrogen levels for one, but estrogen cream to scalp helped not at all. Progesterone levels for another, and progesterone cream to aging head three times per week has made all the difference. Within one month of using it, my hair loss dropped off dramatically--yes, I do count!

I order the cream for my patients from a compounding pharmacy. I make my own from progesterone out of a Prometrium capsule with a little Estrasorb all mixed in Lubiderm. If you'd like the recipe, please contact me.

Occasionally while bouncing around at the 'top of the curve' which is Jazzercise-speak for that hot, sweaty, heart-pounding place at peak heart rate, I wonder if I'm not just a little too old for this.

So reassuring then to read in the Journal of the American Medical Association last month that the risk of pitching over dead as a woman at the 'top of the curve' is 1 per 36.5 million hours of vigorous exertion. This based on drop-dead data from thousands of aging nurses participating in the Nurses Health Study. Of the 84,888 female health professionals followed over 18 years, only 288 met with a sudden, unexpected demise. The good news for those of us exploring the top of our curve, however, is that only 9 of them did so while participating in hot sweaty, exertion.

With that reassurance, I invite those of you in Denver to meet me at the Jazzercise studio at Colfax and Elizabeth for the 10:15 Saturday a.m. Cardio-Quick class. If you introduce yourself and make it through the class alive, I'll buy you a wonderful high fat Starbucks treat.