Polydipsia and polyuria

No point in saying 'drink a lot' or 'pee a lot' when docs can obfuscate the issue with a fancy name for it. Either way, people know these symptoms to be possible signs of diabetes, and they tend to worry when do just that, peeing and drinking more than usual.

My friend J tends to worry no matter what, and anything out of the ordinary in her health or her family's health sends her into a tailspin. So when her son noted that he seemed to be going to the bathroom frequently, she did what she always does in circumstances such as that, she called me.

In H's case, the two important things to consider were: 1) Which came first, the polydipping or the polyurring?, and 2) How was he otherwise?. This young man was definitely a polydipper, drinking the recommended 8 glasses of water per day (which, incidentally, has been recently exposed as one of the top medical myths, so you're off the water-slugging hook!). If you dip a lot, you pee a lot. In addition, he was inclined to hit the head whenever the notion hit his head. If you give in to your bladder every time it twitches a bit, you end up with a lazy-ass little bladder which is unwilling to relax to accommodate even a little shot of urine arriving from the kidneys. This is a common problem among older women who have trained themselves to use the restroom whenever there's an opportunity.

Except for his frequent urination, H otherwise felt well. His energy and weight were good. He slept soundly through the night with no trips to the bathroom. Consider, on the other hand, the polyurring diabetic. They don't just pee a lot of regular old urine, night and day, they're peeing out excess sugar from their blood. The sugar makes the urine concentrated, so the kidneys send out a lot of water with it. As a result, uncontrolled diabetics are basically starving--and dehydrating--in the midst of plenty, their nutritional load pouring into the sewage system instead of into their cells. They begin to lose weight, and lots of it. I had a patient once who was basically a blob, both in personality and body shape. To his delight, his excess flab began to disappear effortlessly; this was too good, slimming down with neither diet nor exercise! His blood sugar, when he finally came in due to exhaustion, was 426. (His personality changed not a whit.)

Please note, however, that this load of poly-trouble characterizes Type 1 diabetes, the kind that begins abruptly and more often in children than adults. Type 2 diabetes, which generally develops in adults as a result of part genetics and part lifestyle, has a more gradual onset and is not associated with the sky high sugars and resultant sugar-laden urine seen in Type 1.

I was able to reassure J and H that diabetes was not a consideration in his situation.

Lack of rhythm and blues

University of Pittsburgh scientists have discovered that mice with mutations in their CLOCK gene are manic mice. The CLOCK gene is involved in maintaining daily body rhythms such as the sleep/wake cycle. Those mutant mice who are engineered to be CLOCKed-out display behavior reminiscent of patients in the manic phase of bipolar disorder--they sleep less, are hyperactive, and get extra-jazzed on sugar water or cocaine.

As a result of their mousy work, the researchers developed social rhythm therapy for bipolar patients--not a group discussion with percussion but rather psychotherapy geared towards developing regular routines. Those subjects who added the rhythm method to their usual clinical management had significantly longer remissions between manic or depressive episodes.

Dr. Ellen Frank said that many patients accused her of trying to make their lives boring. She answers thus:

You can have as many interesting and exciting experiences as you want, as long as you manage to get to bed at the same time pretty much every night and get up at the same time pretty much every morning.

Sounds like she's trying to make them middle-aged!

Fretting to my grave

Here I sit at the computer obsessively checking the conditions at Denver International Airport and the latest predictions from Frontier about the outlook for flight 448 to Philadelphia. Fret, fret, fret. Will my daughter even get over the river and through the woods to DIA? Once there, how is the line at security? Did they properly deice the plane? Will they take off on time? Will her driver, my husband, successfully navigate the icy round-trip on I-70 without mishap?

Took a break from flight checks to check the latest from Psychosomatic Medicine. Scottish docs did some checking of their own on middle-aged Brits with respect to anxious neurotic behavior and their tendency to pitch over dead. Those who fretted endlessly in their own neurotic way were 12% more likely to keel over from cardiovascular disease than those devil-may-care devils who flitted through life without worry.

Those who were extroverted, however, were less likely to die of respiratory disease. Perhaps the socially ept are less likely to smoke? What about those of us who are extroverted AND neurotic? No comment from the researchers on that.

SMURFS in your knees

If this title does not bring silly blue cartoon characters to mind, then you did not raise a small child in the '80's. Those of us who were child-rearers 2 decades ago may well be a subset of the aging population at risk for osteoarthritis of the knees. And now smurfs take on a whole new meaning.

In a degenerating knee sort of way, smurfs are enzymes also known as "Smad Ubiquitination Regulatory Factors." Turned-on smurf2 can turn cartilage cells into hard bone, a good thing if you happen to be a growing child. But smurf2 in an injured knee--say one that was pivoted in the wrong way whilst running cross a tennis court--can set off a chain reaction that ultimately results in the deterioration of the joint. Over time with repeated insults, poof! you got no cartilage but just the dreaded 'bone-on-bone' sort of painful knee joint that's destined for replacement. "Or," says Randy Rosier, MD of the University of Rochester "put another way, activation of smurf2 in the joint cartilage appears to significantly contribute to the onset of osteoarthritis."

Rosier and company are setting out to determine if patients with high smurf2 expression in an injured meniscus demonstrate accelerated wear-and-tear with loss of cartilage within 3 years of the injury. While the Rochester docs know of no way to halt the rampaging smurfs, they do think that the over-smurfed among us can be counseled to change their high impact activities and save their knees.
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*The meniscus is a C-shaped piece of cartilage on either side of the knee joint. These two wedges of cartilage cup the rounded end of the femur atop the flattened tibia below, stabilizing the two bones of the knee into a smoothly functioning hinged joint.

Do it by starlight...

it's the recommended strategy for those who go pee in the night. If you flick on the fluorescents, you prematurely shut off the brain's melatonin which in turn may end your good night's sleep. To ensure a post-void return to dreamland, get an itty bitty night light or just carefully fumble your way to the can.

Viagra raises flower heads too

I read this research item several years ago. Israeli researchers discovered that a small amount of Viagra added to the water in a vase of cut flowers extended their upright freshness for a week or more beyond a cut bouquet's usual lifespan. It does so by slowing the breakdown of cyclic guanosine monophosphate (so now we still don't understand how it works). Dr. Yaacov Leshem and associates discovered this tip for floral potency while working on a process to increase the shelf-life of produce.

At the time, I had free access to Viagra samples but no posies on which to experiment. I did, however, have a more or less fresh Christmas tree set up in the corner of my living room beside a hot radiator. In a typical year, the tree would be dry and shedding needles even before the big day arrived. I crushed up a little blue pill and added it to the water in the tree's stand. The tree retained its fresh pine smell, springy upright stature, and all its needles until New Year's Day when it was time to retire it to the alley.

Alas, no Viagra this year. We do have samples of Cialis, though, aka "Le Weekend" pill, so-named because its boosting effects can last le entire weekend or 36 hours. I figure our current tree could motor on until Valentine's Day with a stiff drink of Cialis-laced water.

It pays to be a little hippie

Well, I used to be a little hippie, and life was good if not lucrative. These days, however, research suggests that those who wear dessert upon their hips have less risk of heart disease compared to those who waist their fat.

This 'apple' vs. 'pear' thing has been known for some time. Abdominal obesity--that fat which is packed under your abdominal muscles and around your organs--is metabolically active, producing inflammatory molecules such as c-reactive protein and interleukin-6 which hasten the formation of cholesterol plaque in the arteries. How do you know where your fat resides? Lie on your back. If your fat puddles off to the side, gotta love it as it's stowed beneath your skin. Does it sit firmly above your body in the supine position like a late-term pregnancy? That's the bad visceral stuff.

This study from the UK was published in the latest edition of Circulation. The Cambridge docs showed that waist-to-hip ratio was a more important predictor of heart disease risk than BMI*. In other words, given similar degrees of overweight, the bigger the hips relative to the waistline, the less the risk of keeling over with a heart attack.

The researchers took it one step further. Even considering various cardiovascular risk factors like smoking and age, their analysis indicated that for every increase of 2.5 inches in hip circumference for men and for roughly 3.5 inches in women, risk of developing CHD was reduced by 20%.

If you're thinking what I was thinking, Dr. Dexter Cannoy has a final note of caution for both of us: We're not saying people should develop a big hip circumference to protect themselves from risk, but for any body size, those with bigger hips tended to be associated with lower risk...
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*BMI combines height and weight in a single number and, on average, the higher the BMI, the higher the body fat except in the well-muscled young.

Go East, young hamster

The 2007 IgNobel awards are out, and the winners in the aviation category are three Argentinian scientists who proved that hamsters on Viagra slipped more easily into an advanced light-dark cycle, the laboratory equivalent of a Californian jetting to New York City. As those of you know who've headed east into lighter later, the first day or two transition can be rough.

Eastbound travel is known to be more taxing on the body's biological clock than heading west. Various combinations of melatonin, coffee, sleep pattern changes, and bright artificial lights have been proposed to keep transatlantic travelers on their game. Now, it appears, this jazzed-up, furry little group has shown that raising levels of guanylyl cyclase and its related kinase along with other body functions raised by Viagra can improve your ability to jet east through time zones.

Happy Hanukkah!

'Top-down' vs. 'Bottom-up' Depression Treatments

Judy, RN commented on my recent antidepressant post that she was surprised that I didn't mention exercise and other therapeutic lifestyle changes (TLC) to improve my patient's mood disorder. I certainly do include those things in my initial meeting with depressed patients, and this particular lady and I had already discussed that. In fact, she is the poster girl for using TLC on her depression, and she was dismayed that despite her efforts, her depression was no better.

Top-down therapy involves the use of TLC or behavior that counteracts negative thinking through action. This favorably alters mood states through cognitive processes controlled by the cortical surface of the brain. Anti-depressants, on the other hand, target brain neurochemistry to work from the bottom-up to change mood and behavior.

The guru of the top-down approach using Cognitive Behavioral Therapy (CBT) is Dr. David Burns. I often recommend his book Feeling Good: The New Mood Therapy Revised as a good self-help resource to my patients. A good web-site for people so overwhelmed with life that they can't even manage their personal space is Fly Lady. She starts the inert and unmotivated with the baby step of nightly cleaning of their kitchen sink.

Researchers have demonstrated that either approach to the treatment of depression favorably alters brain activity, although in different ways. They performed positron emission tomography (PET) scans which shows those areas of the brain that are activated and currently consuming sugar. While both CBT and antidepressants were equally successful in correcting depression, the new, improved brain activity was quite different in the two sets of patients.

Study author Dr. Helen Mayberg concluded: "When treating clinical depression we know that one type of treatment doesn't fit all. Our imaging study shows that you can correct the depression network along a variety of pathways" She went on to note, "The challenge continues to be how to figure out 'how to best treat' for what the brain needs."

Should PCPs be treating bipolar disorders?

Dr. Smak raised a great point in response to my last post on treating depression, namely whether or not we, as primary care doctors, should be treating bipolar disorder. I've been reluctant to do so through the years as the treatment for bipolar troubles has become so complex, and I hate to prescribe meds with which I have little experience. Now, armed with Dr. Stephen Stahl's excellent textbook "Essential Psychopharmacology," I often start treatment, referring on to psychiatrists when patients have an incomplete response to my efforts. This for several reasons:

1) Finding a psychiatrist who is accepting new patients under any given insurance plan is a daunting task, one that would stop any energetic soul much less someone struggling with depression.

2) Finding a psychiatrist who can see a patient in a timely fashion is near impossible.

3) Pharmaceutical companies are directing educational efforts on medications for bipolar depression towards primary care physicians. That may make some of you wince lest my choice of drugs be based solely on who's taken me out to a free dinner lately. I can assure you that I don't venture out in the evening after a long day at work in search of free food, but rather welcome the opportunity to hear clinical research data on drugs that may be helpful to my patients.

Many of my appointments no matter what they're billed as (fatigue, stomach pain, insomnia, back pain) are, in fact, about depression. Once I've identified the mood disorder, I feel like I'm in a good position to propose non-pharmacological fixes (see tomorrow's post) as well as discuss the pros and cons of medical treatment. If I immediately refer to a specialist that the patient doesn't know, needs to call to schedule an appt., and may or may not be able to afford, chances are good that the patient won't follow up, and they will be back again in my office with ongoing depression.

That said, Dr. S., I agree I too am a bit of a wuss once I've gotten the patient on two different meds and they're not yet in remission. I tell everyone up front that we may end up calling on a specialist to perfect the plan.

What to do when the SSRIs don't work

I've known my patient S for years. She is a high energy sort of person, or at least she was until her underlying depression got the better of her once again during these past few months. She'd previously had good luck with Celexa (aka citalopram), so we'd restarted that antidepressant with some initial success. Today, however, she noted it just wasn't enough. The anxiety was better, she no longer felt bleak. The problem though...she didn't feel much of anything at all, stuck instead in a 'wrapped in cotton' sort of emotionless feeling, no enthusiasm or motivation to get anything done at all.

So what to do when the SSRIs* don't work. There's an array of therapeutic options with more or less good science behind them which include adding a second antidepressant such as Wellbutrin or Remeron (mirtazepine), an anti-anxiety agent called Buspar, a stimulant such a Ritalin, or a touch of T3 (triodothyronine). Given that S missed her joie de vivre most of all, after much discussion I pulled out my rx pad to write for Wellbutrin to shore up the dopamine in her brain. She mused about her longstanding depression as I wrote--"been depressed since I was seven."

Bingo, what was I thinking? Depressed since childhood, unresponsive to conventional antidepressants...hallmarks of bipolar depression. I pulled out a copy of the Mood Disorder Questionnaire, a rapid screen for bipolar disorder. The first 13 yes/no questions ask about behaviors common to this disturbance--7 positive answers are highly suggestive of the diagnosis. S answered yes to 12!

Never mind about the Wellbutrin. I wrote a prescription for Lithium, and S was delighted to finally have an explanation for her lifelong struggle with shifting moods.
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*SSRIs or selective serotonin reuptake inhibitors boost the action of a brain chemical called serotonin by preventing its removal from the gap or synapse between one brain cell and the next one down the circuit. These drugs include Prozac, Paxil, Zoloft, Celexa, Lexapro, and Luvox.

I have gotten on some kind of wacky female consciousness mailing list. This item from "Beauty and the Blood" may or may not have appealed to me in my younger hippie days, but today it gave me a good laugh, particularly when hummed to the tune of Row, row, row your boat...

Flow, flow, flow my blood,
Now release the old.
Endings end with beginnings again,
New eggs start to unfold.

Imagine being stranded in a lifeboat off the coast of Antarctica. Worse yet, picture stuck in that bobbing craft in icy waters AND being terribly prone to motion sickness. Denver's own Unsinkable Molly Brown aka Kay Van Horne has been there done that. The story, as you may know from your local papers, ended well. And fortunate for Ms. Van Horne, her quick-thinking niece, also on the doomed ship, just so happened to have one tablet of Dramamine in her pocket.

My recent travel adventure--I just returned from a car trip to the desert southwest--was absolutely tame compared to this, but I share the same trip-destroying tendency towards wooziness as Van Horne. I set out with a supply of Dramamine to survive all those twisty canyon roads, but never even opened the box. Apparently, Prevagen* also prevents motion sickness, and without the sleepy side effects of Dramamine.
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*If you missed the Prevagen post, check out my blog entry of 10/23/07. And note that Prevagen is on sale at amazon.com--25% off until the end of the year.

What are little boys made of?

Sugar, and spice, and everything nice? Well, at least the sugar part if the baby boy happens to be a mouse.

South African scientists found that the higher the blood sugar in mama mice, the greater chance that their little darlings would be males. In species whose males play the field, mating with more than one female, researchers theorize that it is advantageous for healthy moms (bigger and better fed and therefore with higher blood sugar) to have more sons. These strapping lads could sow their seed amongst a bunch of weak females whose sorry little mothers were skinny things with low blood sugar. Weak males, on the other hand, generally don't score at all. Thus, sugar mommies make more sugar daddies which is good for the future of the murine race.

Any particular relevance here for pre-diabetic men and their possible predisposition to produce male heirs? No, but this was just an interesting little bit of science to share.

Pulse pressure

If you're a little stiff from aging--in an arterial sense--new data from the Baltimore Longitudinal Aging Study suggests that you are at increased risk of memory troubles.

Here's one more vital sign to add to your life list: pulse pressure. This is the difference between the top and bottom numbers of your blood pressure. The top number or systolic blood pressure is that pressure generated by your heart as it squeezes blood from the left ventricle into the aorta and from there to the rest of your body. The diastolic pressure on the bottom represents the residual pressure in your vascular system as the heart relaxes and refills with blood in preparation for the next beat. Whether the top or the bottom value is more relevant to your health and length of life has been a matter of some debate through the years, but the systolic one is now generally accepted as most important. That said, not only is diastolic hypertension also of interest, but the gap between systolic pressure is increasingly noted as relevant to future stroke risk.

So, ideal blood pressure is less than or equal to 115/75. The difference, 115-75 or 40, is the pulse pressure. As people age and get all sorts of fat-laden schmutz in the walls of their arteries, this difference widens. Interestingly, while 170/110 (pulse pressure 60) would make your doctor pale, 170/70 (pulse pressure 100) is even worse yet.

Maryland docs studying Maryland old folks as part of the Baltimore Longitudinal Aging Study looked for a correlation between memories lost and pulse pressure. Sure enough, increasing pulse pressures and higher pulse wave velocity* were directly correlated with decreasing memory and concentration functions in aging individuals.

No more of those "at least your bottom number's okay" sort of reassurances of yore. The current goal is to keep the arteries pliable from the get-go by jumping all over cardiovascular risk factors such as blood pressure and cholesterol values. Those strategies that keep the arteries elastic--such as exercise and eating oatmeal--and those meds that directly promote endothelial cell health (those are the little hummers that line your blood vessels) such as ACE inhibitors are top of our A-list.

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*The mountainous curve which can be traced graphically from the pulse in your wrist as a wave of pressure goes by with each beat of the heart; the steeper the mountain, the bigger the difference between systolic and diastolic.

Prevagen on sale

For those of you who've been intrigued by the jellyfish/brain connection and are considering giving Prevagen a try, Amazon.com is having a one-day sale today; a one month's supply for $40 plus an additional 25% off! That ends up half price compared with the Prevagen web-site.

I'm still impressed with the effects of this supplement. I continue to enjoy less fatigue, less tremor, and here's the newest benefit...or coincidence. I generally avoid alcohol as it makes me extremely tired, like end the evening now and go to sleep tired. Last night, I drank one glass of wine and had no sleepiness with it whatsoever (and this after entirely too much dessert with the T-day dinner!).

100 % of the biologic existence of humans was adapted to an outdoor existence of hunting and foraging for foods.
--Astrand, P.O. Textbook of Work Physiology

Beautiful day here. A great day for a walk, or perhaps a final leaf rake. If I'm lucky, I'll get outside for an hour, but I've already been to step class so I'm disinclined to motor on in a sweaty sort of way. Not a chance I'll be cold, not a prayer I'll be hungry.

So my hunter/gatherer genes, superbly adapted to a life of cold, famine, and obligatory exercise, once again will be treated to a day of good and plenty. The human genome was perfected in the Ice Age, yet founders in the Space Age.

Humans survived those difficult pre-supermarket days by developing an efficient physiology that stowed calories against future times when nuts and berries were gone, and the deer and the antelope split. So how can we whittle away our waisted fat when all we need do is forage along Colfax Avenue for fast food any time night or day?

Research suggest the occasional day of fasting might restore balance to our disordered metabolism. In particular, overfed humans become resistant to the effects of insulin, and a day without food 'reminds' the body to delve into the pantry we haul about on our hips and abdomen.

Utah researchers, note that Mormons have lower rates of cardiovascular disease, and the reduced rate is greater than that explained by their non-smoking status alone. When they compared the rates of angiographically proven coronary artery disease between those subjects who fasted for whatever reason on a regular basis and those who kept the intake going regular, those who held fast to fasting were significantly less likely to have gummed up arteries.

The investigators defined fasting as no food or drink for two consecutive meals. Mormons fast once a month, could I? The last time I tried it in preparation for a colonoscopy, I spent half the day starving, then got past the lightheaded obsession by the middle of the day. I would need black coffee, however, is my Ice Age genome adjusted for that?

Why my hair is so thin, my smile so tense

Me: Do you sleep well at night?
Pt: Long rambling discourse on unrelated subjects that I am unable to recount here due to space considerations.
Me: Uh, that was a yes/no question.
Pt: Oh...Long pause...What was the question?

Several minutes later:
Me: How tall are you?
Pt: Hmm, well that depends. Sometimes 5'7", sometimes 5'8".

Dressing like a doctor

Long-time readers know that more than a little thought goes into that sassy professional look I sport at work. From the time I finish hanging out in my robe, reading the paper and drinking my coffee, to the time I roll in the office door dressed more or less like a doctor and ready for action, some 35 minutes have passed. And most of them spent fretting over what to wear and what, once again, to do about my hair.

Imagine my delight when my medical partner called me the other afternoon to "Quick, put on Oprah! It's a show about us!" Indeed, Oprah was featuring middle-aged fashion disasters, including one poor soul whose ungrateful teenager called the fashion police on her. Well, Adele and I may be stuck in yesterday's Chico's, but at least we're not still wearing flowered mini-skirts or fishnet stockings. Oh wait, I never wore those, and neither did she.

Adele was so moved, she went for a makeover. No, that's not me up at the top of this post, it's her, and believe it or not, some of our patients can't tell us apart. And me? I just discovered that Tuesdays are Senior Half-Price Day at the local St. Vincent de Paul Thrift Store.

Chew on this

My dental hygienist and I understand each other perfectly. Carol knows not to pick at the sensitive spot near a lower left molar, and I promise not to smack her hands away while she probes. We do share a love of flossing, however, and here's her latest find.

Check out G.U.M. brand's Soft-Picks. These darling little bristled picks are the very thing; they make satisfying little squeaky noises as you drag an entire village of bacteria screaming from your gum line. The Soft-Pick motto? Healthy Gums, Healthy Life.

Indeed, research shows that poor dental health in middle-age raises the risk of end-of-life dementia by 30-40%. Swedish researchers followed sparsely betoothed women over 24 years, then compared their incidence of dementia with their toothsome colleagues. Tooth counts proved that those women with 9 or less at study's start were 5 times as likely to lose their marbles by study's end.

Floss on.

Getting your hippocampus to the finish line...intact!

The hippocampus is a brain structure responsible for memory functions. Unfortunately, hippocampi tend to shrink under certain stressful conditions such as aging, depression, Alzheimer's disease, schizophrenia, bipolar disorder, post-traumatic stress disorder, epilepsy, and head injury. One reason why hippocampal neurons wither under stress is that they are 'excited to death' through overstimulation by various neurotransmitters such as adrenalin and glutamate.

Prolonged stress can permanently affect memory; major depression is a known risk factor for the later development of Alzheimer's disease. There is good news, however, for beleaguered brains from the world of neuroscientific research.

According to researchers at Washington University in St. Louis, antidepressants not only relieve symptoms of depression, but they are neuroprotective as well. The investigators used magnetic resonance imaging to measure hippocampal volume in 38 depressed women and compared the values with 38 controls. On average, the depressed women had a history of five depressive episodes, some of which had not been treated with antidepressant drugs.

They found that hippocampal volume was reduced in depressed women. Furthermore, there was a direct correlation between hippocampal size and a history of untreated episodes of depression--the longer the women went without medication while seriously depressed, the smaller the hippocampus. Lead author Dr. Yvette Sheline notes that psychiatrists already recommend long-term treatment in persons prone to depression to prevent recurrences and goes on to add that "these apparent neuroprotective effects provide a further argument for at least strongly considering remaining on antidepressants."

Specific medications known to promote good health amongst the neuronal coeds living in the rat hippocampus include: Prozac (fluoxetine), lithium, tricyclic antidepressants such as amitryptilline and imipramine, dilantin, and valproic acid.

An interesting antidepressant tianeptine (brand name Stablon) is available in Europe and Latin America but not in the US. Research indicates that it is a more effective neuroprotective agent against hippocampal shrinkage than Prozac. It works by promoting the uptake of serotonin out of the gap or synapse between one brain cell and the next as opposed to Prozac which blocks the uptake and allows this neurotransmitter to work as long as possible. As many researchers name serotonin as one of the molecules that can excite a nerve cell to death, it makes sense that getting it out of the synapses of those sad and stressed might be good for their brains.

To whoop or not to whoop...

All the world is divided into those who spontaneously whoop during exercise class and those who don't. My experience suggests that those who know when and how to whoop appropriately during aerobics class become instructors, and the rest of us are the silent followers. When my instructor whoops, I feel we should respond in kind to make her feel like we're right with her having fun. But alas, if you have to think is this the right time to make a noise or if you practiced at home to achieve the right sort of noise, you should probably just keep your mouth shut.

I almost felt a joyful noise escape me at the top of the class this morning, but I worried that everyone would stop short and turn around to see who the heck made that stupid sound. In fact, I would have rather fallen off my step than dared a single whoop. I was once in a Jazzercise class where the lone whooper in the class made a high-pitched strangled cry, the sort of noise people make before they have a seizure. I prepared myself to handle this situation in a heroic, medical professional sort of way, but no one missed a step despite episodic gargles from our back row whooper.

Even some instructors ought to hold their whoops. I think Jazzercise instructors are specifically schooled in making enthusiastic vocalizations in Perkiness 101. One instructor at a local studio makes this affected little 'hoo-hoo' noise at regular intervals. If I ever hoo-hooed like that, my fellow classmates would surely dance a wide berth around me.

And this is how I passed my mental time during exercise class this a.m.

Get a grip

...'cause your limp handshakes are creeping me out. I shake a lot of hands in a day. I always greet new patients in the waiting room with a handshake, and a lot of established patients put out their hands when I come out to meet them as well. I try not to think about where those hands have been, particularly during cold and stomach flu season, but I must admit that I often form a first impression from that initial HGS (hand grip strength).

Per ScienceNOW Daily News, "Hand grip strength (HGS) is an inherited trait; about 65% of a person's grip strength is genetically determined, whereas the remaining 35% depends on training and developmental factors such as nutrition." So I shouldn't judge the dead fish approach to greeting, their hands limp in mine, because these people are either born that way or they're malnourished. But evolutionary psychologist Gordon Gallup suggests that there's even more information to be gleaned from that impromptu waiting room test of HGS.

After conducting a study of HGS in a group of 143 undergraduates, both men and women, Dr. Gallup notes: "Our conclusion is that hand-grip strength is an honest indicator of fitness." In fact, Hawaiian investigators studied a grip of middle-aged Japanese-American men and concluded that midlife HGS was highly predictive of disability 25 years hence; those who lost their grip early were nearly 3 times as likely to totter unsteadily through their declining years than those with crunchers for handshakes.

So I have missed many opportunities to gaze into the future of those patients who greet me each day. But in the too-much-information department, Dr. Gallup also reports that men with high HGS have sex sooner and with more sexual partners plus were more aggressive in high school. Now I really don't want to know right up front about about the men I meet!

Quality of sleep

This is one of those QoL inquiries that I ask early on in my annual physicals. Along with 'how's your energy' and 'are you having any fun?', I feel like these quality of life questions give me a good starting place for assessing my patients' general health. N-QoL (nocturnal quality of life) is one of those fancy catch phrases that medical researchers love. Embedded in your N-QoL is your QoS (quality of sleep of course) and your HUS (hours of uninterrupted sleep).

The urological investigators particularly seek information on HUS as a measure of bladder capacity in men with enlarged prostates. A bulgy prostate partially squashes the urethra. A full bladder generates a certain amount of pressure as it contracts to send urine out the urethra. Pressure falls as the bladder empties, and at a certain point, the pressure is too low in the partially emptied bladder to shoot urine through the narrowed urethra. As a result, men with benign prostatic hypertrophy--an enlarged prostate-- incompletely empty their bladders. They have less bladder capacity for newly-manufactured urine heading down from the kidneys and, therefore, a need to void more frequently. This obviously impacts their N-QoL.

Drugs also impact our N-QoL. I love my improved QoS from melatonin and natural progesterone both of which improve QoD (dreaming). Nexium gives me nightmares. Recent evidence suggests that simvastatin (aka Zocor) can also produce nightmares and reduce QoS. Simvastatin is a lipophilic (fat loving) drug as opposed to pravastatin which loves water. We are all fat-heads insofar as our brain is largely made up of fat, so simvastatin crosses into brain tissue where it may adversely affect sleep in some. As sleep gets a little dicey with aging, simvastatin may not be a good choice of drugs for those with QoS issues.

Me: How's your blood pressure been?
Pt: Great!!
Me: That's good news. What sort of numbers are you getting?
Pt: I don't know, I haven't checked.
Me: How do you know then that your blood pressure is great?
Pt: Well I feel fine.

Then substitute blood sugar for blood pressure and play through the same conversation. Play them both several times weekly during annual physicals.

Prevagen safety data

arrived by e-mail today from the manufacturer. Looks good to me, I plan to keep downing this little biolumenescent molecule from the sea in hopes that it will keep my lights on as I age.

Gardasil's efficacy proven for older women

Many women have asked me whether or not the Gardasil vaccine against several strains of human papilloma virus known to cause cervical cancer or genital warts would be appropriate for them. Thus far, the vaccine is approved only for use in women up to age 26 as this is the population that was represented in the study used to obtain the FDA official thumbs-up.

There is no particular reason why the vaccine would not protect older women who have not yet been exposed to these virulent strains of HPV against new infections, and now Merck has provided the data to support its use in this population. Per Merck's Dr. Eliav Barr: "The vaccine performed as we expected. It was highly effective."

Merck will seek approval from the FDA to market the vaccine to older women, and insurance willingness to pay (and this is one pricey vaccine!) may follow.

Prevagen

At the risk of sounding like I've joined the lunatic fringe, this stuff is rather amazing. I've written to the manufacturer for information on human safety data before I wholeheartedly endorse its use.

I have noticed much improved alertness, notably first thing in a.m., after lunch when I struggle at times to stay awake as patients drone on and on and the fluorescent lights buzz softly, and in the evenings over the New York Times crossword puzzle. Most remarkably, I find my essential tremor much diminished.

Essential tremors often have a genetic basis with an autosomal dominant inheritance pattern. If one of your parents had shaky hands or head, there is a 50% chance that you will develop same as you age. It is called an action tremor because it is notable as you extend your arm in action such as using a pen or an eating utensil. Other kinds of tremor are called resting tremors (self-explanatory) or intention tremors that manifest at the end of an action such as pointing at something. The latter two kinds are commonly seen with Parkinson's Disease.

While essential tremors are relatively harmless, they certainly get in the way of everyday activities such as eating. Mine makes it very hard for me to remove sutures, especially teeny tiny ones in facial laceration. If I was a surgeon, I would probably not be a surgeon anymore.

I noted yesterday that the tremor in my left hand was much improved, and today I proved it by easily spooning tea to mouth without spilling or embarrassing myself in front of the cat who was the only one present to witness the experiment.

Prevagen? Coincidence? Psychosomatic tremor reduction? Time will tell. Meanwhile, as Prevagen works by binding calcium within the cell, I wonder about other calcium related duties such as building strong bones and keeping them that way. Do I lose my tremor AND my bone density? I'll let you know what Quincy Biosciences has to say on the subject.

Jellyfish pills: Day one

I took my first jellyfish pill yesterday midday (see post below). Eagerly looking for miracles here--had trouble getting to sleep last night and no trouble waking up this a.m., both unusual. No miracles though, but the experiment is young.

Which blog to blog upon, that is my question? In case you haven't noticed, I have two of them, one for general medical knowledge and one specific to the process of aging. One of my passions is brain preservation, an important undertaking for all of us who are or will be aging. I post some of it here, some of it there, so if you want to do right by your noggin, check 'em both out.

Melatonin

I am eagerly awaiting my supply of jellyfish pills. Meanwhile, I reread the three chapters in Protective Strategies for Neurodegenerative Diseases (I could use a good novel!) and wanted to make sure that those of you who are interested in getting your brain intact to the finish line consider taking melatonin.

Melatonin is a hormone naturally secreted by the pineal gland deep within the brain. It is particularly important in setting biorhythms based on dark/light cycles in the environment. It also has the ability to prevent the accumulation of molecular junk that gums up neurons as a result of natural aging and degenerative diseases such as Alzheimer's and Parkinson's.

Mice are raving about their ability to complete crossword puzzles well into their second year as a result of the routine use of melatonin, and lab data strongly supports its antioxidative and neuroprotective properties. While human data is sparse, studies do show that melatonin is effective in decreasing 'sun-downing' in Alzheimers (a night-time increase in dementia symptoms) and in improving sleep in AD patients.

While not everyone finds melatonin useful as a sleep aid, I get a great night's sleep on 3 mg., and it definitely enhances dreaming. I think I'd take it whether or not it helped with sleep considering its many cellular benefits.

Years ago, my Great-uncle M died unexpectedly in his sleep at a ripe old age. No dwindling, no surgery, no ICU stays, no chemo, no nursing home, just alive and well one day and dead the next morning. But what the family, including his wife, found remarkable was that this old fellow, best known for his sour disposition, had such a peaceful death. Aunt I felt forced to reconsider the possibility that he was a really good man after all.

Few of us meet a sudden death at an advanced age. Many of us will live some time with a serious illness, and all of us hope that we can live well to the end despite the health challenges we will face.

So here's good news indeed. An extraordinary woman who's been there, doing that has written a book about navigating through the world of serious illness and thriving on the journey. Tiffany Christensen was born with cystic fibrosis, survived two double lung transplants, and said final goodbyes to her loved ones on several occasions. At times when she scarcely had the breath to open her dresser drawer much less pull out her clothes or put them on, she discovered a rich inner landscape of emotional growth.

Her book Sick Girl Speaks!: Lessons and Ponderings Along the Road to Acceptance is a must-read for all of us who are facing or will face life-threatening illnesses, or who care personally or professionally for someone else in that situation. Think about it, that's all of us.

Check out her blog Sickgirl Speaks and her web-site, or order her book at Amazon.com.

Reflected glory

If they look good, I look good. I always get a warm glow from comments such as "I want to thank you for sending me to Dr. X. He/she was fantastic." So here's some of the specialists who made me look like a hero this past week:

Oncologists Drs. Kerry Fisher and Deb Cook (both of whom get the special award for that 'send 'em right over' attitude), dermatologist Dr. Migs Muldrow, Dr. Raj Bazaz who must be the world's nicest person as well as an excellent orthopedist as everyone loves him, and surgeon Dr. Stephanie Miller. And a special mention to neurologist Dr. Don Smith who not only saw one of my patients very promptly but sent me a four page consultation report complete with a discussion from the latest medical literature as to why he was recommending that which he recommended!

That which makes jellyfish glow in the deep...

May save your aging brain. Since I wrote this article over a year ago, Quincy Bioscience has brought Prevagen to market as an over-the-counter supplement to light up your faltering circuits. I will have samples in the office soon and plan to try it myself. Read on for more information.

After all, have you ever seen a demented jellyfish? The phosphorescent protein that lights up their quivering goo has a potent neuroprotective effect, at least in doddering old rats. Here's why it may light up your intellect as well.

Calcium is, as we know, a good thing. In particular, it holds up our joints and activates our nerves. When neurons are stimulated by a passing impulse via a transmitting molecule called glutamate, they open up their pores and let the calcium trickle in. Not pour in, mind you, just trickle. If they get over-goosed with glutamate, a situation called excitoxicity, too much calcium enters the cells which upsets it unto death.

Enter aequorin. Scientists have long called on the jellyfish protein as a 'calcium reporter.' In other words, add aequorin to a cell preparation in a laboratory, the aequorin hooks up with the calcium, and bingo! that which is calcium-laden within the cell lights up like a jellyfish.

Mark Underwood of Quincy Bioscience figured out that giving aequorin to rats through the golden months of their lives helped them hang onto the ability to perform tricks despite their advancing age. Rats normally get less tricky as they age because they lose their calcium-binding proteins, allowing free calcium to ravage their brains, which lets the tricks leak out. But rats plus jellyfish protein equals peak performance at mazes and bells throughout the lifespan.

Think about what we could accomplish with a little bread and jellyfish!

Hypocretin

This sounds like the ultimate insult, labeling someone a cretin but not even a very good example of one. Not an epithet at all, this one, but rather a little protein that explains in part why some of us pop out of bed even before the alarm goes off while others snooze on. Persons with narcolepsy are short on hypocretin secreting neurons (a condition that could be called hypohypocretinism).

California neuroscientists* twiddled around with these hypocretinergic neurons in a group of volunteered mice. Dialing up the hypocretin meant the mice rose before the lab alarm clock sounded, knocking it out left those lazy mice abed through breakfast.

Neuroscientists enthused that this research may have a future impact on the life of insomniacs. Those night owls who have hyperhypocretinism may someday take a medication that can tone down their jazzed up hypocretinergic neurons, allowing them to get to sleep at a reasonable hour.
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*Adamantidis, A et al. Nature. 2007 Oct 17; [Epub ahead of print]

Call me a sap or a loser, but this one actually brought tears to my eyes:

The Inner Life of the Cell.

Cold and dry. That's Denver in winter as opposed to the summer when it is hot and dry. Now New York virologists have an explanation as to why influenza virus plagues us here--and throughout the US--in the winter and not in the summer.

No new news that flu flogs us in winter. Epidemiologists have theorized that this may be due to crowding indoors, decreased human host immunity, or environmental factors during the colder months. Drs. Peter Palese et al* used guinea pigs to prove that prevailing temperature and relative humidity are critical to the flu's successful spread.

They found that infected guinea pigs most easily shared influenza with their colleagues when housed in cooler labs (41 degrees F) at the relatively low humidity of 25-30%. The sickened pigs shed the virus for 40 hours longer at this level than when the lab temperature was raised to 68 degrees, and no well pigs sickened when the thermostat was set at 86 degrees. The investigators found no difference in the animals' immune response at the varying temperatures suggesting that the virus itself had better survival and transmissibility under cold and dry conditions.

So do we lower indoor temperatures and jack up the humidity to stay well through winter? Cooler temperatures may be healthier, but microbiologist Dr. Raymond Tellier worries that raising humidity may raise crops of other bad actors for human health, noting: "You don't want to reduce one infectious disease only to increase another."

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*Lowen AC, Mubareka S, Steel J, Palese P (2007) Influenza Virus Transmission Is Dependent on Relative Humidity and Temperature. PLoS Pathog 3(10): e151 doi:10.1371/journal.ppat.0030151

Tune in, turn on...and I forget the rest

Sure, we're getting older, and the occasional fumble-mouthed moment in search of the right word is to be expected. Some overindulgent baby boomers, however, may find that their short-term memory is slipping away much faster than it should. If you picked up the marijuana habit in your youth--and never put it down--you'd better read on before your mind drops out.

Researchers studied brain function, specifically the ability to learn, retain, and retrieve new information, in nearly 150 adults. Over 100 of these subjects regularly inhaled, and we're not talking tobacco. The other folks smoked nothing illegal at all. Compared to the abstinent, long-term users, averaging 24 years of illicit highs, performed significantly worse on all tests. Shorter-term users, smoking 10 years or less, performed quite normally on most mental tasks. Along with the long-term users, however, they displayed a distorted sense of time passing as they puzzled over a problem.

If you want to remember your engagements, and arrive there on time, best stub out the joints.

Me: Do you exercise?

Pt: I almost started to do that several times.

A little extra time, a lot of important information

I find it harder and harder to stay on schedule these days as I look beyond the 'chief complaint' to see what's really going on in my patients' lives.

Yesterday, a 38 year old woman finally came in for a blood pressure check. We'd been nagging her for months to come in for follow-up (she'd request med refills; we'd okay the refill but sent increasingly strong messages through the pharmacist that this was last, last last, or last last last refill without her personal appearance at office.

She showed up one week out of her meds, BP crazy high. I discovered that she'd been unemployed, out of insurance, and she is the sole caretaker for her fifty-something year old mother disabled from a stroke. A fate that my patient is heading straight for with her uncontrolled blood pressure. I hope her graveyard shift cleaning at the airport will provide income and insurance to ease her life, but oy those hours and that fast food at midnight, what's that going to do for the blood pressure?

My Aunt Charlotte used to ask me at every family gathering "So Judy, ven (this said in Hungarian accent) are you going to start vearing lipstick?" Good thing that I was a hippie back then who never really figured out how to talk and wear lipstick at the same time given the latest scoop on lip paint.

The Campaign for Safe Cosmetics found that the majority of brand-name red lipsticks tested had detectable amounts of lead. If you chew off your lipstick--and how else does it disappear and require re-application throughout the day?--think of all that lead consumed over a lipsticked lifetime? Maybe that's why Aunt Charlotte, while staying tall and strong well into her 80s, completely lost her marbles by the end of the line.

Speaking of lead and the life you lead, I noticed in this morning's paper that thrift stores have seen a huge jump in toy donations of the banished variety. If you can't let your kid keep it, at least you can take it as a tax deduction.

Our best shot

Flu vaccination season is here. Some people queue up without a prompt, others decline the offer, citing "I never get the flu," or "The flu shot always makes me sick." To the former I'd say "Well don't push your luck," and to the latter "It's an inactivated vaccine, it can't possibly give you the flu."

Influenza viruses are rarely virulent enough to kill a healthy patient. The only patient of mine who ever died primarily of flu was a thirty-something year old severe anorectic who barely had the strength to walk across the room much less battle her final viral load. Indeed, most flu deaths occur in such compromised hosts, or as a result of a secondary bacterial invasion of flu-weakened airways.

A notable exception was the dreadful flu of 1918 that killed tens of millions of people around the world, many of them in the prime of life. Investigators know that not only did this strain of flu cause a fatal primary pneumonia all on its own, it also opened the door for easy bacterial access to the lungs and fatal secondary pneumonia.

Tennessee researchers discovered a deadly viral protein--PB1-F2--that causes such a dreadful inflammatory mess in the lungs of mice that 100% of infected animals either die of primary viral pneumonia or secondary bacterial infections. They induced an otherwise ordinary variety of flu to express this protein, engineered to be identical to the nasty molecule the 1918 strain produced.

Virologist Dr. Jonathan McCullers concluded: "This is one of the big reasons 1918 was so bad, because PB1-F2 allowed bacteria to cause more problems due to lung inflammation and damage." Scientists can use this information to spot super-flus before they spot us.

Why yoga makes me nervous

I find that a challenging yoga class brings a little thrill of fear to me which is not necessarily a pleasant sensation. Before you think me a total loser, check out this new study whose fancy brain-imaging techniques may explain the connection.

Researchers at the University of Manchester used PET scan imaging to see what parts of the brain lit up when people ached in their arthritic old knees. This technique involves injecting a person with a tagged sugar molecule called F-fluorodeoxyglucose or FDG. FDG is concentrated in neurons as they suck up sugar while at work reacting to the task at hand.

Neurobiologists already know which brain pathways activate when volunteers are pinched or kicked or however it is that researchers induce experimental pain. This same 'pain matrix' is also activated by arthritic pain. These UK scientists were surprised, however, to find that pain from degenerative joints "was associated with increased activity in the cingulate cortex, the thalamus, and the amygdala. These areas are involved in the processing of fear, emotions, and in aversive conditioning."

So if yoga induces pain in degenerating knee joints--and despite all those gentle adjustments from the instructor, I find it often does--aging yoginis might feel fear.

New statin news

I find patients are reluctant to begin statins because they fear these drugs (Lipitor, Zocor, pravastatin and others) will harm their livers. In fact, statins have a strong safety record with respect to liver problems.

Two new reports suggest some interesting non-cardiovascular benefits associated with statin use. German researchers(1) compared a group of colorectal cancer (CRC) patients to a cancer-free group with respect to their use of low-dose aspirin, statins, or both. Regular use of low-dose aspirin reduced risk of CRC by 23% whereas statin use diminished risk by 35%. Use of both therapeutic strategies, as would be commonly seen in patients at high risk for cardiac disease, dropped cancer risk 37%, and use for more than 5 years of the double treatment plunged risk by 62%.

Both smokers and ex-smokers also benefited from statin use with respect to progression of cigarette-related lung disease. Old Oklahoma vets demonstrated a slower decline in lung function and fewer urgent visits for respiratory issues if on statins. The study authors(2) speculated that the anti-inflammatory effects of statins were responsible for the favorable effects on lung function.
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(1)Int J Cancer 2007;121:1325-1330.
(2) Chest Published online October 1, 2007.

The pit and the parabens

I just glanced at the ingredients on my deodorant's label, and it reads like the contents of a well-stocked biochemistry lab. Can this arsenal of armpit aromatizers contribute to breast cancer risk or is this just another urban myth? In case you need one more thing to worry about, read on for the evidence linking deodorant use to breast cancer.

Scientists from the UK noted that the majority of breast cancers are found in the upper, outer quadrant of the breast, nearest the armpit. They wondered if underarm hygiene habits, particularly the application of deodorant, contributed to this skewed tumor distribution. On sorting through 20 breast tumor samples, they found high concentrations of para-hydroxybenzoic acids (parabens) in 18 of the cancers.

Parabens are used as preservatives in cosmetics. Unfortunately, they are xeno-estrogens, meaning that they are molecules whose structure is similar enough to estrogen that they can occupy the estrogen receptor sites on cells. Korean scientists added butyl-parabens to mutant yeast cells (that had somehow been induced to express human estrogen receptors) and found that the parabens not only bound to the receptors, but also exhibited an additive estrogenic effect when administered along with estradiol. The yeast approved of their supple cell membranes and decreased hot flashes, but the investigators were concerned about the implications for human exposure to parabens.

Male rats, however, were not amused when their testosterone levels fell after they were exposed to parabens at levels equivalent to the "upper-limit acceptable daily intake of parabens in the European Community and Japan." Cultured breast cancer cells positive for estrogen-receptors increased their growth rate under the influence of parabens. But a population-based study in Seattle that randomly dialed for deodorant habits amongst breast cancer survivors and cancer-free controls found no association between armpit applications and breast tumors.

Molecular biologist Philippa Darbre was so appalled by her research results that she quit using cosmetic products some years ago. As I review the chemical stew in my Tom's of Maine deodorant, I can rejoice because it's parabens free. Likewise, the yummy-smelling stuff from Avalon Organics. Crocky or no, there's no reason to bother the breasts with the likes of parabens.

This is not cool. The bird flu virus (H5N1) strains in Africa and Europe are demonstrating a mutation that make them more infectious to humans.

Birds are literally hot; their body temperature is 106 degrees compared with our normal 98.6. Our airways are cooler still at an average of 91.4. This new flu change allows the little buggers to live well in cooler climes...such as our upper airways.

While the current influenza vaccine, of course, does not protect against bird flu, the fewer opportunities that H5N1 has to mix its genetic material with usual flu thriving in ordinary people, the better. Do consider getting a flu shot this year and every year.

Panic attacks: False biological alarms

Panic, which is the most dramatic form of acute anxiety, is the cry for life.
---Eric Griez, University of Maastricht, the Netherlands

If you've never had one, you cannot imagine how compelling and physical they are. The feeling is not a 'Hoo-boy am I anxious' one, but rather a 'Dear heaven I am not getting enough oxygen and I may pass out or die' sort of experience. Until I experienced one myself, I put some patients with panic attacks through pulmonary, cardiac, or GI work-ups. Now I often spot them coming based on their chief complaints of 'trouble breathing' as listed on my daily schedule.

I was instantly drawn, then, to an article in an October issue of PLoS One* regarding altered sensitivity to carbon dioxide as the basis of panic attacks. Scientists previously noted that individuals prone to panic have panic-attackish sorts of episodes if exposed to inhaled gases heavy on the carbon dioxide. The panic response to rising levels of carbon dioxide makes evolutionary sense, but an overactive, internal suffocation monitor can lead to unwarranted alarm.

Dr. Griez et al invited 64 panic-free volunteers down to the lab to suck a little air with varying concentrations of carbon dioxide. As carbon dioxide content rose, so did the volunteers' feelings of fear, depersonalization, and a loss of sense of reality. The authors are hopeful that this laboratory model of induced panic attacks may lead to better opportunities to study drug therapy for patients with panic disorder as well as for chronic pulmonary patients dealing with behavorial panic resulting from their high body levels of CO2.

My situational panic disorder developed after I was in a car accident. Although I was not injured, in the moments before the impact my best guess assessment was that I would die. I subsequently became scarcely able to breathe while driving and assumed (what internist wouldn't?) that I had a mid-chest tumor pressing on my trachea. Once I identified my difficulties as panic, the road back to carefree driving was a long strange trip through various medications and behavioral therapy.

If you suffer from panic attacks after in intense experience such as mine where you perceive your life is in danger, check out Crash Course. Dr. Heller's techniques were the most helpful to me in my recovery.
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*Griez EJ, Colasanti A, van Diest R, Salamon E, Schruers K (2007) Carbon Dioxide Inhalation Induces Dose-Dependent and Age-Related Negative Affectivity. PLoS ONE 2(10): e987.

Oh dear, do those of you who 'fessed up as fans of For Better or Worse, and Funky Winkerbean feel a little drained this a.m.? What a way to start the day: tragicomics!

Exercise that is good for the heart is not detrimental to the knee joint.
---Flavia M. Cicuttini, PhD and colleagues*

Well that's good news. I was just debating tonight whether to take my right knee to step aerobics tomorrow or not. One deep knee bend over the sprinkler system three weeks ago left me with screaming pain from the lateral meniscus. It's much better now--who knows why--and I wondered if it was sheer folly to step out to a little music much needed by me for the heart and the soul.

Dr. Cicuttini et al studied nearly 300 adults over 10+ years. At study's end, their knees were, on average, 58 years old. The investigators correlated their activity logs with the amount of cartilage still clinging to the top of their tibiae on the bottom of their knee joints. Those who particpated in more frequent vigorous exercise in the years prior to the study had a significantly larger chunk of residual cartilage compared with those who sat out the decade on the couch. And the best predictor of defect-free cartilage was each individual's current participation in vigorous exercise.
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*Racunica TL, et al "Effect of Physical Activity on Articular Knee Joint Structures in Community-Based Adults" Arthritis Rheum 2007; 57: 1261-1268.

Dr. Smak, whose blog posts invariably ring true in my experience and often crack me up, commented today that inspecting used tissues is often instructive. Reminds me of a patient's visit last cold and flu season that sent my staff scurrying for the Lysol.

She came to her appointment for 'sinusitis' carrying a large grocery sack. She didn't, however, save her contents for my eyes only but proceeded to dump them over the front office counter.

"See," she said, indicating at least a hundred used tissues spread out on the surface, "I used all of these in just one day!"

Even the earliest physicians supported inspecting your a.m. productions


Rise early...every day to see what has gone down from the anus.
If it has gone down like black lumps you shall say his belly is
in a bad state, blistered.
--Ancient Egyptian medical text, circa 2,000 BC

She's got Bette Davis eyes...

Did Bette Davis have thyroid eye disease (TED)? Her prominent eyes are characteristic of a mild case of TED or Graves ophthalmopathy. This eye condition is associated with hyperthyroidism which is also known as Graves Disease where the body directs antibodies against its own thyroid tissue causing the gland to overproduce thyroid hormone. At times, these same antibodies cross-react with the tissues behind the eyeball causing the eye to bulge outwards.

Three times in as many months I have had female patients (this condition--as are all autoimmune problems--is more common in women) look at me through Bette Davis eyes. Not only were their eyes quite prominent, they also displayed lid lag (the eyelids lag behind the eyes' movement as the patient looks downward) and a staring gaze as the retracted upper lids revealed a band of the white part of the eye above the colored iris they looked straight ahead.

One of these patients was indeed hyperthyroid on lab testing while the other two had normal thyroid function. All three women had elevations of the auto-antibody called thyroid stimulating immunoglobulin or TSI. Unfortunately, treatment for hyperthyroidism does not affect the course of the eye problem, and a few patients will ultimately need surgery to not only avoid 'Marty Feldman eyes,' but to relieve the eye irritation that results from an inability to completely close the lids over the eyes.

BRBPR

The world is divided into those who look at their productions before flushing, and those who push the lever with nary a backward glance. Even though I declared myself a non-discloser in my last post, I must admit I am one of the former. It's just good self-care I think.

What you do NOT want to see is BRB or bright red blood. This BRBPR (that's Per Rectum per MD abbreviations) is alarming, and no further prodding should be needed to visit your MD for prodding. Yesterday was BRBPR day--two women with same, but two different problems.

I've mentioned before my reluctance to examine 'samples' that patients bring me in baggies and bottles, but BRBPR Patient #1 was an exception. These (blood) out-of-body experiences tend to look worse to the bleeder than they really are, so Pt. #1's specimen in a jar was instructive. It was indeed blood--not bits of sun-dried tomatoes--and a fair amount of it at that, deep maroon and mixed in with stool.

Other than this being episode #3 in as many months for her (no alarmist she!), she felt quite well, no pain, no fever, no weight loss, no loss of appetite. Classic story for diverticular bleeding. Diverticula are little intestinal outpouchings that occur commonly in middle-age and beyond. Those of us who are under-fibered and stopped up on Western diets are at particular risk. Mostly asymptomatic, diverticula can become inflamed (diverticulitis) or occasionally hemorrhage. There's no depouching a colonic pouch, however, if they continue to bleed--and they can bleed big-time--the solution is a surgical parting with that part of the colon.

Pt. #2 was also passing BRBPR. She was thankfully sampleless, but her bleeding occurred after she began large doses of ibuprofen for back pain. She developed diarrhea (a known Intestinal complication of ibuprofen) and the blood followed. While diarrhea can cause hemorrhoids to flare-up and bleed, I suspect she will be found to have intestinal ulcerations from the use of this OTC analgesic.

8 Random Facts About Me

Tagged by Suture for a Living means I now must list 8 facts about me and tag 8 others to do the same. I am a listener, not a self-discloser, by nature, so this is a rough one. Here goes:

1. I love shopping in thrift stores.
2. I was a hippy in the early '70s.
3. I have a mild case of disposaphobia, and in particular I am a victim of unread magazines.
4. I am teaching myself Spanish just to see if I can do it by reading my son's old textbooks and watching Spanish language TV. I will never understand why they talk so fast that I can never understand them.
5. I often cry over the morning paper, including the comics Funky Winkerbean and For Better or Worse. What sort of comics make you cry over them?
6. My favorite guilty pleasure is Mexican pizza from Taco Bell.
7. I used to smoke cigarettes.
8. Drinking alcohol makes me so tired that I am always sorry when I do.

It's hard for me to spout random facts about myself on the Internet, so I'm going to pass on tagging others even if it means I break the chain and will have seven years of bad luck.

I came of age in the '60s, so I'm a little behind in the world of body beautification. How, I'd wonder, do so many women have blond hair, curls, tan breasts? Well, of course, it's dyed, it's permed, it's a tanning booth stupid. I understand the how of the latest trend in pubic hair or lack thereof (it's waxed), but I don't get the why.

I try to keep my observations to myself on various piercings, tattoos (can't really say 'so what's up with the green teddy in a pink nightcap on your chest, dude?'), and shavings, but recently I just had to ask a twenty-something whom I've known since she was in high school about her pubic hairstyle.

The pattern, she laughed, is called a landing strip. Or did she maybe say a parking stripe? Either way, I got the point.

A novel way to lose weight

I'm always delighted when patients lose weight, and I always ask them how they did it. Here's a new one:

Phil lost weight because his wife had a hysterectomy. Well, you might say, she obviously ceased cooking during her post-op recuperation, and he then lost weight. Not that simple.

Phil's wife is a lousy cook. Despite her deficiencies in meal prep, and his lack of time, interest, or skill in doing it better himself, he ballooned up to nearly 300 pounds. You see, even though he did not enjoy the meals, he felt bad that his wife was near housebound with heavy periods and pain, so he always took seconds to make her feel better.

After many years of sympathy seconds, he actually became diabetic within the last year. As his weight topped out in spring, I pleaded with him to lose weight. This summer, he carried 10# less into his follow-up appointment. She felt better, and he passed on the extra helpings.

And I always thought it took exercise and self-discipline...

My laughs for the day

I was hauling a box loaded with textbooks into the post office to mail to my daughter. A thirty-something man behind me hurried forward to open the door for me.

Me: Thanks
He: You're welcome, that looks heavy. (He leans forward confidentially) Besides my dad is watching from that car over there, and he'd be mad if I didn't help the lady.

Later, taking blood pressure on a woman during a physical exam.

Me: Hold this (I thrust the BP gauge into her other hand)
Me: Uh, could you move your thumb so I can read the dial?
She: Oh sorry, I didn't even realize what I was holding. It could've been a turd for all I knew; I'm a teacher, I'll hold anything.

The point of no return

I've noted in my practice that people go for years with slightly abnormal, gradually increasing, blood sugars, a state known as impaired fasting glucose. Then abruptly and suddenly, they plunge into diabetes. Phoenix doctors, analyzing blood sugar data over years of studying Pima Indians (an ethnic group known for high prevalence of diabetes) confirmed this pattern.

A consistent trend was apparent in those individuals who became diabetic over the course of the analysis. Blood sugar at first rose in an even, linear sort of way, then turned upward with a rapid exponential rate.

The timeframe of this latter change may be very rapid for some individuals - beyond our ability to detect with biennial exams, meaning that some individuals transition from a normal to a diabetic state in less than 2 years, and how much less we do not know.
---Dr. Clinton Mason, National Institutes of Diabetes and Digestive and Kidney Diseases

Dr. Mason theorizes that interventions could prevent this rapid final rise of blood sugars into the diabetic range, thus delaying for years that dangerous development.

We can't change them into the happy, laughing life of the party, but we can keep them out of the coffin.
---Steve Cole, genomics researcher at UCLA

The chronically lonely are known to be more likely to suffer from ill health. A recent study suggests that this state of mind actually affects gene action in a way that decreases immune response and increases inflammation.

Dr. Cole and his colleagues set out to find the biological basis for the detrimental effects of loneliness on health. They studied the DNA of a group of 153 volunteers, looking for abnormal gene expression as related to the self-expressed degree of loneliness in their subjects.

The UCLA Loneliness Scale was used to determine just how isolated these folks felt. Then DNA gleaned from white blood cells of the 8 top lonely scorers was compared with the DNA from the 6 subjects most connected to others. The researchers found 209 genes abnormally expressed in the lonely genome, many involved in activation of the immune system and production of inflammation. The genes in charge of inflammation were overexpressed, and those that regulate the production of antibodies against bacteria and viruses were underexpressed.

These results may explain why isolation and loneliness increases vulnerability to infection and cardiovascular disease. Dr. Cole theorizes that strategies that decrease inflammation may promote better health amongst the isolated.

Programmed cell death (PCD)

That's a good thing. All you have to do is look in the mirror after a certain age to realize that old cells don't function like young ones. Eliminating old cells in an orderly fashion (and this is done by voluntary cellular suicide) prevents the buildup of abnormal cells whose DNA is mutating in an unfortunate sort of way after years of attacks by roving bands of free radicals.

Population studies suggest that those in the populace who are physically active have a lower risk of colon cancer. Dr. Kristin Campbell and colleagues in Seattle set out to determine if regular exercise encouraged old colon cells to check out in a programmed sort of way.

Nearly 200 men and women were randomly assigned to slouch on in their usual low-activity sort of way or join in a fun aerobic exercise program for one hour on six days each week over the course of a year. Colon tissue samples were collected from all before and after the study period (whoops--fun's over!).

The analyzed samples indicated that exercise increased PCD in the bowels of men but not in women. Campbell was unclear why women's colonic linings were uninterested in the effects of exercise. With regards to the suicidal cells of men, she noted: "We are interested that we saw changes--now we have to figure out why."

Speculum reprieve...

for certain groups of women. The U.S. Preventive Services Task Force has reviewed the pros and cons of that annual dreaded ritual of a Pap smear and determined that some of us can pass:

The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease.

The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer.

This does NOT mean those of you in the above mentioned groups should forego the annual exam, including the health review, blood pressure check, and breast exam. Just say no to the speculum.

Glycosylated hemoglobin

If you don't know what this is, chances are good that neither you nor your near and dear have diabetes. This test, also known as hemoglobin A1c or HbA1c, is a measure of how much glucose your iron-containing hemoglobin molecules are carrying.

Over the course of the 120 day lifespan of a red blood cell, the hemoglobin within binds irreversibly with glucose, forming glycosylated hemoglobin. The higher the level of glucose in the blood, the greater the fraction of hemoglobin A all gummed up with sugar. Although a little junk food binge would be immediately reflected in subsequent blood sugar measurements, it would take 2-4 weeks of binging to affect the HbA1c levels.

For that reason, HbA1c is used to monitor long-term success in the treatment of diabetes. It is not used to diagnose diabetes; the disease is defined by elevated fasting glucose levels or an abnormal glucose tolerance test. Boston researchers* using data from the Women's Health Study, however, have found that elevated HbA1c levels even though still within the normal range are potent predictors of future diabetic risk.

Over 26,000 women age 45 and older with baseline A1c levels of 5 (ideal is <6% and goal for diabetics is <7%) were followed over 10 years for the development of diabetes. Relative to the old gals who maintained A1c values of 5, those who dinked above 5.5 but less than 6 had three times the diabetic risk; this risk rose 29-fold for those between 6 and 6.4 and the women above 7% had 81 times the risk which pretty much means they became diabetic.

Dr. Aruna Pradhan and colleagues issued the usual bland sort of 'needs further study' statement: Although these data do not support the use of HbA1c as a single measure of diabetes risk, our results do suggest that the prognostic significance of elevated HbA1c may warrant a greater emphasis in primary prevention.
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Am J Med 2007;120:720-727.

A vast sea of misery could be avoided if this condition received the same attention and resources as AIDS or cancer.
---Marjorie Wallace, chief executive of the UK mental health charity SANE on depression

Depression has a greater impact on quality of life than most medical conditions. Worst of all with respect to overall health is the combination of depression plus a co-morbid medical condition.

If my patients wonder why I increasingly run behind through the day, on average it's because I often ask "And how are you holding up with all this." Seldom a short answer to that one.

Vaccination Schedules

One dose is better than no dose.
---www.immunize.org/guide

Yesterday a young woman came in for her second dose of Gardasil. The recommended interval between dose #1 and dose #2 is 2 months, but she'd received her first shot three months ago. She asked me if that was a problem.

Increasing the interval between shots in a 2-dose or 3-dose series does not diminish the effectiveness of the vaccine, it just delays the development of immunity against the disease. Per the CDC, the vaccination series does not need to be started over again in this case.

More problematic, however, is decreasing the intervals between doses to accomodate patient preference in scheduling. This, the CDC web-site notes, can prevent a full antibody response to the vaccination. On the other hand, even if you never get back for that follow-up dose of hepatitis-A, hepatitis-B, Gardasil, or MMR, a little immunity is better than none at all.

Good IDEA-033

I am a great fan of delivering drugs through the skin. As we age and transdermal technology expands, we may tape ourselves together with patches containing hormones (for women and for men), antihypertensives, antidepressants, neurostimulants (Ritalin), and now this, slather-on pain relief:

IDEA-033 is a formulation containing ketoprofen in an ultradeformable vesicle aka Transfersome. Ketoprofen, a non-steroidal anti-inflammatory drug or NSAID (same class of drugs as Advil and Aleve) is loaded into these ultradeformable carrier particles and smeared on painful, arthritic knees.

Germany's Matthias Rother explains the idea behind IDEAs: "Once the Transfersomes are on the skin, water starts to evaporate and deprive carriers of their suspending medium. Carriers reaching their solubility limit are attracted by the higher water content in the skin, resulting in spontaneous migration of IDEA-033 through the skin barrier.

Now in the skin, the little Transfersomes migrate into the next structure down which is the unhappy knee joint. Once there, the ketoprofen goes to work on the inflammation, delivering pain relief equivalent to Celebrex.* Best of all, there's no associated stomach irritation as would be found with an oral NSAID.
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Ann Rheum Dis. 2007;66:1178-1183.

Gardasil

Gardasil

This vaccine against several strains of the human papilloma virus (HPV) is recommended for girls and women under the age of 26. This group, when sexually active, is particularly vulnerable to the carcinogenic effects of certain HPV sub-types, particularly 16 and 18.

I have many women past 26 ask me if the shot would be appropriate for them as well. The problem, as women get older, is that they are more likely to have already been infected by these strains of HPV. Once exposed to 16 and 18, a recent study suggests that the vaccine is not particularly efficacious in improving the possibility that women can immunologically kick these bad actor HPV types out of their cervical cells.

Researchers* studied 2000 HPV-positive women in Costa Rica over a 12 month period. One group received the bivalent HPV-16/18 vaccine and the others received a control vaccine against an unrelated virus. Both groups developed acquired immunity against the virus at similar rates, suggesting that those who did mount an immune response were doing so under their own power without a boost from the vaccine.

This study emphasizes that there is an optimal time to vaccinate against this cancer-causing virus, and that is before exposure, i.e. before the onset of sexual activity.
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Hildesheim et al. JAMA. 298, 743(2007).

Good news for old coots

Men prefer mates who are younger and women prefer mates older than themselves.
--Fieder, M, Huber S. Biol Lett. 2007 Aug 28.

Old(er) guys who snag young wives appear to have an evolutionary advantage over younger men. According to the anthropological team of Fieder and Huber, "maximum offspring count" occurs if HE is 6 years older than SHE.

This study was based on data from 10,000 Swedish baby boomers. They found that a pairing of younger moms with older dads produced 5% more progeny than same-age couples. Over a large population, this may represent a huge evolutionary advantage to those women who genetically find older guys attractive and vice versa.

Doc-in-a-Van

Some patients are just plain uncomfortable sitting in a doctor's office.
--Randolph Swiller, MD, Ft. Lauderdale, FLA

So if the patient won't come to Dr. Swiller, he comes to them. In fact, that's what he does, all car rounds all of the time. He believes that medicine has become "time-centric and impersonal," and that home visits are "one way physicians can reclaim the high ground in medicine."

My lowdown on his high ground is that it sounds wildly impractical and inefficient. I am sure, however, that there are any number of people right here in Denver so spooked by the very idea of medical care that they would never set foot in a doctor's office. A free-wheeling MD (and Doc Swiller offers sliding scale visits!) could certainly change their lives.

In our culture, it's a difficult thing to talk about.
--Patricia Lenton, University of Minnesota's School of Dentistry, on bad breath

And this is one of my dilemmas--do I, and how do I, talk to people about body odors?

I spend a lot of time with people in the closed quarters of a small exam room. Cigarette smokers who smoke in their cars reek of old smoke. I don't have any trouble discussing their habit with them. People who drink alcohol before their appointment smell strongly of that, and I always initiate discussions with them--especially if they're my first visit of the morning!

But people with B.O. so bad that I have to abandon the room for an hour or two lest future patients think that I smell of old sweat, well I just can't bring myself to mention that. Likewise bad breath.

I feel like it's my duty to do so, but mentioning another person's odor is so taboo, I still can't point this out to my patients.

Gee whiz moments

Spontaneous gut feelings may be the stuff of which great discoveries are made. Consider Archimedes running naked from his bath after discovering the principle of buoyancy. Here's a real-life, up-to-date, Eureka moment from the Center for Marine Science (CMS) at the University of North Carolina.

Marine biologists already knew when there's a red tide in the morning, asthmatics take warning. The microorganism responsible for red tides produces a powerful toxin that constricts airways. If an onshore breeze blows this noxious spray inland, susceptible individuals may experience an asthmatic attack. But these little red buggers, aka Karenia brevis, also make a substance dubbed brevenal that counteracts their pulmonary poisons and reverses bronchial spasm.

CMS investigator Andrea Bourdelais discovered this potentially useful substance while dosing guppies in the lab with K. brevis products. Those guppies that survived the first red blast seemed oddly immune to another dose of red tide toxins. Per Dr. Bourdelais:

I had a spontaneous gut feeling--a gee-whiz moment--that the first material was an antidote to the second one.

Not only does brevenal block red tide brevetoxins, the substance also seems to promote mucous clearance. Airway blockage and sticky mucous are two lethal characteristics of cystic fibrosis, and brevenal seems to counteract these tendencies more potently than amiloride, a drug currently used to alleviate CF symptoms.

Will brevenal effectively work in humans born with this genetic disease? While trials on asthmatic sheep suggest this may be the case, scientists plan to first test brevenal on manatees. This endangered Florida sea mammal is also rendered breathless by red tides. Veterinarians at Lowry Park Zoo in Tampa, Florida have the FDA green light to break out the brevenal for manatees affected by the next red tide.

Never-ending coughs

As the new school year approaches, I face once again the prospect of being shut up in an exam room with someone in thin control of thick secretions. There are days during the cold and flu season where I feel like shouting into the waiting room "Go home, there is nothing I can do for you. Pick up a prescription for codeine cough syrup from the receptionist and call me in two weeks if it hasn't gone away."

Now, courtesy of The American College of Chest Physicians, there's a whole new lexicon in cough diagnoses. No more 'cough due to post nasal drip' as in the gunk slipping down the back of your throat is making you cough. Upper airway cough syndrome sounds more worthy of that pricey visit co-pay anyway, and the new name recognizes that it's not just about the mucous stuck in your throat anymore but also about inflammation of the cough receptors in the upper airway.

What about the never-ending coughs from hell following chest colds? These coughs last more than 2 months here in Denver where the air is dry and filled with dust and automotive schmutz through the winter months. These coughs are now called post-infectious cough secondary to upper airway cough syndrome.

While the chest docs recommend treatment with an antihistamine-decongestant combination drug, I prefer prescription Tessalon Perles (generically available as bezonatate) which specifically quiets those unhappy cough receptors. The new guidelines also tap an inhaler called Atrovent (ipratropium) as useful for post-infectious coughs.

Zelnorm is back

On a limited basis. If you found this drug to be a moving experience for your chronic constipation, the FDA has created a loophole through which you can get back on it.

This is the IND option, or investigational new drug protocol program, which states:

In some instances, patients with a serious or life-threatening disease or condition who are not enrolled in a clinical trial may be treated with a drug not approved by the FDA. Generally, such use is allowed within guidelines called a treatment IND, when no comparable or satisfactory alternative drug or therapy is available.

So while Zelnorm was yanked from the market in March when its use was linked to increased risk of ischemic cardiovascular outcomes, youngoid women under 55 with constipation from IBS or CIC (chronic idiopathic constipation) can apply for a waiver.

Big-time constipation is a real show-stopper. If you miss your Zelnorm, ask your MD to call the manufacturer at 888-669-6682 to open up options for your bowel woes.

Death by caffeine

Despite my dispatches on the health benefits of real deal coffee, I had no less than three patients yesterday admit apologetically that they still drank coffee. No apologies needed, I'm a fan! I don't even trust people who don't drink the stuff.

Imagine then how dear to my heart is Mark Malkoff who visited every Starbucks in Manhattan within a single day. Would you like to watch him do it? Check out 171 Starbucks in 24 Hours. While you're visiting energyfiend.com, you can also determine how much is too much by clicking on "Death by Caffeine." I found that 56 1/2 cups of my morning coffee would do me in.

THE defining moment

Well I've been debating ever since my last posting about whether or not to share this DM with you. I don't want you to think me unprofessional, and, after all, I did sign this Med Blogger Code of Ethics thing. However, if I relay something that happened in the course of practicing my profession in a dispassionate sort of way, how could that be deemed unprofessional?

The schedule noted her visit as Stomach flu. She sat down by my exam room desk and began rummaging in her large bag. After extracting a baggie, she tossed it across the desk to me.

Uh-oh. Close encounters of the turd kind. Thank heavens for Snap n' Seal. This, she declared, is what's coming out of me. What almost came out of me is uncontrollable laughter. The final crowning moment of the quintessential DM? She started to leave the room without her production at the end of the visit. Would you mind, I asked gently, taking that along with you?

Defining moments

I find many of patients get associated in my mind with one 'defining moment,' whether it be some event in their lives that they've described to me or some notable medical problem that they've had. When I see them in the waiting room or even just seeing their name on the day's schedule evokes these strong associations.

One delightful sixty-something African-American woman wished to travel several years ago and went looking for a tour group to join. By some means unremembered, she hooked up with a busload of middle-aged white guys from a poker club in Colorado Springs. This odd pairing of my patient with this bunch of buddies turned out splendidly. While she has not been able to travel much since, the C. Springs men have called her on several occasions to join them on the road or just to see how she's doing.

Another one of my patients exactly my age told me on questioning that she had attended Kent State during her undergraduate years. Immediate goosebumps for me: "So you were there in the spring of '70?" (talk about a defining moment for an entire generation) "My roommate," she says, "died that day in my arms."

One of my favorite layered memories of a patient involves first finding years ago an extensive inflammatory cancer in her breast. On surgery, all lymph nodes found were positive for cancer. That, of course, is not the good part of the memory. What makes me smile is that ten years later she brought me a bottle of wine to celebrate a decade cancer-free. Even better yet, now 16 years have passed and wine or no, I love seeing her for mundane routine check-ups.

Brains join bowels and skin...

as body parts that thrive with daily caffeine.

French researchers studied 7,000 men and women with respect to their drinking habits and their ability to retain their marbles over the course of 4 years. The men, unfortunately, became tongue-tied and befuddled independent of coffee consumption. But the women, particularly the old gal octogenarians, remained nimble in word-finding and spatial orientation by tossing back three cups daily of the real caffeinated deal.

Per Karen Ritchie of the French National Institute of Medical Research:

The more coffee one drank, the better the effects seemed to be on (women's) memory functioning in particular.

Coffee also seems good for the basal ganglia, a part of the brain that regulates movement. Trouble here causes movement disorders such as Parkinson's Disease and also the abnormal muscle spasms known as dystonia. One form of dystonia is blepharospasm or eyelid twitching. Think Chief Inspector Dreyfus in "The Pink Panther." Coffee consumption inversely relates to risk of Parkinson's (the more you drink, the lower your risk of developing the disorder), and now a study from Italy suggests that daily use will also keep your eyelids still(1).
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Defazio G, et al. J Neurol Neurosurg Psychiatry. 2007 Aug;78(8):877-9.