Saturday, September 29, 2007

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

Wednesday, September 26, 2007

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.

Tuesday, September 25, 2007


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.

Monday, September 24, 2007

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.

Sunday, September 23, 2007

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.

Saturday, September 22, 2007

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...

Monday, September 17, 2007

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.

Sunday, September 16, 2007

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.

Saturday, September 15, 2007

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.

Friday, September 14, 2007

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."

Wednesday, September 12, 2007

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.

Saturday, September 08, 2007

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.
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.

Friday, September 07, 2007

Vaccination Schedules

One dose is better than no dose.

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.

Thursday, September 06, 2007

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.
Ann Rheum Dis. 2007;66:1178-1183.

Wednesday, September 05, 2007



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.

Hildesheim et al. JAMA. 298, 743(2007).