Tuesday, November 27, 2007

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.

*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.

Friday, November 23, 2007

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!).

Sunday, November 18, 2007

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?

Thursday, November 15, 2007

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".

Wednesday, November 14, 2007

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.

Tuesday, November 13, 2007

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.

Sunday, November 11, 2007

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.

Friday, November 09, 2007

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.

Thursday, November 08, 2007

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.

Monday, November 05, 2007

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.

Sunday, November 04, 2007


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.

Thursday, November 01, 2007

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.