Monday, December 31, 2007

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.

Thursday, December 27, 2007

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.

Thursday, December 20, 2007

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.
*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.

Monday, December 17, 2007

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.

Friday, December 14, 2007

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.

Tuesday, December 11, 2007

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...
*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.

Sunday, December 09, 2007

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.

Saturday, December 08, 2007

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."

Friday, December 07, 2007

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.

Wednesday, December 05, 2007

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.
*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.

Monday, December 03, 2007

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.
*If you missed the Prevagen post, check out my blog entry of 10/23/07. And note that Prevagen is on sale at off until the end of the year.

Saturday, December 01, 2007

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.