Fidgeting and weight loss

I got a pedometer that actually works this holiday season. I discovered not only do I get well over half of my recommended 10,000 steps in a 90 minute Jazzercise workout (did that yesterday), but also that I don't sit still very long. This reminded me of a study I wrote about some time ago, so I thought I'd share it with you that you might consider the health benefits of racing around looking for your keys etc. as you consider your New Year's Resolution List (1. Fidget more, 2. Run upstairs to answer the phone instead of putting the handset on the table next to your recliner, etc.).

Consider inclinometers and triaxial accelerometers. Gizmos found in the instrument panel of a fighter jet that were sewn for this study into the high-tech underwear encasing the more or less active behinds of twenty Minnesotans. While all of the subjects were self-proclaimed 'couch potatoes,' half were lean and half were mildly obese. Dr. James Levine and colleagues then recorded 25 million underwear-generated data points on posture and movement from each subject over ten days. The Mayo Clinic investigators believe the results may explain why some persons tend to put on the pounds more easily than others.

Healthy adults gain weight when energy in (food) exceeds energy out (daily activity). While energy expenditure occurs during exercise, a large part of our daily calorie output is Non-Exercise Activity Thermogenesis or NEAT. Dr. Levine defines NEAT as "physical activities other than volitional exercise, such as the activities of daily living, fidgeting, spontaneous muscle contraction, and maintaining posture when not recumbent." The more you twitch, squirm, and generally fussbudget through your daily activities, the more calories you burn in this unexpected way. The researchers discovered that their obese volunteers were seated daily for 164 minutes more than were lean participants. In fact, if the heavier group had demonstrated the same NEAT behavior as their skinnier colleagues, they would've burned off an extra 350 calories per day or the equivalent of 7 pounds per year.

The Mayo endocrinologists had previously conducted research on the effects of overeating on NEAT. They stuffed an extra 1000 calories/day over 8 weeks into sixteen normal weight volunteers. During the two month feeding extravaganza, the subjects increased their energy output in subtle but significant ways, burning the majority of the extra calories as NEAT. Based on these studies, the researchers theorize that while obese individuals may "have a biologically determined posture allocation" (genetically inclined to hit the recliner), perhaps they can be taught to consciously overcome their torpid destiny with increased body busyness as part of a weight loss program.

"Studied calm"

I'm still reading Jerome Groopman's book "How Doctors Think", and I still highly recommend it to you. Not only does he illuminate the processes--some good, some ill-considered--that doctors use to arrive at clinical decisions, he recommends various participation strategies to patients that they should use to keep their doctor on an objective path to a diagnosis.

Dr. Harrison Alter is an ER physician that Groopman interviewed for this book. Alter notes that the emergency room atmosphere can be hectic and chaotic, and he personally works on fostering "studied calm, consciously slowing his thinking and his actions with each patient in order not to be distracted or pressed [into a hasty decision]. "

Well, you don't have to practice in an ER these days to feel pressed for time. I too have to make a conscious decision to slow down and forget the schedule, settling into my chair and focusing on the patient and what she's saying. Sometimes, this take-a-deep-breath-and-listen attitude pays off big-time.

I was running nearly 15 minutes late when I called Ms. V in from the waiting room. She's a 70-something dynamo, raising her teen-aged granddaughter and taking care of her ailing spouse. The previous morning, she'd had nothing to eat in preparation for a glucose tolerance test. After two hours at the lab where she drank the hyper-sugary Glucola and had hourly blood draws, she headed home, lightheaded and nauseous. Once there, she proceeded to begin cleaning the kitchen, leaning into those counters with her usual elbow grease. Moments later, she dropped to the floor, hitting her head and not really coming to until the paramedics arrived. While she was cleared for home at the ER, the doc there urged her to follow-up with me.

Ah, that is so you, I said to Mrs. V, cleaning up in lieu of relaxing over a late breakfast. On the other hand, I thought, it is so not you to faint. Groopman warns against making clinical judgments based on what we know or expect about a patient. I checked her goose egg of a lump on her head, took her blood pressure, then asked "So anything else going on?"

Well, she said, she'd been having episodic shoulder pain, did I think perhaps she had strained a muscle? And she'd nearly fainted in the Sears parking lot the week before. Ms. V has hypertension, high cholesterol, pre-diabetes, and her EKG at my office looked vaguely abnormal. I sent her directly to the hospital for admission to the cardiology service, and the following morning they put a stent into her nearly obstructed main coronary.

Here's to studied calm.

Living through cancer

A friend and I are gathering material for a how-to guide for cancer patients. Last week's JAMA had an interesting essay on that subject by Deborah Lewis, a social worker and breast cancer survivor. Titled "Legacy," her comments address her cancer experience as it relates to her father's death from heart disease. In particular, she found herself "playing follow-the-leader behind my father's tough but frail, limping frame" because she discovered that parents teach their children how to handle illnesses, aging, and death. She notes:

Before I got sick I thought people could choose how to confront serious illness. Once could either wallow in self-pity or buck up and move that rubber tree plant. Now that I've had cancer I understand that there is no deliberation and thought. You handle it the way you are going to handle it. Either you have high hopes or you don't; sometimes the ant just can't.

But she proves that she mostly can, living through her treatment in the way she saw her dad manage his own heart disease. Her imagined conversation with him:

Me: One time I threw up while I was running, heaving behind a distant neighbor's bush, my hands braced on my knees while the sweat dripped off my forehead. I wiped my mouth with a leaf and finished my run.
Dad: You're proud of that, aren't you? The vomiting and running thing?
Me: Yes, actually. I am.
Dad: I am too.

Social anxiety disorder

(aka generalized social phobia or GSP)

No one likes to be criticized, but criticism affects some more than others. I believe, for instance, that women who are unable to extract themselves from abusive relationships are more likely to react strongly and fearfully to criticism which further traps them in a toxic bond. Psychiatrists at the National Institute of Mental Health theorized that individuals with GSP who are fearful of social situations may demonstrate a stronger brain reaction to criticism than persons free of such anxieties.

They performed functional magnetic resonance imaging scans on subjects with GSP and controls. While under observation, the scanees read comments such as "You are ugly" "You are quite the looker" or "He'd look better with a paper bag over his head."

The GSP victims got all hot and oxygenated in their medial frontal cortices (brain area in charge of representation of self) and their amygdalae (brain area responsible for fear reactions) when they were slipped a slip with a personal insult. They had no such reaction to praise, nor did negative comments about others raise their amygdaloid activity.

Comments such as 'buck up honey, all those people are human just like you and they all go to the bathroom just like you' are unlikely, therefore to change the neural activity of those with GSP. Anti-anxiety agents that tone down the amygdala are helpful, and further research into changing neural circuitry is anticipated.

Early a.m. calls

Ordinarily I'm up by 6:30 a.m. I recognize, however, that patient problems don't follow my schedule, even my more leisurely Saturday morning agenda. I also know that nagging problems have a way of seeming more urgent through the wee hours of the morning, so that which is not an emergency (say the discomfort of a bladder infection) can move a patient to place a call to me at oh-dark thirty.

That said, here's the gist of my conversation with a patient of one of my call partners at 6:30 yesterday morning:

Pt: I've had an irregular heart beat on and off for two weeks now.

Me: Is it worse this morning? Are you having shortness of breath or chest pain?

Pt: No. It's just been on my mind and I thought I'd run it by someone.

Turns out this fellow is quite the work-out fiend, feels fine when he works out without any sensation of skipped beats (typical of benign premature contractions), and I think he just wanted reassurance before he went off to his early morning work-out. I was tempted to berate him a bit for his timing (I know some people call off-hours because they know they'll get right through to the doctor), but I held my tongue as he was not my patient.

Would I have been justified in schooling him on after-hours etiquette?

Irritable bowel syndrome

Irritable bowel syndrome or IBS is a diagnosis of exclusion. In order to conclude that a patient suffers from IBS--a cluster of unpleasant abdominal symptoms including pain, bloating, gas, constipation, and/or diarrhea--we first must exclude other possible reasons that they may be suffering so.

There's a lot to be said about IBS and the many ways that it can seriously affect quality of life even if it does not result in serious illness. The pain can be quite debilitating and result in frequent absences from work or school. An article in last month's British Medical Journal discussed three simple strategies that significantly decrease the discomfort of IBS.

In a meta-analysis (a study of studies that combines results of multiple trials to amplify the significance of results) researchers found that fiber, anti-spasmodics, and peppermint oil all performed significantly better than placebo in relieving the pain and screwy bowel movements of IBS. They reported the number of patients needed to be treated for one to experience significant relief from the heartbreak of IBS were: 11 for fiber supplements (using psyllium compounds such as Metamucil) 5 for anti-spasmodics (hyoscyamine sold as Levsin, NuLev, Transderm Scop, and generically), and just 2 1/2 patients needed treatment with peppermint oil (187-225 mg. in water 2-4 times daily, available OTC) for 1 to feel better!

"How Doctors Think"

I love highlighters. And I adore those tiny sticky strips with which I mark interesting passages in the books I read. So imagine my delight when a well-known pharmaceutical company via their local sales rep gave me four highlighters, each with scores of matching sticky tabs bursting out the sides. Of course, all these freebie pens bore the branded name of an expensive, widely-advertised anti-depressant.

Before I get to my point here, let me assure you that these gifts in no way influenced my prescribing habits. The pens, in fact, were all dried-up and hopeless for highlighting, but that made me no less likely to dole out the drug. The tabs were all I could hope for, but I promise you I've written not one additional prescription based on my delight. My patients often do well on this med, and that makes me more likely to prescribe it. Many who love the mood boost stop taking it, however, due to intolerable side effects, and that makes me less likely to write for it.

So there's a little insight into how this doctor thinks, but what I'm really plugging here is Dr. Jerome Groopman's must-have book "How Doctors Think." I'm halfway through it, and pages read thus far bristle with my ill-gotten, dirty-drug-money sticky tabs, each one flagging a point I wish I'd made in a book I wish I'd written. Not only should doctors read this book to understand why we think the way we do or to change our cognitive strategies in useful ways, you and I as patients (or as people who love and support patients*) should pay close attention as well.

Regular readers know that I've spent more than a little time these past two years as a designated listener and an advocate for friends and family working their way through the medical maze. I've seen how my colleagues listen or don't, and how they arrive at outrageous conclusions...or good ones, and the ways in which doctor/patient interactions influence the outcomes. Dr. Groopman has lots to say on the subject; more to come in later posts.
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*Two other excellent books that will help you become your own best advocate are Sick Girl Speaks and Pursued by a Bear.

Geraniums for the common cold

Argh, it's starting already, the steady stream of the walking wounded with their steady stream of respiratory secretions. All of them sharing a small exam room with me, one after the other, and looking for relief for their common colds.

I want to shout to the waiting room, go home, rest, drink fluids, don't cough on me. I understand, however, that no one's got time to be sick, and they wouldn't be in my waiting room if they didn't feel awful. So I was interested to read in last month's Health magazine (it comes free with my morning paper subscription) that a South African geranium used early on in the course of a cold may shorten the illness by two days.

There's a host of studies supporting the efficacy of extract of Pelargonium sidiodes (EPs or essence of geranium). Doctors at the National Medical University in Kiev invited 206 cold victims down to the lab (but I'll bet they passed up the opportunity to get up close and personal in an exam room with these people). All the patients were assessed for their Cold Inventory Score (CIS)* intially and after treatment with EPs or some murky liquid placebo.

Darned if those dosed with the real botanical deal didn't blossom forth to health at double the rate of the control group by day five. And ten days into the illness, the experimental group was more than twice as likely to zero out on their CIS score compared to their phyto-free colleagues.

So who wants to try Umcka ColdCare? You can get it in Denver at Sunflower Market or Vitamin Cottage, or find a store near you online at Nature's Way and hook me up with your testimonial.
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*The CIS is a fancy way to prove the obvious, namely that the person in front of you coughing, sneezing, and wiping a Rudolph Red nose has a cold. The researchers asked "Do you have nasal drainage, sore throat, nasal congestion, sneezing, scratchy throat, hoarseness, cough, headache, muscle aches, and fever?" They then computed the sum of symptom intensity differences (SSID) of the cold intensity score (CIS) from day one to day five. Don't ever think that there's no scientific method behind phytomedicinal research!

Been there, done that? Share your cancer advice

I asked one of my patients years ago about the best advice and the worst advice she'd received during her treatment for breast cancer. I don't even remember what she said was the best so horrified was I to hear that my advice was the worst.

I had told her she should consider quitting her job in order to deal with the upcoming treatment. I meant well; why spend energy on work when you will need all your inner resources to undergo chemotherapy and radiation? Now I know that 1) if you quit work you lose your insurance, and 2) ongoing work may provide a measure of satisfaction and normalcy to a life that has been transformed by a cancer diagnosis. I currently advise newly diagnosed patients to consider filling out paperwork to activate the Family Medical Leave Act so absences for treatment or side effects won't jeopardize their job.

I am collaborating with my friend and colleague Gail Harrison (who has been there/done that cancer journey) on a book for newly diagnosed cancer patients. Please consider sharing your stories if you have been down that road as well, or pass this questionnaire on to a friend or family member who has been through this experience.

Getting a call back from the doc!

Just finished a week of testing for my nearest and dearest. Getting the results was a bit of a challenge, even when I pulled rank with the "This is Dr. Paley calling Dr. R. for test results" which presumably pushed pushy me to the head of the phone call line.

Here's an article I wrote several years ago on the subject. I'd love to hear your stories about getting through (or not) to your physician.

"Hands, touching hands...

Reaching out,
Touching me,
Touching you.
--Neil Diamond

Yech, maybe not. Consider this study out from the University of Colorado in Boulder.

Scientists in the ecology and evolutionary biology department there used gene sequencing techniques to check out the bacterial communities living on hands in the University community. Not only did your average student mitt carry around 150 different species of bacteria, left hands and right hands carried different species, coeds had a greater diversity of species than their male colleagues, and regular hand washing did not cut down on the wide spectrum of bacterial types.

Do we dare shake hands ever again, or just nod and smile with shaking hands when we meet another traveling petri dish on the road of life? Study co-author Rob Knight has this reassuring news for the shakers and movers amongst us: "The vast majority of bacteria are non-pathogenic, and some bacteria even protect against the spread of pathogens."

Huh?

Pt: I have a tickle in my throat, so I tried not breathing for a couple of hours.

(Seriously, he was perfectly serious).

"I need a breast biopsy..."

per the frantic e-mail on my desk, "but can't afford it. Can you order the new blood test instead/ how much will it cost?"

Argh, that dreaded phone call about the abnormal mammogram. I've gotten one as have many of my patients. Follow-up, at times, is simply a matter of additional mammographic views, maybe follow-up films in 3 or 6 months, perhaps an ultrasound. Radiologists are extremely cautious in their reports, often calling patients back for further imaging, and sometimes--insomnia city-- advising a biopsy.

I've read hundreds of abnormal and suspicious reports. Often, there is a 'vague rounded density' that turns out to be just the superimposed shadows of breast tissue heaped on breast tissue, all normal. Frequently, there are 'microcalcifications' that look benign but a short-term follow-up is ordered to assure the little flecks are stable and not increasing in number.

But... this lady's report said "highly suspicious" and "spiculated" and these are not hedge words but a near definite diagnosis of cancer. This is not a dink around with a brand new screening test sort of report, but a work out a payment plan and get that biopsy done report.

Tomorrow: What's up with this new screening test? I didn't know, so I looked it up.

Glycemic index

Bagels and cornflakes and jelly beans, oh my. These--plus baked potatoes--are the worst of the worst of food choices for those of us who do not want to develop diabetes. These foods not only have a high glycemic index but also a high glycemic load. So flakes in the a.m. may leave you flaky and foggy-brained long before lunch.

All carbohydrates are not created equally in that some raise your blood sugar more rapidly than others. The glycemic index (GI) is calculated by measuring the change in blood glucose level that occurs when a person who has been fasting consumes that food. The elevation is then compared to the blood glucose response associated with a standard highly refined, high-carb food such as white sugar (which has a GI of 100).

The higher the GI, the more the food acts in the body like pure sugar, stressing those balancing mechanisms charged with keeping our blood sugar in an ideal operating range. Cornflakes (GI=92) send blood sugar soaring, causing the pancreas to respond with the release of lots of insulin which then efficiently sweeps the carbs into the cells. This causes blood sugar to plummet, leaving Kelloggs consumers with a mid-morning blood sugar too low to sustain brain functioning. While a trip to the office jelly bean (GI=78) jar may restore the blood sugar briefly, this quick fix just perpetuates the vicious cycle.

But nothing is really all that simple. Milk (GI=27) on the cornflakes changes the cereal's effects in unpredictable ways. And some foods with high GIs may have low glycemic loads (GL) which measures the actual blood sugar response to typical servings of foods. So a low GL (considered to be less than 10) on a high GI food choice indicates that you'd have to eat a ridiculous quantity to raise your sugar in ways predicted by its GI. For instance, pineapple has a moderatly high GI of 66 but a low GL of 7. You would have to consume 1 ¾ pounds in a sitting to raise your blood sugar in the same way that a handful of raisins (GI 64, GL 28) would.

Is your head swimming as if you just ate a baked potato (GI 85, GL 26) without sour cream, butter, and a steak (GI 0, GL 0) on the side? Experts agree that this approach may be too complex for many of us, encouraging us instead to eat foods that are not highly processed--which generally increases GI--and a diet that includes a wide variety of fruits, vegetables, and low-fat dairy products.

LDL particle size

LDL stands for low density lipoprotein, a worthy protein that picks up cholesterol particles that have either been absorbed from your diet or manufactured by your liver and totes them out to the cells. And it's a good thing that we have LDL-C; our cellular membranes are made out of cholesterol as are our steroid hormones. But as you know, while a little LDL-cholesterol (LDL-C) is a good thing, a lot is not. In susceptible persons, excess LDL-C enters the arterial wall where it may become oxidized and set off a world of inflammation and cholesterol schmutz known as atherosclerosis.

Turns out, there's bad LDL-C and then there's really bad LDL-C, and the difference lies in the particle size. There's no improving on the metaphors of noted lipidologist Dr. Thomas Dayspring, so here's the scoop in his own words:

Large-sized LDL is a beach ball. It bounces off the artery and goes back to the liver. Small LDL is a bullet. It lacks vitamin E, is very prone to oxidation, and crashes right through the artery.

So how do you know if your cholesterol is bouncing or crashing? LDL particle size is measured in the pricey VAP test which stands for vertical auto profile, but the information is actually right there on your standardized lipid profile. If you've got triglyceride levels over 200 and HDL-cholesterol (that's high density lipoprotein or the good stuff) levels below 45 (35 for the guys) we're probably talking bullets in your bloodstream.

Any hope of changing bullets to beach balls? Well surprise surprise, it's the same old song as always--weight loss and exercise. But wait, there's drugs that help as well, including Tricor, gemfibrozil, niacin, and the diabetic medication metformin, Actos, and Avandia.

"Happiness is a Serious Problem"

Current events make the pursuit of happiness even more of a challenge than usual. One of several books I'm juggling now is Dennis Prager's 1998 bestseller "Happiness is a Serious Problem." Perhaps we are missing some opportunities to increase our satisfaction with our personal situation. Here's Prager's take on health:

Take the expectation of health. For most people, the only time good health brings them happiness is when they do not expect to be healthy and then find out that they are. Imagine that you discover a strange new lump on your body. You go to the doctor, who tells you that it looks suspicious and that you should have a biopsy. After waiting a week for the results, you learn that the lump is benign. That day will be one of the happiest days of your life.

Now this is remarkable because the day before you discovered the lump you were not one bit healthier than you were on the supremely happy day you learned that your lump was benign. Nothing in the state of your health has changed, yet you are now profoundly happy. Why? Because on this day, you did not expect to be healthy.

...[I]deally, we should awaken every day and be as happy about our good health as if we had just received the wonderful news that a lump was diagnosed as benign.

No talcing please!

I first heard this one 30+ years ago, and I always wondered if it was an urban myth of the bizarre variety. But here it is again, this time backed by research from Harvard Medical School. Epidemiologists there sorted through years of data from the Nurses Health Study regarding who used talcum powder on their nether parts, and whether those who did were more likely to contract ovarian cancer compared with those who dusted not.

Turns out that those who took a weekly powder were 36% more likely to end up with ovarian tumors, and a daily dousing raised the risk 41%. Talcum powder is made from hydrous magnesium silicate which has properties similar to asbestos. Neither talc nor asbestos has any business on your bum!

"Wild thing, I think you move me..."

"It is highly possible that estrogen modulates motion abilities..."
---Karl Grammer of the Ludwig Boltzmann Institute for Urban Ethology

Well, duh Dr. Grammer, just ask an aging postmenopausal woman as she gets out of a chair about the lack of estrogen and the consequent lack of ability to move. Anyway, that was a mini-rant and NOT what this post is about.

In the 'what WILL they study next' dept., we have the following information out of the University of New Mexico. Evolutionary psychologists there were wondering how human females attract mates at the appropriate time of the cycle to generate species-appropriate reproductive behavior. They recruited lap dancers from local clubs to collect data on tips earned as correlated with phase of the menstrual cycle.

Women, as opposed to say a lady chihuahua or chinchilla do not go into heat but rather have a 4-5 day fertile window mid-cycle called the estrous phase when they are highly fertile. The researchers compared tips generated during these ovulatory days compared with those brought in during the luteal phase (post-ovulation time when perhaps a woman might be more inclined to eat her mate rather than mate her mate) or while the dancers were menstruating.

Sixty days, 5300 lap dance incidents later, here's the scoop. Data from 11 women with normal menstrual cycles indicated estrous earnings of about $70 an hour whereas hourly income fell 33% to $50 for those in the luteal phase and plummeted to $35 an hour for those who were menstruating. The seven women on birth control pills earned less throughout the study period.

So there's apparently 'something in the way she moves' during estrous that attracts clients like no other time of the cycle. And no estrous? May as well move on to another profession because she's not moving up in this lap dancing business. All good for the future of pill-free couples, but no wonder that some of my patients lose that loving feeling whilst on birth controll pills.

Beta blockers and post-traumatic stress disorder

One of my family members watched another person die suddenly, violently, and unexpectedly this weekend. I think I'm more freaked than my near and dear one is, but here's my doctorly thought processes after I was done flipping out.

Norepinephrine (NE, aka noradrenaline) is a neurotransmitter integral to the stress response and the formation of emotional memories. The beta-sympathetic nervous system (the automatic 'fight or flight' response that occurs without conscious activation) is mediated by NE which enhances the vivid but not necessarily accurate memories associated with highly emotional experiences. Think of a moment that was a charged one for you, say where you were when President Kennedy was shot (if you're old enough) or when you first heard about the World Trade Centers, and notice the details of that memory compared with other, blander recollections.

Experts call the development of post-traumatic stress disorder (PTSD) a 'derailment of memory process.' Not everyone is prone to an exaggerated or detrimental response to strongly charged experiences, but those who are can develop stubborn and destructive behavior patterns that ripple way beyond the actual trauma over time. While bioethicists argue over the morality of supressing intense and unpleasant memories, for better or worse it is possible to attenuate these memories through the use of beta-blockers. Amazingly, not only do the benefits of such therapy accrue when the medication is used shortly after the traumatic even, but also when the event is re-enacted through scripted imagery after some time has passed.

Should I offer beta-blockers (such as propranolol or metoprolol) to my family member? Perhaps I should just take a deep breath and take some myself.

The amygdala and the social conservative

I've mentioned before that I have an overactive amygdala. Through a series of genetically determined events that I've explained before here, I get an intense second-hand fear response that renders me unable to watch scary movies. Just can't take it when the actress hears a noise and heads right down to the cellar to investigate when I know full well she should run even as I also know it's only a movie.

Now anxiety is a good thing when it sets off an appropriate 'fight or flight' response that allows us to recognize danger and either run or creep down those stairs provided we're fully certified in the martial arts (of course, karate is no use at all against the supernatural...). And it's a bad thing when it renders us unable to leave the house or apply for a job (met a patient like that just yesterday). But who'd have thought that an overactive--or indifferent--amygdala might affect our political beliefs? Well, color me conservative as I read the following from Science Magazine.(1)

Political scientists teamed up with psychologists in Texas and Nebraska to find out if our political beliefs might have a biological basis. In their own words:

In a group of 46 adult participants with strong political beliefs, individuals with measurably lower physical sensitivities to sudden noises and threatening visual images were more likely to support foreign aid, liberal immigration policies, pacifism, and gun control, whereas individuals displaying measurably higher physiological reactions to those same stimuli were more likely to favor defense spending, capital punishment, patriotism, and the Iraq War.

During session one, the scientists quizzed the group--preselected for the strength of their political convictions no matter what the content of their attitudes-- on their political beliefs, demographics, and personality traits. When the subjects next came down to the lab, they were hooked up to physiological equipment that measured change in skin conductance as well as the strength of their blink or startle response. They were then shown three threatening images (a very large spider on the face of a frightened person, a dazed individual with a bloody face, and an open wound with maggots in it) or three sweet little pictures (a bunny, a bowl of fruit, and a happy child) interspersed amongst non-charged visuals.

Arousal causes increased moisture on the skin which increases conductance and fear causes a hard flinch or blink response of the muscles around the eye. Well I don't think I'd have a problem with a maggot show, but I know my heart rate would rise and I'd shut my eyes in moment to a large spider crawling on someone's face. The investigators found that an exaggerated response to the threatening pictures did correlate with a more conservative or socially protective attitude.

While the researchers were reluctant to conclude just what cause and effect processes were at work, they conjectured that "political attitudes and varying physiological responses to threat may both derive from neural activity patterns, perhaps those surrounding the amygdala. Amygdala activity is crucial in shaping responses to socially threatening images and may be connected to political predispositions."

Please note that in no way do I imply that all social conservatives have an exaggerated fear response. Nor do I think that close vigilance on the part of our society with respect to external danger is a bad thing.
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Oxley, DR, et al. Political Attitudes Vary with Physiological Traits. Science19 September 2008: Vol. 321. no. 5896, pp. 1667 - 1670.

Viagra, women, and antidepressants

Depression is a surefire way to kill your libido. Treating depression with antidepressants is also a surefire way to kill your libido. Initially, patients may be so relieved to no longer be depressed that they are willing to give up their sexual interests for the medication benefits. After awhile, however, the increased pleasure in life and relationships makes intimacy issues unacceptable.

Doctors at the University of New Mexico wondered if phosphodiesterase type 5 inhibitors (aka Viagra, Cialis, or Levitra) might improve the sexual outlook for women whose spirits have risen on antidepressants even as their libidos have fallen. Viagra and company are known to lift certain parts in men on depression meds.

Over a period of 4 years, they randomized 98 women whose depressions AND sexual interests were completely squashed on serotonin reuptake inhibitor type medications. Taking no one's word for granted, they not only followed up the women's sexual activity event log, but also administered the Clinical Global Impression function scale, the Female Sexual Function Questionnaire, the University of New Mexico Sexual Function Inventory (female version of course), AND the Hamilton Depression Rating scale (just to make sure no depression was creeping back in the picture).

The women on the real deal Viagra sent their Clinical Global Impression sexual function scale soaring to nearly double the levels of their pre-treatment activity. They also improved their scores on their Sexual Function quizzes. The investigators do note that this study selected for a group of women motivated to improve their sexual functioning and relationships, and therefore the findings might not be generalizable to all women experiencing such troubles while on antidepressants. It's also possible that filling out forms and quizzes on sexual functioning might enhance sexual interest.

I find this study particularly interesting as Viagra-like drugs work particularly well in men through the promotion of blood flow into certain parts that must be engorged with blood for proper sexual functioning. It is encouraging to find that the medications can increase interest and activity in women whose sexual response is less dependent on the localized pooling of blood.

Herd Immunity...

or why you should get a flu shot.

Flu season is coming, and hopefully this year's outbreaks will be preceded by a robust flu shot season. Here are the 2 most commonly cited reasons why my patients decline the vaccine:

1. I always get the flu from the flu shot. While some people notice fluish sorts of symptoms such as mild fever and muscle aches after receiving the shot, the inactivated viral particles which comprise the vaccine cannot cause disease.
2. I never get the flu. Well, lucky you. Remember, however, those who await your arrival back home. Perhaps you generally don't get the flu, but if you with your hardy immune system pick up a mild case while in close proximity with the coughing public, that young child, elderly grandma, or chronically ill spouse could be vulnerable to an amplified version of same with devastating or even fatal results.

Be a good member of the herd. When you get vaccinated, the influenza virus does not get a free ride in your respiratory tract on to its next victim.

You can change your wicked ways...

but at the heart of your matter, your poor choices live on.

The Coronary Artery Risk Development in Young Adults (CARDIA) study followed twenty years of health outcomes in over 3500 young adults. The researchers studied modifiable risk factors such as cigarette use, prehypertension (BP's 120-139/80-89), LDL-cholesterol, and fasting blood sugars.

Many of the subjects with less than sterling health habits didn't smoke that much nor did they have huge elevations in the other parameters studied. Many of them turned their acts around and improved their lifestyle choices over the course of the trial. Despite improvements made, their early adult profiles were more predictive of the presence of coronary artery calcification (CAC) after age 35 than their most current situation. CAC has been shown to correlate with the presence of atherosclerotic changes in coronary arteries.

Voltaren Gel

This is a great idea, but the logistics are awkward.

Voltaren is an non-steroidal anti-inflammatory (NSAID) pain reliever, and a rather effective one at that. It is available in pill form as the generic diclofenac. The downside of any NSAID is its adverse effect on the stomach and intestinal tract, causing pain, gastritis, ulcers, and diarrhea. In addition, the drugs can increase the risk of stroke and heart attack, and, in susceptible individuals, can decrease blood flow to the kidneys thus increasing the risk over years of use of decreased kidney function. Specific to Voltaren is the risk of "severe hepatic reactions, including liver necrosis, jaundice, fulminant hepatitis with and without jaundice, and liver failure" per www.voltarengel.com. Well shoot, who wants any of that?

We do, however, want arthritis pain relief, and Voltaren does that well. So Novartis minced it up and put it in an alcohol-based gel so that we could smear it right on our throbbing joints. Once absorbed through the skin, it reduces arthritic hand pain 46% after 6 weeks of use, and pain levels plunge 51% after 3 months of slathering it on arthritic knees. Drug levels reaching your stomach, kidneys, and liver are 6% that of an oral dose so, while the risks are not nothing, they're a whole lot less than the pill delivers.

The problem is in the how much cream how often department. The web site recommends 2 gm four times daily to upper extremity sites and 4 gm four times daily for the lower extremity. A tube of toothpaste is 170 gms so that amount of Voltaren Gel would get you through just over ten days of knee treatment. The stuff is definitely gooey, lightly but pleasantly scented, and dries within 4-5 minutes leaving a light sheen but no residual sticky stuff. I cannot imagine using it during the workday if I wore pantyhose. Pulling them back up again after gelling your hip would be like getting a wet bathing suit back on a small child. But then again, who wears pantyhose anymore? What about for one throbbing , chronically hyperextended index finger swollen from years of writing chart notes and prescriptions? The very thing I think, but you can't wash the area for 1 hour after each application.

The other problem is cost. By my calculations, you would apply your way through $172 worth of gel to service one bum knee for a month. Does insurance pay? Dunno, but I kind of think not.

Red Yeast Rice

I was very grateful that i didn't have to be put on Lipitor. I just took one every evening after dinner, that was it, That easy!
--A happy Red Rice Yeast consumer on Amazon.com

Interesting stuff, this red yeast rice (RYR).* Used for over 1,000 years in Chinese medicine to promote circulation, this medicinal food is made by fermenting rice with red yeast or monascus purpureus. One of its active constituents --monacolin K-- is also known as lovastatin. Monacolins inhibit hydroxymethylglutaryl-CoA reductase (HMG-CoA reductase) which is an enzyme essential to the body's production of cholesterol. In fact, lovastatin was the first statin drug marketed in the U.S. years ago under the trade name Mevacor.

So is RYR an effective, natural, and SAFE way to lower your cholesterol? Even though the Chinese have a century+ of casual, everyday, human trials, the first formal study of the substance was conducted there in 2002. The results confirmed its efficacy: total cholesterol, LDL cholesterol, and triglycerides dropped by 23, 31, and 34 percent, respectively and HDL levels increased by 20 percent. In other words, RYR did all the good things that statins do because RYR is basically a statin or rather a statin is basically RYR. Other studies, one of which was conducted by the American Heart Association, confirmed the general findings although the benefits weren't quite as robust.

The doses used in these studies were 1.2-2.4 gms/day; some Asian diets include up to 55 gms of RYR per day. Because agents such as RYR and statins decrease the production of coenzyme Q10 which is important to energy production in muscles, supplementation of CoQ10 is recommended with either the nutraceutical or the pharmaceutical approach. The standard dose of lovastatin, however, is 20-40 mg/day whereas the daily amount present in most RYR preparations varies between 5-15 mg.

ConsumerLab.com is an independent testing laboratory that evaluates the quality and contents of nutritional supplements. In a recent investigation, they looked at different RYR products both for the amount of active ingredient (lovastatin) and for the presence of citrinin, a renal toxin that may be produced by yeast grown on cereal grains such as rice. Nature's Plus® Herbal Actives Red Yeast Rice contained very high levels of lovastatin whereas Walgreen's brand contained very little of the active monacolin. Four products had citrinin contamination.

What's in it for your brain? Recent Taiwanese studies of RYR compared its protective effects on cells under ambush from beta-amyloid (the sticky protein that gums up the brain in Alzheimer's disease) with those of lovastatin. The RYR won hands down in not only protecting against cell death from beta-amyloid but also in decreasing inflammation and oxidative stress. This same research group found that rats infused with beta-amyloid learned more, had better memories, and accumulated less beta-amyloid when they signed up for RYR supplements with their kibble.
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*Red mold rice (RMR) if you're a Taiwanese biotech sort, and red mould rice if you're British.

Making scents of the gene pool

Is this your man?

Here's an interesting theory on how we choose our mates, and how birth control pills may be messing with our offspring's chances of survival. Well, obviously, if we don't have children at all based on the use of BCPs, this is a moot point. Assuming, however, that we choose the father of our future kids during a phase in our life when we're not quite ready to make them, here's the scoop.

Scientists believe there are advantages to dipping into a gene pool far different from our own when constructing the DNA of the next generation. Not only will this strategy decrease the likelihood of passing along two copies of a gene mutation for an inherited disorder, research suggests that the children produced from a thoroughly mixed-up match of chromosomes will also be resistant to a wider range of diseases. Those genes in charge of the composition of a person's immune system are called the major histocompatibility complex (MHC), and MHC heterozygosity (meaning mom's MHC contribution is quite a bit different than dad's) gives the kids a survival advantage in future battles against a wider array of disease-causing pathogens.

Interestingly, MHC is a major determinant of body odor in mice and men and women too. The olfactory neurons of mice in charge of odor recognition respond to fragments of MHC molecules even when these peptide pieces are present in extremely small quantities. Many rodent studies confirm that mice prefer nonself MHC-types as mates.

So what's this got to do with BCPs? A 1997 study found that all male subjects and those female participants not taking contraceptives preferred the smell of used T-shirts from persons with MHCs different than their own. The more the subject liked a T-shirt's odor, the less similar their MHC profile to that of the T-shirt's owner. No such correlation was found between Pill-users and their favorite unwashed T-shirt smells.

So if you want to party hearty with respect to producing hardy children with top-notch immune systems, sniff out potential mates in a Pill-free mode before you mate.

How a Corvette smashed my nail

My patient arrived at his physical with a blackened fingernail. When I asked him how he damaged his finger, he replied "I passed a Corvette on the highway, and that's bad luck." I replied that mostly Corvettes are going too fast to pass, bad luck or not, but what did that have to do with his nail. Here's the scoop.

For reasons unknown, he'd always believed that overtaking these sports cars was an invitation to disaster. Recently, however, he decided to defy his magical thinking and left a 'vette in the dust. Within 15 seconds of completing the deed, he got a flat tire. While changing the tire, 1) his girlfriend's nose got smashed by the car trunk as it swung open, and 2) he smashed his finger with the tire iron.

Never a dull moment at these physicals!

Hepatitis A vaccine for post-exposure prevention

(In case you're wondering what all this vaccine information is about, I am preparing a workshop on immunizations, so my brain's shot full of shots.)

In a recent post, I mentioned that hepatitis A immune globulin (IG) is the preferred approach for the prevention of infection in folks who've been exposed to the disease through household contacts or 'fecal fingers'. My information, I discover, is running about 10 months behind the times.

Last October, researchers published a study in the NEJM (1) comparing the use of HAV vaccine with IG in persons ages 1-40 exposed to hepatitis A. The two groups were randomized to receive one therapy or the other within 2 weeks of viral exposure. Few subjects developed hep A no matter which shot they received, and the CDC concluded that the two strategies were equally efficacious.

As a result, they now officially recommend the HAV vaccine for postexposure (less than 2 weeks) prophylaxis in this age range as 1) it's less painful, 2) it's more widely available, and 3) the shot provides longterm immunity. Older persons or people with chronic liver disease tend to be sicker with hepatitis A, so the CDC continues to recommend IG for them. What they really recommend, however, is that all children get this shot after age 1, and most adults should consider receiving a shot as well so they can eat unwashed lettuce with impunity and immunity.
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(1)Victor JC et al. Hepatitis A vaccine versus immune globulin for postexposure prophylaxis. N Engl J Med 2007 Oct 25; 357:1685.

Gardasil vaccine

It's important that women understand if they're sexually active, there's a chance they won't receive full benefit from the vaccine.
--Dr. Laura Koutsky, epidemiologist at the University of Washington

I get asked this question a lot by women who are already sexually active including some who have had abnormal Pap smears as a result of infections by the human papillomavirus (HPV). HPV infections cause virtually all cervical cancer, and bad actor HPV types 16 and 18 are responsible for 70% of these malignancies. The Gardasil vaccine (and the not yet approved Cervarix vaccine) is highly effective at inducing immunity against these carcinogenic viruses; in fact, this vaccine is the first one to specifically designed to prevent cancer caused by a virus.

Dr. Koutsky and company (an enormous panel of clinical investigators) published the results of their FUTURE II trial, aka Females United to Unilaterally Reduce Endo/Ectocervical Disease, in a May, 2007 edition of the NEJM(1). While the vaccine prevented 98% of cervical lesions--precancerous and malignant--in subjects who tested negative for exposure to HPV types 16 and 18 at the time of entry into the study, it was only 44% protective in women previously infected with these cancer-causing viruses.

The ideal population, therefore, that will benefit from this vaccine is those girls/women not yet exposed to the virus. The CDC's Advisory Committee on Immunization Practices has recommended without reservation that girls 11 and 12 years of age receive this shot.
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(1)The FUTURE II Study Group. Quadrivalent Vaccine against Human Papillomavirus to Prevent High-Grade Cervical Lesions. NEJM,Volume 356:1915-1927, May 10 2007.

B.Y.O.P.

Looks like I'll not only be buying my own pens in 2009, but will need my own darn sticky notes and mugs as well. New guidelines for pharmaceutical companies will end this mini-fountain of free office supplies, and physicians will have to make their own judgments about the drugs they prescribe free of that subliminal influence from their writing utensils and coffee cups.

Now I do agree that this is a silly use of funds that could (but won't be) diverted to more productive ends by the companies who distribute these freebies by the gross. I am a bit miffed by the implication that a free roller-ball pen (and they are a godsend for those of us who spend our days scratching our way through handwritten charts) would change my decision-making process. I do rely on post-it notes to remember the next step in patient care ('Call Dr. M,' 'pre-authorize MRI,' 'check on last week's labs,' etc.). On the downside, I sometimes find to my horror that I've given a post-it note to a patient that incidentally advertises vaginal cream or a drug for erectile dysfunction. But I swear that I've never noted the note, then changed my therapeutic plan based on its message.

Oh well, I'll buy my own pens, apply my own message-free sticky notes, and drink my morning coffee from a mug that declares I'm "over 50 but not over the hill". But I'll hold out hope that the new conduct code won't cut off those drug money cookies.

Who needs a shingles shot? Part II

I wrote some time ago about who needs a shingles shot. Here is a summary of the last 4 people I've seen in the office, all in the past 2 weeks, who wished they'd had the shingles shot before their leftover chickenpox (herpes zoster virus) staged a comeback.

The first patient was down on my schedule as 'bug bite.' I'm always suspicious, even in summer, that a 'bug bite' appointment will actually be shingles. Indeed, this 38 year old man's painful 'bite' was, in fact, a cluster of herpetic blisters on his left shoulder. He is too young to have been offered a shingles shot as they are approved for persons sixty and over. The shot would doubtless work on younger patients, but they are quite expensive, and insurance companies would be disinclined to pay for the vaccine in this low risk population.

The second patient complained of a 'bee sting.' This theoretical bee had gotten her on her left buttocks, an area not commonly at risk for a bee attack. At 62, she could've had a shingles shot instead of this stinging red circle of blisters.

The third patient, only 52, is undergoing chemotherapy for cancer. Her shingles were extensive, painfully covering most of her buttocks. She is at risk for a recurrence of herpes zoster as her treatment has compromised her immune system.

The fourth patient--age 49 and therefore too young for the shot-- came in with back pain which she described as a strip both numb and painful from her lower back around to the middle of her front at the level of her lowest rib. She had no rash...yet. I don't know for sure, but her presentation was typical of the pain that precedes a shingles outbreak.

I actually saw one other person this week who could've used a shingles shot, but he needed it 12 years ago when he was 81. Now at 93, he continues to have a painful itch over his left eye up onto his forehead from his remote encounter with his resident zoster virus. He really should re-up his immunity now against another potential attack, but he's not fond of shots.

Who is?

Face it, not in the exam room!

We always ask our patients to bring in a list of their current meds. As I perused my patient's list this afternoon, I noticed that he had written 'face' by one of his prescription drugs given to him by another MD.

I asked him what that meant. He said that when he told me on his last visit that he was on that medication, I'd made a face. He wondered what the face meant.

While I couldn't recall making a face nor any reason why that particular medication should make me grimace or roll my eyes, I did think that I should keep my future opinions off my mug.

Who needs a Hepatitis A Vaccine?

Fecal fingers.

Yucko. But that's what they're called, the 'fomites' (vectors or vehicles of infection) that bring you hepatitis A. That occasional, unclean digit of the unwell worker who forgot to read the sign you've seen posted in restaurant restrooms, namely "Employees are required by law to wash their hands before returning to work." I'm sure the majority of kitchen- and wait-staff are law-abiding citizens, but what if they're stomach's upset AND they're in a bit of a hurry.

There are worse things than having hepatitis A (like having hepatitis B or C). Unfortunately, however, this disease which was formerly known as infectious hepatitis can take a chunk of days from your life and a chunk of points from your sense of well-being. While children can contract the disease with few or no symptoms, adults are generally nauseated, yellowish, and too exhausted to care, and may remain thus for weeks. Fortunately, hepatitis A virus (HAV), unlike B or C, cannot set up permanent housekeeping in your liver in a chronic sort of way and only rarely causes liver failure.

We have shots, a series of two to be exact spaced at least 6 months apart, that can raise your immunity to fecal fingers at least in a HAV sort of way.* As you ponder whether or not this shot's for you, consider that 1) I haven't seen a case of hep A for years (and I do check liver functions in persons with persistent nausea and GI upset), and 2) If you happen to have eaten in an establishment subsequently found to be the source of a HAV outbreak, we can administer hepatitis A immune globulin (IG) to you. This drug contains preformed antibodies to HAV and is 85% effective in preventing a hep A infection in persons exposed to the disease. Protection from an IG shot lasts for 3 months. It is made from blood products from paid donors, and while there are no reported cases of hepatitis B or AIDS from hep A immune globulin, this blood products from paid donors thing may seem a little unsavory.

The vaccination is made from HAV raised in cultures, then inactivated with formalin. You can't get hep A from the shot. Several different brands are available, and none are preserved with the controversial, mercury-based preservative thiomerisol. The shot is highly immunogenic meaning that nearly everyone who gets it quickly develops protective levels of antibodies within one month of the first dose. So if you've put off getting the hep A vaccine,and you are planning travel to a country known to be high-risk for HAV infection, chances are good that even a last-minute shot will afford you some protection. The shot is considered very safe.

Many school systems require the two-dose hep A series for children entering school. Remember that 85% of children do not develop symptoms of hep A, so an unvaccinated child who contracts the infection while traveling out of the country can bring the disease back to more vulnerable personal contacts at home. The incubation period for the disease is 2-6 weeks. Adults in high-risk groups for infections (say those who are in institutions or immuno-suppressed) or persons who work with high-risk groups, and anyone traveling to a high-risk country should consider receiving vaccination against HAV.
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*There are other infections leaping from the fecal fomites such as salmonella and shigella.

How much sleep do we need?

or how do I get my teenager up for work on a summer morn'?

Generally he gets his own darn self up, but this a.m. was an early start, and early start and summer and teenager are not necessarily part of the same sentence. When I first woke him up, it was clear that no one was home behind his eyes. After I poured water on his head, it was clear that an angry but wakeful human had taken charge.

Here are some observations from a recent article in ScienceNOW Daily News(1) about how much sleep animals need in the wild and why that may or may not apply to humans and the subset of humans known as teenagers:

1. "Animals sleep less if they need to graze extensively--as with herds of horses." This is a tough one, he already grazes extensively. The problem must be, however, that if all the grass...er food...is right there in the 'frig, he doesn't need to spend much time doing so. Note to self: Empty out 'frig.


2. "Animals that sleep in groups, such as herds of grazing animals, get less sleep than species that live alone." Scientists theorize that this is based more in eating habits of herd animals rather than the herdiness of it all. M. certainly has quite a sociable herd to graze with, but, again, the good grazing is apparently too close at hand.

Perhaps when he moseys back down the road to school, no more 'summertime, and the grazing is easy. This kid has a 9 a.m. class this fall; I hope the living is lean and dangerous at school. Or maybe not...
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(1)http://sciencenow.sciencemag.org/cgi/content/full/2008/722/2?etoc

Deplin testimonial

I posted some time ago about Deplin, a glorified B vitamin (methylated folate to be exact) that may supplement antidepressants by promoting the production of neurotransmitters in the brain. I've prescribed it to some people not on antidepressants and found that many of them have a positive response with respect to energy and focus. Check out this e-mail from a patient with MS who struggles with low energy and lack of focus:

This new addition to my Rx. closet has made an incredible difference. I feel human, actually went for a walk with my dog last night (1st time in 10 years), feel more alert, have terrific energy and life is suddenly colorful.

Who's the pain in the butt here?

My patient has a pain in the butt. Not 'is a' mind you, but 'has a'. I've never seen anything like it. Her sit bones (ischial tuberosities) are painful to sit upon. She's o.k. with standing or lying, but her sitting hours are intolerably painful so, therefore, seriously curtailed.

I didn't know what to do with her (my father's advice from my childhood regarding things medical that were problematic --"Don't look at it for three days and it will go away"-- didn't work). Ibuprofen and such made no difference. I had to send her to a specialist, and believe me, it was hard to know just what specialist to use.

The orthopedist ordered an MRI of her butt. It showed minimal inflammation of the spot where the hamstrings insert onto the butt bones, but treatment for tendonitis, including cortisone injections, was useless. The neurologist was clueless, the physical therapist energetic but likewise without results.

We finally sent her to a pain management specialist. If you can't beat it, treat it. She was frantic to travel (out of the question) or simply to read a book in the seated position (if you're like her, reading while lying down is a recipe for sleep).

He listened to her story. Don't know if he examined her butt. He suggested Tylenol (heavens, Doc, been there/tried that already!). When she asked him what else could she do to once again achieve comfort in her life, he answered "Just stand up!"

I kid you not, that's what our pain specialist recommended.

The ups and downs of being a doc

Life and a road trip recently took me through Rawlins, Wyoming. Hours of driving through the monotony of southwest Wyoming dictated the need for a pit stop; time to eat and rest glare-weary eyes.

We found a little restaurant, actually the only diner on Main St. that teemed with life and advertised breakfast served all day. Several stuffed animals graced the entryway, real stuffed animals including a bobcat caught for all eternity mid-leap as he brought down a fleeing pheasant. The women's room sported, of course, the title 'Cowbelles' and the men's merely 'Cowboys.'

The meal was so-so, they were out of blueberry muffins and I passed on the alternative biscuits and gravy. As we finished our meal, a tall and sunburned man strode by, balding head shaved close, a slight potbelly protruding over his turquoise studded belt buckle and a beeper hanging off the belt. Most heads turned as he passed, a wide variety of townfolk waved and called "Hi Doc."

Ah, a diner in a town where everybody knows your name. I longed to jump up too and yell "I'm a Doc" and have them all laugh with delight that this dusty aging hippie in coffee-spotted capris and a t-shirt was a colleague to their own dear Doc.

Anyway, Doc Rawlins got to the counter to pay his bill, and I waited to see if they would offer him a bag of blueberry muffins to add to the bag already on his waistline. But instead, the older woman at the register started in on a long story about her bowels and her trip to the regional hospital. Not that I was eavesdropping, but shoot, we were sitting nearby, and I was hoping, at least, for some wonderful tale about how the Doc had saved her aging aunt.

Then I remembered that I live in a neighborhood and shop at a grocery store where many know my name. Why one patient one day described her vaginal woes to me in produce, and another pulled down her lower eyelid in paper goods to ask me whether or not her bloodshot, oozing eye was conjunctivitis. It was. I called in a prescription right then and there to the pharmacy located just east of aisle 18.

On my second day back to work after our Wyoming tour, the nurse practitioner asked me to look at a cat bite, or rather a young woman's hand with four cat bites on it one of which had penetrated her thumbnail. In the day since the feline's attack, the hand had swelled some, the thumb turning pink and puffy. Cat bites are nasty affairs; think for a moment what sorts of fishy things go in that mouth. I told the NP to call a hand surgeon and confirm that oral antibiotics would suffice for a now.

Several minutes later, she returned, sadly shaking her head. "No go, Chief," she reported, "I couldn't get past the front desk with my question. They offered me an appointment for next Tuesday."

What sort of nonsense was that? I strode to the phone and pulled the officious "This is Dr. P, I need to talk to your on-call physician now about a patient."

"Just a moment, I'll get Dr. W," the receptionist said. A moment later she returned to ask "Would this be about a cat bite perhaps? We just had a patient call here for advice a moment ago."

The hand surgeon came on the line shortly thereafter and confirmed the NP's plan as a good one. I realized then, once again, the value of the title and the ease with which it takes me right to the top. Maybe someday it will get me blueberry muffins as well.

Payback time for moms

The female brain is a dynamic structure, which expresses its plasticity most readily following reproductive experience.
---from the Department of Psychology-Neuroscience, University of Richmond

According to research out of the University of Virginia(1), there may be psychological compensation for all those sleepless nights, saggy breasts, and stretch marks that accompany motherhood. Those tedious months of pregnancy, suckling, and pup-rearing...oh right, we're talking rats here.

Neuroscientist Dr. Craig Kinsley and colleagues proved that mother rats adapted better to the stress of confinement in a Plexiglas restraint tube than their female colleagues who'd not yet coped with the demands of ungrateful offspring. Did they consider that lady rats--married, with children--may have just been grateful for the relative peace and quiet afforded by those Plexiglas walls? Speaking from my current perspective of mom to one teenager on site for summer, I would easily adapt, right here, right now, to voluntary confinement at an air-conditioned hotel.

The researchers conclude: "The data suggest that reproductive (hormonal) and/or maternal (pup exposure) experience may inure a female and her brain to stress, rendering her less susceptible to the behavioral-or other-disruptions that stress sensitivity can produce."
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(1)Wartella, J et al. Single or multiple reproductive experiences attenuate neurobehavioral stress and fear responses in the female rat.Physiol Behav 2003 Aug;79(3):373-81.

Lab test for ovarian cancer

A friend/patient of mine was recently diagnosed with Stage IV ovarian cancer. That, of course, is one of the most difficult aspects of ovarian cancer, namely that it is relatively symptom-free until it reaches an advanced stage.

In retrospect, she identified certain vague abdominal symptoms in the months prior to diagnosis (constipation, bloating, the development of a small 'middle-aged' pouch in the midriff), most notable and puzzling to her through the winter and spring was the increasing agitation of her devoted dog. The dear but scruffy mutt would scarcely leave her side, and no sooner did my friend lie down, but the dog would lay paw or muzzle on her abdomen. Most dramatically, the dog would eye her directly with long and beseeching looks.

An article in the June, 2008 edition of Integrative Cancer Therapies(1) may explain her canine's consternation. Swedish researchers in collaboration with members of the Working Dog Clubs of Sweden and Hungary theorized that dogs could be trained to recognize the characteristic odor of ovarian cancer. They not only found that the scent of an ovarian tumor in a doggy sense is different from that of other gynecological cancers (e.g. cervical or uterine) but that these cancer-screening pooches correctly sniffed out early-stage and borderline tumors as well as big, advanced ones.

The authors wrote: "Our study strongly suggests that the most common ovarian carcinomas are characterized by a single specific odor detectable by trained dogs, and while we do not believe that dogs should be used in clinical practice, because they may be influenced during their work [now what, really, could distract a dog?]... still, under controlled circumstances, they may be used in experiments to further explore this very interesting new property of malignancies."
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(1)Horvath, Gyorgy, et al. Human Ovarian Carcinomas Detected by Specific Odors. Integrative Cancer Therapies Vol 7 Number 2 June, 2008.

It took all my education...

A man came in today worried about a red area on his arm. The spot was about the size of a quarter and had two raised bumps within its circumference. He told me that he'd had two similar areas recently, one on the other arm and one on his back, both now resolved. All of them itched.

And they pay me for this?

Tumor necrosis factor

This sounds like a good thing, right? Produced by cells of the immune system, this protein's name implies that it is a sort of cellular "ace-in-the-hole," inducing death in wayward cells and their mutant offspring before a cancerous tumor is formed.

When first discovered in 1975, tumor necrosis factor (TNF) was noted to induce death in malignant cells in laboratory studies. Unfortunately, it is most complex in its actions, proving toxic to healthy cells and actually promoting the growth of certain kinds of cancer. TNF in the wrong place at the wrong time causes unwanted inflammation. This little troublemaker is a destructive party crasher in the joints of persons with rheumatoid arthritis, It also has destructive, pro-inflammatory effects in Crohn's colitis, smoking-related lung disease, atherosclerosis, Alzheimer's disease, and doubtless much more of that which ails us. It contributes to the profound wasting of AIDS and induces fever and shock in the face of overwhelming bacterial infections.

TNF is a good thing if you happen to do battle with a saber-toothed tiger, accidentally drive a Folsom point into your leg, or fall off your bicycle and scrape your knee. TNF is known as an 'acute phase reactant'; as the body's own EMT, it is one of the first responders at the scene of injury or infection. Produced by activated white cells and the endothelial cells that line blood vessels, TNF attracts bacteria-killing white cells known as neutrophils, promotes the passage of these cells through the blood vessel lining into damaged tissues, alerts the liver to produce pro-inflammatory molecules such as c-reactive protein or CRP, suppresses appetite, and promotes fever.

If TNF and company are activated, however, by cigarette smoke, doughnuts, McDonald's french fries, or too much waisted fat, this same immune response sets off a world of trouble in our arteries. Likewise, auto-immune diseases such as lupus or rheumatoid arthritis cause TNF inflammatory responses in joint spaces and other body tissues.

Body balance or homeostasis depends on equilibrium between troubleshooters such as TNF and peacemakers such TNF inhibitors. Therapies directed against TNF have changed the long-term outlook for patients with rheumatoid arthritis. These new drugs include TNF antibodies such as Remicade and Humira, and proteins that fuse with TNF such as Embrel. Early suppression of the joint-destroying inflammation associated with RA can prevent skeletal deformities and pain, markedly improving a patient's quality of life. Unfortunately, blocking a bad actor such as TNF which also has essential immune functions is not without problems. For one thing, TNF has an active role in the body's response to mycobacterial infections. As a result, cases of active tuberculosis have been reported with the use of anti-TNF agents.

Optimal vitamin D doses

I thought everyone had heard the news about the widespread deficiencies in vitamin D, yet the majority of people whose D levels I check measure way, way low in this essential vitamin. Even those who take a daily multi-vitamin with 400 units of D per tablet (the current RDA) are failing to top 30 ng/ml, the lower end of the desirable range.

Doctors in Beirut studied two groups of adolescents over 16 weeks. Half took 1400 units of D3 per week (the RDA for this age group is 200 units) and the other half took 14000 units per week. By study's end, the high dose group had a significant upward change in their serum D levels, but, better yet, demonstrated "substantial increments in lean mass, bone area, and bone mass."(1)

Many of my patients take 400 units of D3 per day, the amount present in most multi-vitamin pills. Per Toronto's Dr. Reinhold Vieth and colleagues "Supplemental intake of 400 IU vitamin D/d has only a modest effect on blood concentrations of [vitamin D], raising them by 7–12 nmol/L [2.8-4.8 ng/ml], depending on the starting point."(2) So if you're skidding along in a pasty white fashion, no sun plus one multivitamin pill/day, and your vitamin D level is around 11 (like so many of my patients), adding one more 400 unit D tablet per day will only get you up to 15, still terribly deficient.

Experts recommend supplementation in the neighborhood of 2000 units per day. Studies suggest that fracture risk falls with D levels of 30 ng/ml, and the improved outcomes not only result from stronger bones but also from greater muscle strength.
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(1)Maalouf J, et al "Short term and long term safety of weekly high dose vitamin D3 supplementation in school children" J Clin Endocrinol Metab 2008; DOI: 10.1210/jc.2007-2530.

(2)Vieth, R et al. "The urgent need to recommend an intake of vitamin D that is effective" American Journal of Clinical Nutrition, Vol. 85, No. 3, 649-650, March 2007

Dr. Ed Hepworth, Denver, CO

Credit where credit's due. I know that people search for patient reviews of physicians, so here's one from a woman who had complicated sinus surgery with Dr. Ed Hepworth here in Denver:

This guy's incredible. Man, he's good!

Lipotoxicity

Here's the new lipocentric news! What is not news, of course, is how lipocentric we're all getting, our fat or lipid-filled midriffs featured front and center in a pregnant abdomen sort of way. Researchers now, however, are theorizing that the fat load we carry as a result of overeating and undermoving is the primary metabolic driver behind the current epidemic of type 2 diabetes. Dr. Roger Unger of the Touchstone Center for Diabetes Research concludes in a recent JAMA editorial that "If this is in fact the case, [high blood sugar] should be corrected by eliminating the lipid overload."(1)

Want the skinny on fat overload? Check out: Lipotoxicity for the details.
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(1) Unger, RH. Reinventing Type 2 Diabetes. JAMA, March 12, 2008, Vol 299, No 10.

Designated Listener, Part II

Seems like there's a run of bad health luck in the lives of those around me here recently. I found myself, once again, sitting in as designated listener for a loved one (LO) during an important consultation. This time, I noticed a few eye-openers about the way my colleague conducted the visit, so here's three rules for MDs in the consultation room:

1. Doctors who don't get appropriate touching should skip touching altogether.
   This guy often stood with hand on LO's shoulder or occasionally sat with hand on LO's knee. I prayed that LO would not haul off and smack him. Honestly, it was not the time or place for such touching, and, in any case, LO exudes 'don't touch me' from every pore of his body.
2. Explain your thoughts, but don't dither.
   The doc was clearly puzzled by the situation and was thinking on his feet. As he mused about the possibilities in a roundabout, back-and-forth, sort of way, he finally came up with what I thought were three appropriate theories. LO concluded, not inappropriately, that this physician was fairly clueless about LO's condition.
3. Explain, but don't over explain.
   The physician gave so many simplistic 'for examples' that he came off as patronizing. Patients may need simplification, but, here I completely agree with LO, this was WAY too much dumbing down.

As an aside, our consultant stood through most of the visit in a stance appropriate to a college defensive back. I assume that at some point in his career he was just that, but it was a little strange there in the examining room.

Blood vessels love grape juice

They're not just passive pipes anymore. Blood vessels, or rather the single layer of cells known as the endothelium that line these passages, actively regulate blood pressure, blood flow, clotting, inflammation, and the immune response. And endothelial cells love purple grape juice whether it's fermented or not.

Persons with arterial disease such as hypertension or atherosclerosis are known to have endothelial dysfunction. In other words, their blood vessels are unable to expand normally in response to such things as exercise and cannot, therefore, efficiently increase blood flow and oxygen delivery when needed. Researchers are able to measure the health of the endothelium and its ability to increase blood flow by a simple test called flow-mediated dilation (FMD).

This test uses ultrasound technology to measure the diameter of the brachial artery at the elbow. A blood pressure cuff is then inflated on the forearm to the point where blood flow through the area is stopped. When the cuff is released, blood surges back into the forearm. Ultrasound is again used to the brachial artery, and the state of blood vessel health can be judged by the post-test expansion of this artery.

Fifteen patients with proven coronary artery disease were hooked up with daily grape juice over the course of 2 weeks(1). Prior to being juiced, these patients, as expected, demonstrated impaired FMD. After 14 days of Welches (and this must be concord grape juice), their FMD tripled. No such changes were observed in other studies conducted with OJ or grapefruit juice.

Grape juice kind of makes my skin crawl, but I drink it anyway. Pair it up with dark chocolate and oatmeal, and your endothelium will be relaxed, your arteries surging with blood.
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(1)Stein, JH et al. Purple grape juice improves endothelial function and reduces the susceptibility of LDL cholesterol to oxidation in patients with coronary artery disease. Circulation. 1999 Sep 7;100(10):1050-5.

Designated listener

Unfortunately, I was the designated listener for a good friend yesterday. I sat through the doctor's appointment with her and took notes while she more or less heard the words that would change the course of the rest of her life.

The doctor did a wonderful job with a most difficult task. She started the conversation with "I am so sorry that you have to come see me today." She spent nearly an hour and a half with us, explaining and also doing a fair amount of listening herself.

Afterwards, we went out to lunch. Shortly after ordering, the waiter returned to the table. "I'm afraid I have some bad news," he said. "We're out of the foie gras."

She and I didn't know whether to laugh or cry. Bad news indeed!

The benefits of Deplin

I wrote about Deplin recently. Billed as a 'medical food,' it is an fancy new methylated version of folate that easily enters the brain. Being a good sport and an inquiring mind as well as a doctor, I thought I'd give it a try.

The downside of Deplin is that it does indeed interfere with sleep. On the plus side, however, I have noticed an increased ability to focus on loathsome tasks involving numbers. My theory is that I have been borderline low on norepinephrine, the lack of which makes me inattentive and anxious. This new source of methylated folate is, perhaps, hard at work promoting norepinephrine production in my aging brain.

I have not yet heard back from several patients whom I have started on Deplin. I hope that it will improve their response to antidepressants and decrease that lethargy that sometimes accompanies the use of SSRIs. This side effect may be due to a down-regulation of norepinephrine receptors in the brain.

I said...MOVE YOUR REINDEER!

You may be surprised to discover that reindeer herding is a hazardous, noisy profession, what with all those braying reindeer and roaring snow mobiles. However, Finnish researchers have found that hearing loss among the herders is not just about nerve damage from noise exposure. Those tundra hands who escaped job stress through smoking, particularly those indulging in more than 144,000 cigarettes (a pack a day for 20 years), had significantly more hearing loss than their non-smoking herd-buddies.

Lest you think this danger does not relate to your daily life, this finding was repeated in a study of 1,500 Japanese office workers exposed to nothing more than the ringing of phones and computer games, There, the risk of high-tone hearing loss among heavy smokers was more than two times greater than those who abstained.

No wonder our pleas to our smoking friends to quit sometimes fall on deaf ears.

"Etiquette-based medicine"

Patients ideally deserve to have a compassionate
doctor, but might they be satisfied with one who is
simply well-behaved? ...A doctor who has trouble feeling
compassion for or even recognizing a patient's suffering
can nevertheless behave in certain specified ways that
will result in the patient's feeling well treated..
---Michael Kahn, MD

Dr. Kahn calls for a good manners curriculum in medical education in the latest edition of the New England Journal of Medicine.(1) He provides an example of a behavioral checklist that clinicians should follow to promote civility and respect in our patient encounters, including:

1. Introduce yourself.
2. Shake hands.
3. Sit down.
4. Smile if appropriate.

I'm sure you've all had encounters with physicians who were less than polite. My Mom's first doctor at the nursing home, shortly before I fired him, spent five minutes in her room during which he never looked at her once nor addressed a single remark to her. I saw a dermatologist a few years back who walked in one door of the exam room, moved slowly past me looking closely if briefly at the area of concern on my forearm, then scurried out the door at the other end of the room. Period. End of encounter.

I agree with Dr. Kahn. If you can't teach all medical students compassion, pass along a few basic rules of etiquette, and train them to shake hands and sit a spell.
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(1)Kahn, MK. Etiquette-Based Medicine. NEJM. Volume 358:1988-1989.

Post-vaccination syncope

Early in my medical school career, some brave pediatrician rounded up a group of us to observe a circumcision. The mom among us (brave soul had a young son at home) turned white as a sheet mid-procedure and sank to the floor in a faint.

This loss of consciousness as a result of undergoing an unpleasant experience is called vasovagal syncope. Completely involuntary, changes in automatic body functions after an intense experience result in overactivation of the parasympathetic nervous system (drop in heart rate) and withdrawal of sympathetic tone (dilation of blood vessels with a subsequent drop in blood pressure). Blood flow to the head diminishes (thus white face), and down she goes.

Actually, she is not completely accurate. The most common vasovagal reactions we see at the office are young men swooning after blood draws. Per the May 2nd Morbidity and Mortality Weekly Report, however, there's a new trend in fainting--teenage girls going to ground after vaccinations.

Experts theorize that the upswing in adolescent girls getting shots due to the rise in recommended vaccines such as the Gardasil series against HPV has caused this surge in syncope. While sinking to a prone position restores blood flow to brain, the worry here is that the young lady will injure herself while sinking, or will take out others if she sinks and drives.

Last year, one of my neighbors, a girl of 15, came to my office from her nearby school to get her tetanus shot. No one likes to be needled, but K was particularly dramatic about her distaste for the task. Nevertheless, she finally received her shot, and fifteen minutes later, we headed for my car as I was done with work and had offered to take her home. Halfway there, K complained of dizziness, and when I looked over she was out like a lightbulb, twenty-some minutes post-vaccine.

Our experience underlines the importance of the Advisory Committee on Immunization Practices' (ACIP) recommendation: Keep the drama mamas and the papas under observation for 15 or more minutes after they twitch their way through their ordeal.

Aspirin and breast cancer

I am often asked whether or not I'd recommend the daily use of aspirin. Specifically, with respect to heart disease prevention, 2003 guidelines suggest that those at 10% risk of a heart attack in the next 10 years do just that. Wondering if that's you? Check out Risk assessment tool. Some suggest that the 10% threshold be raised to 15-20% 10 year risk to avoid putting every man over 70 on aspirin due to the risk of bleeding in the GI tract.

Doctors at the National Cancer Institute checked out questionnaires from over 127,000 female AARP member with respect to NSAID usage (aspirin, ibuprofen, and other anti-inflammatory analgesics) and breast cancer incidence over six years(1). While the use of non-aspirin NSAIDs did not affect the risk of breast tumors, the daily use of aspirin dropped the risk of estrogen-receptor positive cancers (the most common type) by 16%.

Just yesterday, a patient asked me if she would experience pain if daily aspirin use was irritating her stomach to the point of bleeding. I have had three patients over 25 years of practice with catastrophic hemorrhages from aspirin use. Two of them started vomiting bright red blood as their first sign of trouble. The third walked into the office on shaky legs, weak and white as a sheet from blood loss over the previous months. He did not realize that black stools were a sign of blood loss through the GI tract. Pepto-Bismol users, don't freak out. PB makes stools black too!

Do I take a daily aspirin? Yes, I do. I've done so every since the Nurses' Health Study results showed that 20+ years of consistent aspirin use, at least 4-6 times per week, cut the risk of colorectal cancer by 46%(2). This study was published in 1995, so I've got 7 years to go to reap my rewards.

Please note, this post is for informational purposes only. Decisions such as daily aspirin use should be made in consultation with your personal physician who is familiar with your health history.
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(1)Gierach, G et al. Nonsteroidal anti-inflammatory drugs and breast cancer risk in the National Institutes of Health-AARP Diet and Health Study. Breast Cancer Res. 2008 Apr 30;10(2):R38 [Epub ahead of print].
(2)Giovannucci, E et al. Aspirin and the risk of colorectal cancer in women. N Engl J Med. 1995 Sep 7;333(10):609-14.

Deplin

see also Deplin Testimonial for a report on Deplin from a patient with multiple sclerosis

The PamLab drug rep is moderately annoying. I hate to think that the messenger would affect my interest in the message, but, alas, it did for months. He finally staged a lunch 'n learn,* but also, much more importantly, he brought in an article by Dr. Stephen Stahl that caught my attention big-time.

Dr. Stahl is Dr. Psychopharmocology. He literally wrote "The Book" also known as Essential Psychopharmocology. If ever you suspected that the use of psychoactive drugs is a lot of baseless hooey, check out this tome.

Unfortunately, this world is a fast-paced one that demands more attention, energy, and multi-tasking than many can manage. As a result, there's a lot of overwhelm and depression going around. One could only wish that antidepressants were unnecessary, but a lot of people struggle to get a grip on their mood while being bombarded with the pressures of modern life. As a result, these drugs can be lifesavers, or at least change surviving into thriving.

That said, antidepressant medications aren't perfect. In many cases, some relief is obtained, but it's either not enough or marred by the side effects of the drugs. So patients find themselves limping along with ongoing fatigue, inertia, decreased concentration, or other symptoms that impair their quality of life.

The search continues, therefore, for 'augmenting agents' that improve response to antidepressants. Enter Deplin, billed as a 'medical food' which falls somewhere between food and drugs per the Food and Drug Administration who will soon need to change their name to the Food, Medical Food, and Drug Administration. Per them, Deplin aka L-methylfolate--an active form of folate--is so classified because it is:

...intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.(1)

Now how good is this?!? A new drug, er medical food, that's a glorified vitamin, that has great science behind it for the treatment of depression which is at least half my practice. And being a child of the '60s, always willing to pop a pill to alter mood, I've tried this product myself, and I'm impressed with the results after just a few days of use. But this post is long enough, check out methylfolate and depression for more information on how Deplin works.
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*And lunch was a Subway sandwich on a stale roll and a liter of Diet Pepsi. After the luncheon, he left but hurried back in to grab the leftover pop. So don't think he bought my interest with a fancy meal!
(1)Food and Drug Administration/Center for Food Safety and Applied Nutrition. Food Safety and Applied Nutrition, Medical Foods. Available at: http://www.cfsan.fda.gov/~dms/medfguid.html.

Lovely Confections in Denver

Sometimes a person has just got to indulge. When it's that sort of time, I tell my patients to make sure those calories are really worth it.

Lovely Confections at Colfax & Steele didn't get Westword's Best of Denver award for cupcakes for no reason. These little cakes are so rich and good they sent shivers up my spine. Alas, sharing two with a teenage boy meant less than one for me.

Paxil and the blahs

Paxil (paroxetine) used to be my favorite choice of medications for the longterm control of anxiety. It worked quickly, and rapid relief of anxiety is a good thing.

I've mentioned before, however, how some people experience a dulling of emotion on Paxil. One patient yesterday called it 'robot mode.' That 'whatever dude' sort of attitude may be a welcome relief from all overwhelm all the time, but patients like this lady eventually want more from life than just freedom from fretting. In particular, she hated the inertia she felt at days' end when choosing between attending her kids' sports events versus sitting quietly doing nothing at all.

Unfortunately, in her case, no drugs at all is not a choice. Job, kids, financial worries, and her serious generalized anxiety disorder just don't work out together. Adding Wellbutrin didn't help; we're trying Effexor now.

A dark patch on the skin

A thirty-something year old lady came in today for her physical. Among other things, she complained of a dark patch on the outside of her left ankle along with pain in the same spot. Dark patch and pain, no connections so far.

So I check it out. The patch is slightly irregular and brown with faint overtones of red. It looks like nothing familiar so far, not fungal, not eczema, not psoriasis. Not tender to touch nor hot in an inflamed sort of way.

The pain occurs while walking, so I ask to see her walk barefoot across the room. Bingo. We have a too many toes sign signaling flat feet, flatter left than right. No wonder her collapsing left ankle hurts. But what about the dark patch?

Does it itch? You bet, she says. Do you scratch it? Are you kidding, she counters, all the time. Ah ha, it's that hyperpigmented Iscratchtoomuchandirritatemyskin chronic skin change sort of look. I see that lots in the middle of the back in older people still limber enough to reach around to scratch.

Patches of skin near the spine itch due to a radiculopathy (now how good a word is that) meaning that a little nerve branch going to the skin called a radicular nerve gets pinched as it passes out of an arthritic spine. The skin supplied by this nerve starts to itch or burn, the patient scratches it lots, and the skin gets dark from chronic irritation. Then I look like an amazing medical intuitive when I ask if that area bothers them.

The brown discoloration of chronically scratched at skin is caused by hemosiderin. This pigment is a breakdown product of hemoglobin. As people dig at itchy spots over time, tiny blood vessels rupture and release hemoglobin into the skin. This iron-carrying molecule from blood is deposited into the space between cells and is subsequently broken down into hemosiderin, leaving a permanent discoloration to the skin. You often see this same blotchy brown residue in the lower legs of elderly persons with varicose veins who develop an itchy condition known as stasis dermatitis.

Godspeed Vernice Griffin

I attended a memorial service this weekend for a remarkable woman/friend/patient. The service itself was remarkable as Vernice had prepared a slide show set to music of her life. But truly wonderful was the woman who outlived her 3 month pancreatic cancer prognosis by 2 years.

In 2006, Vernice had returned to work as a visiting nurse. As she drove through northeast Denver, a gunman walked in front of her car when she pulled up to a stop sign. He looked her in the eye, arm rising and gun cocked in hand, fully prepared by his cold and mocking gaze to shoot. He leveled his gun, and Vernice told me that she considered whether or not this was an easy way out of her battle with cancer. In what must've seemed like a lifetime but perhaps was a second or less, she chose life and ducked. The bullet took out a piece of her wild mane of auburn hair, but Vernice lived on for another year and a half as if her pancreatic cancer was nothing more than a chronic annoyance.

Now that's grace under fire! Good-bye Vernice, you will be missed.