Thursday, January 31, 2008

Male commuters walk on the wild side

Here's an interesting item from Science Magazine comparing bus-riders living dangerously to strutting peacocks:

Oxford psychologists Robin Dunbar and colleagues observed 1,000 men and women waiting for the bus over a three month time period. Their more pedestrian conclusion was that men were more likely to cut it close with respect to catching the bus, often arriving at the bus stop at the absolute last moment before departure.

More dramatic, however, was the jaywalking behavior of the bus-riding men. When observed by women, the scoff-laws were much more likely to make risky dashes through traffic on their way to the stop. The article doesn't say whether or not near death by squashing ruffled the riders' feathers, but the investigators did compare the feats to mating displays.

Sunday, January 27, 2008

One problem with Paxil...

and Prozac, Zoloft, Celexa, and Lexapro

Several years ago, I treated a teenager with Paxil for show-stopping anxiety. He came back two weeks later no longer feeling much anxiety. In fact, he wasn't feeling much of anything. In his words:

I couldn't get my shoes tied this morning. It wasn't that I didn't know how to tie my shoes, I just didn't much care whether they were tied or not. It seemed like too much trouble.

This blah sort of feeling (other patients have variably described it as a lack of emotions, loss of joy, inability to cry, being wrapped in cotton, and viewing life from a fishbowl) is a big problem with this class of drugs known as SSRIs or selective serotonin reuptake inhibitors. My psychiatrist colleagues tell me as many as 40% of patients will experience this dulling of emotion.

While patients may initially welcome the resolution of depression and anxiety, this inability to feel quickly becomes a problem. My patient who called me a saint post-Cymbalta prescription had this problem as well with the SSRIs. More later on why Cymbalta and Effexor are not so dulling, and why Cymbalta may have it over Effexor.

Friday, January 25, 2008

Phone follow-up

Even as I found the phoned request for a two week time-out in a rest home amusing due to the enormity and impossibility of the task, I did recognize that this lady was at her wits' end. A single mother of tweenaged girls, she is struggling with extraordinary fatigue, even more than expected for a single mother of tweenaged girls.

I'm not sure which came first, the depression or the fatigue, but I do know she is seriously depressed. We have since had a long phone discussion about her faltering mood, and have a plan in place--albeit short of a two week vacation--that will address her troubles.
Here's the kind of patient phone message that makes my day:

Cymbalta has changed my life. You are a saint!

Check here later for information on why SSNRIs made her feel good and me look good.

Thursday, January 24, 2008

Dr. Smak is the queen of the outrageous patient calls, including the following:

Please write letter on letterhead stating that patient is unable to do work of any kind for 3, 6, or 12 months.

Call and leave message on machine when complete. Patient will be gone all day hunting.

Here's my 'did-they-really-say-that?' phone message of the day:

Patient is having a lot of stress with her kids and her health. She would like to check into a Health & Wellness Center for 2 weeks. 'A place where I can be monitored and relax.' Advise.

Wednesday, January 23, 2008

Beyond Zetia

This Zetia business seems to be rocking the cardiology world just like the Women's Health Initiative blew up conventional wisdom on hormone replacement therapy.

Cholesterol in the body comes from two sources: one pool manufactured in the body, and the other from the diet. Zetia is a drug that lowers LDL-cholesterol levels by partially blocking the absorption of cholesterol from the small intestine. Statins such as Zocor and Lipitor, on the other hand, decrease some of the activity of an enzyme that is important in the body's own cholesterol production. Zetia has been heavily marketed as a good drug for persons with high cholesterol who either can't tolerate statins or who don't reach their goal LDL-cholesterol levels on statins alone.

The ENHANCE trial found that persons taking the Zetia-Zocor combination for 2 years (aka Vytorin) did no better than those on Zocor alone with respect to unwanted thickening of their carotid arteries. As a result, not only are cardiologists taking sides in the Zetia/no-Zetia debate, now they're wondering if lowering LDL-cholesterol is even an important goal in the war against heart disease. Consider these varied opinions from the nation's top heart specialists:

The idea that you're just going to lower LDL and people are going to get better, that's too simplistic, much too simplistic.
Dr. Eric Topol, Scripps Institute

The message for me is not that lowering LDL cholesterol doesn't work to prevent disease progression or to prevent clinical events. The important thing to remember is how the cholesterol levels are lowered...There are many advocates out there who espouse lowering LDL cholesterol by any means possible. But let's be clear: 95% of the studies that form the basis for the cholesterol hypothesis are based on studies of statins
Dr. Steven Nissen, Cleveland Clinic

Anytime you can lower LDL-cholesterol levels safely, you are going to see reductions in the risk of clinical events.
Dr. Patrick McBride, University of Wisconsin

Per Dr. Nissen, the bottom line here is that statins not only lower LDL-cholesterol, but they also can raise HDL-cholesterol (a weensy bit), decrease triglycerides, and lower c-reactive protein or CRP. CRP is a pro-inflammatory molecule in the body; when present in elevated amounts, CRP not only is a marker for risk of coronary artery disease, the substance actually causes trouble in arteries whose walls are streaked with fat.

The Premarin drug rep started sneaking through our door after the 2002 WHI results were released, sheepishly bearing samples and M&M's. The Avandia reps don't even come around anymore. Come to think of it, haven't seen the smiling face of the Vytorin rep in the last week either.

Monday, January 21, 2008

Quitting cigarettes and risk of cancer

...a sort of lean, puffing, self-damaging-yet-self-repairing machine

Mrs. P smoked, as did so many of her generation. She started in her 20's when her doctor suggested that smoking might improve her cold symptoms and, unfortunately, kept it up for five decades after her cold resolved. When she experienced some dizzy spells at age 70, she finally stubbed out her last cigarette.

Three months later, she was diagnosed with lung cancer. How ironic, we thought, to finally quit and be felled by cancer shortly thereafter. But now, three doctors from India have a theory that might link the one event (the end of smoking) with the other--the development of cancer. They proposed in the journal Medical Hypotheses that lung cancer may be triggered by quitting smoking. Of 312 lung cancer patients they treated in a four year period, 182 or 58% had recently quit smoking. They felt the correlation was way too strong to be a coincidence.

They hypothesized that biological mechanisms that prevent cancerous changes get strengthened through years of smoking. As long as the smoker continues to inhale noxious substances, the body copes with the mess in a habitual clean-it-up-as-best-we-can sort of way. Upon cessation of the habit, however, the doctors theorize that:

...a surge and spurt in re-activation of bodily healing and repair mechanisms of chronic smoke-damaged respiratory epithelia is induced and spurred by an abrupt discontinuation of habit, goes awry, triggering uncontrolled cell division and tumor genesis.

Remember, this is just a theory, albeit a fascinating one. I'm not going to counsel a smoking soul to keep on puffing just to avoid the post-smoking tumor risk. I think it possible that smokers with incipient lung cancer get signals from their body that cue them in that it's (past) time to quit.

Tuesday, January 15, 2008

These studies light up my lines

First estrogen in the post-WHI days. Then Avandia after studies linked this diabetic drug to an increased risk of heart disease in a population already at enormous risk of same. Now Zetia hits the headlines, and patients hit speed-dial to Capitol Hill Internal Medicine.

For those of you not yet chasing your cholesterol numbers, Zetia is a cholesterol-lowering medication that works in an entirely different manner than the statins such as Zocor (simvastatin) or Lipitor. For that reason, persons unable to tolerate statins or those whose cholesterol levels do not fall sufficiently with statins can be switched to Zetia alone for a 15% drop in their LDL levels or to Vytorin which teams Zetia with Zocor for an even larger reduction in LDL than Zocor alone.

When we monitor cholesterol levels to gauge the success of treatment, we are actually looking at 'surrogate markers.' We don't have any practical way of monitoring the actual health of your inner arterial wall, so we know, based on mountains of data from years of studies, that LDL-cholesterol levels tend to correlate with the amount of gunk in your arteries and the risk that they will ultimately block off under a heap of goo and clot.

Well, we used to know that. New data* from the ENHANCE trial suggests that, when it comes to Zetia, lower LDL levels do not necessarily translate into lower risk. This study followed 720 patients over 2 years (note small trial size and short trial duration), comparing IMT (intima media thickness of the carotid arteries which uses ultrasound technology to indirectly measure wall thickening in neck arteries**) in subjects on Zetia and Zocor vs. those on Zocor alone.

The results showed not a whit of difference between the combination of the Z drugs (aka Vytorin) and Zocor alone. Vytorin and Zetia are brand name only drugs, thus more expensive and far more lucrative to the manufacturers, while Zocor is available generically. Dr. Steve Nissen, an outspoken cardiologist from the Cleveland Clinic, is emphatically urging docs to abandon Zetia. Industry-backed investigators are hedging.

Hmm, what to say to those callers?
*Actually, it is oldish data that has only been newly released, and perhaps only released under pressure from a congressional committee.
**IMT is also a surrogate marker,
Seven years of post-grad training for this?

Young fellow mildly smashes finger in dog cage, presents vaguely mangled finger tip with tiny piece of skin raised beside nail for my inspection.

YF: Should I just pull this off?

Me: On average, it's better not to pull things off your body.

Thursday, January 10, 2008

Wee beasties in Baggies

Many of the blogs I visit have the most wonderful pictures, especially of birds, on them. The women of Canada must make up for their gloomy winters with spectacular photos, finding brightness in gloom.

I am sorry to say that I missed out in sharing the most amusing digital picture of my week as it wasn't on my camera. This was a new one for me; a patient brought in her camera with four pictures of small white specks that she'd extracted from her nose. Even with my strongest readers on, I couldn't make out the legs and the tails that she pointed out on these splotches.

Figuring that a picture was worth a thousand words, but the real deal was even better, she also brought in a Zip Lock bag with more nose specks, and a few scalp specks as well. I was speechless, and a weensy bit grossed out.
Why MDs miss breast cancer

The leading cause of physician delay in diagnosis of breast cancer continues to be inappropriate reassurance that a mass is benign without biopsy.
William Goodson, MD, Archives of Internal Medicine 2002; 162: 1343-1348

Several years back, a 40-something year old lady, new to my practice, came to see me for a physical. I was taken aback to find a large mass in one breast. When I asked her what was up with that lump, she replied that she'd had it for years and that her previous doctor assured her it was benign. No biopsy, just negative mammograms and clinical follow up over time.

As far as I'm concerned, you don't know that a mass is benign until you KNOW it's benign, as in tissue in hand and examined microscopically. With my urging, she saw a surgeon and had a biopsy, and it wasn't benign. The final diagnosis was ductal carcinoma in situ, fortunately, and she required no further treatment after the lump was removed.

My current patient of concern is a man who's noted a breast lump for months. He's had a mammogram and an ultrasound, and both were consistent with gynecomastia, a benign enlargement of male breast tissue. But...the surgeon not only said no big deal, come back if it gets bigger, but he also said that insurance wouldn't pay for further testing or excision as they would consider it a cosmetic procedure. Well it's bigger now, and I've urged him to go back to the surgeon to have it removed and not to take insurance won't pay as an answer.

Dr. Goodman concludes: Reducing delay in diagnosis will require less willingness to rely on clinical examination to decide that a mass is benign, [and] less reliance on benign mammography reports to decide not to biopsy a mass. The worst breast cancer I ever found in a woman--already spread extensively to lymph nodes--did not show up on mammography at all.

Tuesday, January 08, 2008

I Am Impressed

Just because Will Smith let me down, doesn't mean that no one is paying attention to my enjoyment of a night out at the movies. I just spoke with the Guest Services Coordinator for Harkins Theatres in Scottsdale, Arizona who was responding to my blog entry about my Harkins experience.

She paid close attention to the accessibility problems for my family member, namely the long walk from the closest handicapped spot to the front of the theater. The doors open on a street with limited parking whereas the handicapped spaces are located off the sides of the building which are equipped with exits only.

I appreciated her personal attention, and I look forward to their efforts to remedy the situation. Now, if only Will Smith's agent would call...

Monday, January 07, 2008

Blah, you think it's dark where you are, check out these afternoon photos from Ontario taken by Ruth of Body and Soul on the first day of winter. These Canadian bloggers take winter dark very seriously.

If the dark's got you down, check out The Center for Environmental Therapeutics. You can take some little quizzes about the states of your psyche and circadian rhythms. Find out your morningness-eveningness type (I'm 'moderate morning,' but really needed no fancy automated questionnaire to tell me that), whether your gloomy mood is SAD, sub-SAD, or just ordinary sad, and whether or not a light box would light up your world. And if light therapy is recommended, you can not only order a big old unit to blast out the blues, they'll even tell you the best time of day to use it.

Sunday, January 06, 2008

I Am Letdown

I can hardly bear to watch scary movies. The special effects and 'cheap thrill' moments (picture the alarming shot of the dessicated dead girl curled up in a closet near the start of "The Ring") give me an adrenalin surge that is far from entertaining. Evidence presented in the May, 2005 edition of Nature Neuroscience suggests that I may be experiencing the effects of inheriting a short version of the serotonin transporter gene.*

Apparently, I'm genetically doomed to never finish a scary movie, unable to watch tragic films (e.g. "Requiem for a Dream"), or read through a tragic book (stopped "A Map of the World" abruptly on page 19 when the little girl disappears). On the other hand, a little excitement in an implausible sci-fi flick (say "Independence Day" or "The Day After Tomorrow") is one of my favorite pass-times, so I was eager to see "I Am Legend."

Alas, I am disappointed. Aside from the extraordinary computer animation of post-plague NYC as weed-choked wasteland where herds of gazelles hop through lines of abandoned cars with Will Smith in pursuit, the movie was ridiculous. Even the abrupt appearance of the lean and buff viral-ridden zombies did not raise my heart rate. These hairless dudes were clearly spending sunny days working out in subterranean health clubs to get in shape for evenings spent chasing Will and his canine companion.

And I'm sorry to report that the brand new Harkins Theaters at Northfield are already seedy and hard to access for the physically challenged. Should've stayed home and watched the original "Haunting of Hill House." Oh wait, those walls that breathe and halls that whisper ruin my sleep.
*For more information on short serotonin transporter genes, see Short-changed on serotonin transporter gene?.

Saturday, January 05, 2008


Well, now how unlikely is that? Hook yourself up now and again to a gizmo that monitors AND moderates your breathing rate, then drop your BP up to 36 points! I would've rated this gizmo as weird, but after witnessing its effects this week in the office, I'm tentatively branding it wonderful.

Ms. L is seventy-something, and too active with her worldwide travels to let hypertension get her down. She's on three different meds in two different pills: a beta-blocker and a two-fer-one combo called Lotrel which combines an ACE inhibitor with a calcium channel blocker. She arranged her Wednesday appointment to discuss her elevated pressures--158/96--despite all those drugs.

Prior to her visit, she hauled out her RESPeRATE machine, just for grins, and breathed to the tones. She bought this machine a couple of years ago, but like all health habits that take a little time, it got shelved due to busyness. The manufacturer claims that slowing your respiratory rate to 10 or less breaths per minute allows small blood vessels to dilate. Same amount of blood through now larger vascular space equals lower pressure. Ms. L stuck her arm up on the desk to get her BP checked--a moment that often causes white coat hypertension in the doctor's office--and poof there's our proof! 122/78! I checked both arms, just in case, and she was symmetrically normotensive.

These little hummers set you back $290 at Hypertension sets you up for heart attacks, stroke, and dementia. RESPeRATE, $290. Peace of mind? Priceless. I don't have hypertension, but I think I want one.

Friday, January 04, 2008

How many ways to say no?

Me: Are you exercising?

Pt: Not particularly actually currently.

Thursday, January 03, 2008

DEA gives thumbs up to a 3 month supply!

Those of you with ADD, if you've been paying the least bit of attention, have noticed that getting prescriptions these past 2 years has been a pain in the neck.

The Drug Enforcement Administration (DEA) which supervises the distribution of controlled drugs implemented a policy that prohibited physicians from writing more than one month's prescription for schedule II controlled substances--including stimulants like Ritalin and narcotic analgesics such as Percocet--in a single office visit. As a result, the number of last-minute, contentious phone calls between my patients and my office staff rose exponentially as forgetful patients and those frantic with pain tried to get their meds filled at the end of the month.

But now we're back to the 90-day rule. Three prescriptions can be issued at once, each for a month's worth of drugs, two of them labeled 'do not fill until' preset dates in the future.