"My little toenail looks gross!"

I came back in the room after my patient was dressed for the last word on her physical. She had shoes and socks off, a sure sign that she'd just remembered some foot issue.

Her toenail did indeed look gross. The toenail was split all the way down, and the skin around it was heavily calloused. Not a wart, as she theorized, but the result of narrow shoes smashing her 5th toe beneath her 4th.

I asked her to stand up with her bare foot next to her stylish brown leather heels. There was no relationship whatsoever between the shape of her foot and those lovely stilettos. I indicated my stumpy black Merrill's, suggesting that a better match between shoe shape and foot would heal up that toenail. Not only was the shoe too narrow, but the height of the heel was forcing her forefoot to be solidly crammed into the pointy toe.

She stopped short of gagging at my footwear choice and agreed to seek a more practical shoe.

What's going around, March, 2008

What better way to pass the viral misery than to think of ways to corrupt other people's songs. Too sick to sleep, too sick to read, too miserable to watch TV, here's my creation:

Croup

(Croaked to the refrain of Joni Mitchell's "Both Sides Now")

I've looked at croup from both sides now,
As doc and victim, still somehow,
It's cough/chills/aches that I recall,
I've got no time for croup, at all.

Wise words from an orthopedist

My patient was worried about her knees. Pain prevented her from getting down into a squatting position. Shoot, I haven't been able to do a deep knee bend for years, but I certainly could relate to fretting over aging joints. So I sent her off to Western Orthopedics where she met with Dr. Raj Bazaz.

He checked out her knees and declared them fit for service for years to come. His best advice to her? Don't do deep knee bends.

She was delighted with the visit.

Recurrent urinary tract infections

Phone calls in the night are a surefire way to set my heart racing. Death, destruction...or a patient with a urinary tract infection? I try to be understanding at 2 a.m., and heaven knows I do understand the agony of dysuria, that urgent, can't-be-quenched, fire of an infected bladder that sends a woman back and forth to the bathroom. And all too often, the middle-of-the-night episode is just one in a series of pesky infections.

What's up with recurrent urinary tract infections (UTIs)? Similarly plagued St. Louis rodents are providing clues as to why some UTIs are so hard to beat.
Washington University researchers induced UTIs in a group of volunteered rodents down at the lab. The rest reads like a science fiction story.

As expected, the e. coli bacteria invaded the epithelial cells lining the mousy bladders. Once inside the cells, the microbes set up housekeeping, forming a "biofilm" around themselves and their offspring. This protein shell protected them against attack from both antibiotics and the mouse's immune system. The growing colonies of bacteria, encased in their armor of protein, formed pods that pooched out from the bladder wall into the cavity of the bladder. Occasionally, the pods ruptured and spilled bacteria into the urine, thus creating another round of midnight misery for the mice. The Washington investigators theorize that if humans also experience attacks from the bacterial pod people, this would explain the recurrence of some UTIs after treatment.

And why my phone rings in the wee hours of the day.

On the dangers of not drinking

This from Dr Jane Østergaard Pedersen National Institute of Public Health, Copenhagen:

Another important finding is that physical activity can reverse some of the adverse health effects associated with alcohol abstention. People who did not drink but whose physical activity was moderate or high had a lower risk of IHD [ischemic heart disease] than the inactive nondrinkers.

I just told a group of nurses yesterday that while moderate alcohol intake (from 1-14 drinks/week) decreased risk of heart disease and raised levels of HDL-cholesterol, we were not yet recommending that non-drinkers consider drinking. These Danish researchers analyzed 20 years of data from nearly 20,000 persons enrolled in the Copenhagen City Heart Study. They found that mortality from ischemic heart disease and all cause mortality dropped with physical activity or moderate drinking, but dropped most with those Danes who celebrated their post-exercise glow with a beer or two.

Pedersen concludes: "The lowest risk of death from all causes was observed among the physically active moderate drinkers and the highest risk as seen among the physically inactive non- and heavy drinkers."

So drink a little, move a lot. And if you don't drink, you gotta' move!
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1. Østergaard Pedersen J, et al. The combined influence of leisure-time physical activity and weekly alcohol intake on fatal ischaemic heart disease and all-cause mortality. Eur Heart J. 2008; DOI:10.1093/eurheartj/ehm574.

Tart cherries, arthritis, and all that ails you

How good are Montmorency cherries? Well suffice it to say that at a certain point, I just had to stop reading the bushels of cheery cherry news in order to get this post written.

First of all, they're a wicked good source of melatonin. So much so that Dr. Russel Reiter, the so-called 'dean of melatonin research,' has now become the darling of U.S. cherry growers. Dr. Reiter has proven in his Texas neuroendocrinology lab that eating tart cherries replete in melatonin will make you replete in melatonin.

Hard to say what's next best about cherries. Probably their anthocyanin content. These cherry compounds are potent cyclooxygenase (COX) inhibitors. If that term rings a bell, it's because COX-2 inhibitors have been big news lately, first as miracle compounds that decrease arthritis pain without bothering the stomach, then as pharmaceutical villains for the faint of heart who wonder if Vioxx and Bextra caused their hypertension or heart attacks. For heart-safe and stomach-safe COX-2 inhibition, eat cherries.

After Michigan State University investigators patented a process to separate cherry from anthocyanin, the folks at Overby Farms used this technique to make cherry little dog biscuits for arthritic pooches. You will enjoy HipBones. The MSU investigators subsequently discovered that humans may lose weight, lower cholesterol, and increase insulin production with high anthocyanin-content foods, so buy some of those biscuits for yourself.

And now this final word about cherries from Iowa's Dr. Raymond Pohl, and then I'm plum cherried out. He writes that the perillyl alcohol in the fruit "shuts down the growth of cancer cells by depriving them of the proteins they need to grow. It works on every kind of cancer we've tested it against."

For a world of testimonials from aching humans and their canine companions, look around the web.

*This is the advertising slogan for "Tart is Smart" cherry juice. Check out tartissmart for more information on cherries than you could ever hope for, plus retail locations where you can buy this good red stuff. For those of you in Colorado, visit your local Albertson's!

Gross hematuria

Well I suppose anytime you see blood in your urine it's kind of gross. Scary too. In a medicalspeak sort of way, however, gross hematuria means enough blood in urine that anyone could see it by just taking a peek before they flush. Microscopic hematuria, on the other hand, refers to hidden blood which is only found when the urine is examined under the microscope. The clearly visible sort of bloody pee is always a problem, but here's an instance where the problem was out of the ordinary.

This patient came to me doubled over in pain. He explained that he had a history of kidney stones, and had begun experiencing the typical pain from flank to groin earlier that day. The pain of kidney stones is reputed to be one of the worst pains imaginable. Sorry to be a cynic, but I felt half sympathetic AND half skeptical about the truthfulness of his story. But he brought records from another state that confirmed two previous episodes.

Most persons with a kidney stone develop microscopic hematuria, so I asked him to leave a sample of urine for analysis. He limped dramatically off to the bathroom, and emerged after awhile with a grossly bloody sample. Bright clear yellow urine shot through with strands of blood as if he might have drawn blood from his arm and squirted it into his fresh sample. I have no doubt this fellow had kidney stones in the past, and no doubt that he developed a liking of the strong narcotic pain relievers prescribed for these episodes. I invited him to head over to the ER if he was in that much pain for I was unable to help him.

Real honest-to-goodness gross hematuria is always a cause for investigation and solution. Many women have had the alarming experience of seeing blood in their urine, accompanied by the characteristic burning and urgency of a bladder infection. Some runners can bleed into their urine after extreme workouts. Otherwise, gross hematuria is quite worrisome for urological cancer and requires a careful workup.

Tips from a pro

She's the professional patient who's not always patient. After a lifetime of cystic fibrosis and two double lung transplants, Tiffany Christensen knows her way through a medical maze. Her recent post on the top ten tips for navigating same includes a most important piece of advice:

Here’s the greatest irony of illness: when you are at your worst is exactly the time when you need to be at your best! If you aren’t up for self-advocacy, bring some one who can do it for you.

Check out the rest of her list at Navigating the medical maze. And if you happen to be facing a serious illness, know and love someone who is, or think you might someday be so challenged, her book "Sick Girl Speaks" is essential reading, and a mighty good read at that.

Pink urine

Two encounters from another day on the front lines as a PCP:

1. Pale pink urine, prettiest pee I've ever seen, like a fine rose wine. Beets, it turns out, really do turn urine pink.

2. On another note, to my patients if you're reading my blog, do NOT bring in used tissues to prove the color of that which you are coughing up. I will take your word for it.

Traumatic brain injury

You do not want to knock your noggin, not even a nudge!

Used to be, if a head-injured patient didn't lose consciousness, we didn't call it a concussion. Increasing evidence confirms, however, that any blow to the brain, including those that seem relatively minor, can lead to serious problems.

Canadian researchers looked at 69 traumatic brain injury (TBI) patients*. While the investigators measured injury severity by the depth of coma or degree of altered consciousness, they soon found out that even those who had walked out of the ER post-trauma demonstrated significant changes on MRI scanning one year after the fact. And, surprisingly, these high resolution scans showed that the white matter --that deep portion of the brain that contains crucial connections between nerve cell bodies-- sustained the biggest tissue loss in the walking wounded as well as those who were down for the count.

White matter matters have been a been a matter of some attention since MRI technology has come into vogue. White matter injuries that show up as bright spots on the brain are common with aging and correlated with cardiovascular risk factors such as hypertension. The more that's the matter with a person's white matter, the more likely they are to have trouble carrying out complex mental tasks. This same sort of cognitive difficulty is seen in post-TBI patients, and now we know why.
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*Levine, B, et al. Neurology, March, 2008.