Sunday, April 27, 2008

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.

Wednesday, April 23, 2008

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.

Monday, April 21, 2008

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.

Sunday, April 20, 2008

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.

Tuesday, April 15, 2008

Oxidative stress in feces

While reading a book recently called Vitamin E & Health published by the New York Academy of Sciences, I came across something entirely new for us to worry about. Here's the scoop on stressed-out stools:

Dr. Charles Babbs of Purdue University made the "chance discovery" that one part feces in 10,000 parts liquid generated detectable quantities of highly reactive hydroxyl radicals." (I wonder what he was doing when he accidentally stumbled on that little pearl of wisdom?). In other words, the bacteria in poop makes such great quantities of these bad actor hydroxyl molecules, it is as if the rotting wad that daily traverses your colon had been exposed to 10,000 rads of gamma irradiation! And you do NOT want highly reactive slop making its way through your abdomen, messing with your colonic DNA.

So how do we keep from harboring such a molecular time bomb within our colons? No surprises from a book about vitamin E--take vitamin E...and avoid dietary iron and fat. Why not iron?

Iron is an essential part of the hemoglobin molecule which transports oxygen to our tissues. No iron, no life. Excessive iron intake, however, may rust out your lungs, your bowels, and your pancreas, at least if you happen to be a rat from the South or an aging woman from Iowa.

Data from Tennessee rodents showed that dietary iron increased oxidative stress in feces, and stressed-out stools, as noted above, increases risk of DNA mutations and cancer in colon cells. Midwestern investigators found that postmenopausal women in the Iowa Women's Health Study with high iron diets were more likely to get lung cancer, colon cancer, and type 2 diabetes, especially if they drank alcohol.

I recommend multi-vitamins WITHOUT iron to all my patients (and the rats that love them) who are no longer growing or losing blood through their monthly cycle.

Sunday, April 13, 2008

Does housework improve your health?

Could be per London researchers who published their study in the British Journal of Sports Medicine. When I read, however, that their data suggested as little as twenty minutes per week of straightening up could straighten up attitudes, I thought "You must be joking."

The doctors sent out questionnaires to nearly 20,000 Scots over an eight year period. They asked participants to: 1) Report on their usual level of physical activity, and 2) take a little quiz assessing their current mental health. They found:

1. Those who puttered 'bout the house and garden for 20 minutes 1-3 times per week were 24% less likely to be in psychological distress.

2. Subjects who upped the putter to 4-5 sessions weekly were 16% less distressed, suggesting perhaps there's a limit to how much time you can muck in the clutter and benefit from having done so.

3. Best of all, no surprise, were those who increased intensity of activity; their bursts of sports rewarded them with 33% less angst.

Well yeah, we know about endorphins and all that; regular hot and sweaty stuff has just got to be good for the mood. But what about this stab or two per week at tidying the home? Does the satisfaction of stacking magazines and emptying waste baskets feed back to a brighter mood?

This, of course, is the rationale behind cognitive behavioral therapy; play like you care and then you start to care. I've mentioned Fly Lady before, the balabusta* who urges women overwhelmed and undermotivated to start the first day of the rest of their lives by cleaning the kitchen sink each night. If you get a grip on one small spot in your chaotic life, next thing you know, you'll be wiping around the kitchen sink, sweeping the floor, combing your hair, and taking on the world.** Hard to believe, however, that those persons spending just long enough each week to conquer the sink and perhaps the stovetop could be experiencing either enough endorphin high to boost their moods or getting cognitively motivated to become undepressed.

My experience with persons in psychological distress is that they simply don't do housework. Period. And those persons not in psychic trouble straighten up their houses as a matter of course.

Makes you wonder about the quality of the medical research that drives our beliefs.
*That's Yiddish for super-woman; she cooks, she sews, she works, she raises children, and does it all in style.
**Sort of a "If You Give a Mouse a Cookie" approach to mental health.

Friday, April 11, 2008

Risk factors for gout

About once a month, some aging fellow (sorry guys, it's more prevalent in men than women) hot foots it into my office with a hot foot. Gouty feet do not like to be touched; that joint at the base of the big toe--the most commonly affected site--is red, hot, swollen, and strictly hands-off on exam.

Gout is an inflammatory arthritis caused by the precipitation of uric acid crystals in the tissues in and around the affected joint. Uric acid is a metabolic waste product produced during the breakdown of purines which are compounds present in foods such as meat and seafood.* High intake of these foods in susceptible individuals can increase the risk of a gout attack; one study of middle-aged health professionals found that those who chose beef, pork, or lamb as a main dish 2 or more times weekly doubled their risk of gout vs. the group that hardly ever ate meat. On the other hand, those old guys who drank low-fat milk thrice daily were half as likely to suffer from gout attacks compared to those who had none. No mention made of those individuals who both ate meat and drank low-fat milk.

I've just learned about another dietary risk factor for this painful condition, namely sugar-sweetened soda. Now no one ought to be drinking this garbage, and here's another reason why. Investigators made another pass at the health professional data with respect to pop preference. Compared to those who never drank the stuff, those who consumed one can daily were half again more likely to get gout and those who had two or more servings daily nearly doubled their risk.

I ask a lot of people about what they eat and drink, and, believe it or not, two sodas per day is not that unusual.
*Purine-rich vegetables such as peas, beans, and mushrooms do not increase risk of gout.

Thursday, April 03, 2008


Twofers --pills that include more than one blood-pressure lowering medication-- are a good choice for the treatment of hypertension even when the patient's blood pressure is not that hyper. Not only does the combo form eliminate one prescription co-pay and improve patient compliance, attacking hypertension with two different therapeutic approaches often achieves better control.

A popular and effective twofer pill called Lotrel has now become one of those 'stop the study' pills--therapy so effective that they stopped the study as it was no longer ethical to withhold the drug from the control group. This medication, now available in some strengths as a generic, combines an ACE inhibitor called benazepril (Lotensin) with a calcium channel blocker called amlodipine (Norvasc). Each of these drugs works in a different way to cause relaxation of the blood vessel walls. As a result, the same fluid volume (that would be the circulating blood) moves through a larger space causing a drop in pressure.

Here's what the Avoiding Cardiovascular events through Combination therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial accomplished. Over 11,000 hypertensive subjects, all of whom were over 55, obese, and many were diabetic were put on one of two different twofer drugs: Lotrel or lotensin plus a diuretic. Those patients who took Lotrel were 20% less likely to end up with a stroke, heart attack, unstable angina, or a need for procedures to open their coronary arteries over the first 3 years of the study. These results were highly significant in this high risk group, and may well change our standard protocols for treating hypertension which has, until now, started with a diuretic then added on an ACE inhibitor.

Per ACCOMPLISH investigator Dr. Michael Weber: Right now, there is a recommendation that when you're putting together combination treatment for hypertension you need to normally include a diuretic as one of the two agents. I'm sure that recommendation will change.

My medical partner and I have long been impressed with the efficacy of Lotrel in hypertension control.