Friday, February 29, 2008

Idiopathic hypersomnia (IS)

Think perpetual teenager. As in back in the days when you were one or parented one, holding mirror to Rip Van Winkle Jr.'s nose at 2 p.m. to see if you/he could still be counted among the living. Only this Sleeping Beauty is no longer a teen, and snoozes on even if it means losing a job or failing a course while remaining oblivious to the wake-up bells and whistles going off around him.

I hate these idiopathic diagnoses. This one is basically a fancy way of saying the patient sleeps too much and we don't know why. Now how is that going to make a person feel better about not only sleeping too much, but once up, being so out of it that he or she can't even remember what was said or done in those first few hours of the day? Well, if misery loves company, this diagnosis says you sleep too much, we don't know why, AND there are other people just like you sleep too much in the same way so it's a syndrome and not just you.

The symptoms of IS include excessive daytime sleepiness, tendency to nap, long nighttime sleep durations, difficulty awakening, and confusion on finally getting up which is also known as 'sleep drunkenness.' And don't mistake these people for healthy hypersomniacs or those people who thrive on a long night's sleep and then function perfectly well by day.

So what do you do with a drunken sleeper who's had no drinks at all but just seems that way? Per Medscape author Muhammed Faisal Hafeez Khan, MD of Duke University, you ply them with the same sort of stimulant medication that persons with ADD use. In addition to Dexedrine, he recommends a trial of Provigil (modafanil) which, if used at bedtime, promotes morning wakefulness. This drug was originally developed for narcolepsy and is now approved to rally shift workers and persons with sleep apnea to full alertness.

Wednesday, February 27, 2008

Medial epicondylitis or Snow-shoveler's elbow

I'm told that I hold a snow shovel wrong. Who's to say really what's right or wrong when it comes to wielding a snow shovel? My spouse claims the proper way is to grip the snow shovel with the left hand by grabbing it fingers down. That, unfortunately, requires that you have a brachioradialis muscle on the top of your forearm with which you can both grip and lift pounds and pounds of snow. I was not issued one of those muscles.

So what's a spaghetti-armed doctor to do? Exactly what my mush-armed patient did--grab the shovel handle in an underhanded sort of way, which brings the trusty biceps into play along with the pronator teres, flexor carpi radialis, and palmaris longus muscles on the palmar side of your forearm. After moving mountains of snow, these overused muscles which attach on the inner aspect of the elbow, start screaming with pain. This is known as medial epicondylitis, golfer's elbow, or, for all of us who weathered this difficult winter season, Snow-shoveler's elbow.

Those scoopers who favor the overhand shovel technique, however, would overuse the brachioradialis muscle causing pain at its tendinous insertion on the outer aspect of the elbow. This is known as tennis elbow, or Snow shoveler's elbow.

I assured my patient today that the orange crocuses were in bloom in my garden, and the end of the snow surely cannot be far behind. Tendinitis starts to heal when the patient stops bothering the tendon. While extraordinary repetitive motion creates tendinitis, ordinary daily activities like lifting kids, books, grocery bags, and suitcases can perpetuate the problem.

Tuesday, February 26, 2008

BRCA genes and the women who worry about them

Tumor suppressor genes are worthy bits of genetic info that produce DNA-repair proteins. Left uncorrected, broken DNA can lead to cells no longer subject to orderly growth and development. Unfortunately, tumor suppression genes are also subject to mutated DNA which then produces faulty proteins unable to do their fix-it jobs. Persons who inherit abnormal copies of BRCA1 or BRCA2 are particularly susceptible to ovarian, breast, or prostate cancers.

Women in Denver with a strong family history for either of these cancers can sign up for care through the Rocky Mountain Cancer Center's High Risk Breast Cancer Clinic at Rose Hospital. Drs. Dev Paul and Michele Basche along with genetic specialists evaluate risk and may recommend adding MRI surveillance to annual mammograms as well as genetic testing for BRCA mutations.

According to the Myriad model based on my family history and ethnic background, my risk for a BRCA mutation was 16%. My insurance approved genetic testing (although they will doubtless end up paying far less for it than I will), and I was eager to know the outcome. Fortunately, my test was negative.

One of the things that makes BRCA testing more appealing than other genetic inquiries, say one into Alzheimer's risk, is that something can be done if the test is positive. A newly published study* in the Journal of Clinical Oncology confirms that the current strategy of removing the ovaries of BRCA-mutation positive women is beneficial to their long-term outcomes.

When the researchers compared women with BRCA1 or BRCA2 mutations who either underwent oophorectomies or not, those who chose surgery had a significantly reduced risk of cancer compared with the control group. Specifically, risk reducing oophorectomy was associated with an 85% reduction in BRCA1-associated gynecologic cancer risk and a 72% reduction in BRCA2-associated breast cancer risk.

One of my patients with a BRCA2 mutation (2 sisters, a mother, and a cousin all dead or dying from cancer) was in yesterday, completely satisfied with her decision to undergo this surgery. She had a laparoscopic removal of the ovaries with Dr. Michael Moore in Denver, and declared him "the best."
Kauff, N, et al. J Clin Oncol. 2008 Feb 11 [Epub ahead of print]

Monday, February 25, 2008

New blood test for ovarian cancer

First it was 'Kathy's story,' an e-mail that circulated for several years about Kathy and her tragic bout of peritoneal cancer. The moral of her story was get a CA125 test. I read the latest header on the latest CA125 e-mail as my patient set it on the desk in front of me today, 'Do not take no for an answer.' Another day, another woman wishing we had a decent test to detect early ovarian cancer.

I would never deny a woman this test, but I do emphasize to those who ask that it is a terrible screening test for ovarian cancers. Believe me, I wish both personally and professionally that we get a good test, both sensitive (picks up ovarian cancers reliably when they're present) and specific (only positive when there actually is a tumor), and let it be found ASAP!

Coincidentally, this headline news came across my screen tonight. So put this in an e-mail and circulate it to all your girlfriends!

"Blood test detects early stage ovarian cancer with 99 percent accuracy"

Yale researchers went looking for unique proteins shed by ovarian tumors. Since these proteins are only made by ovarian cancer cells, their presence in a patient's blood is diagnostic of a tumor. Apparently, however, it takes a heap of a lot of cancer cells to raise protein levels to detectable levels, so the first test attempt based only on tumor proteins was not sensitive for early cancers. On a second pass, the New Haven scientists added an assay for proteins made by a woman's body in response to the foreign tumor tissue.

Score! Four tumor proteins plus two immune-response proteins equals this new highly sensitive, highly specific test. The test now enters phase III clinical trials--the last step before applying for FDA approval--through the Early Detection Research Network (EDRN) of the National Cancer Institute (NCI)and LabCorp.

Saturday, February 23, 2008

Bystolic and stress

All stressed out and nowhere to run, no one to punch out. I was at a meeting yesterday, one of the most stressful meetings I've ever attended. My heart was pounding, I'm sure my face was red, and I had no recourse but to listen politely to the proceedings. If ever there was a stress test for my aging heart, that hour-long ordeal was it.

My forty-something year old patient lives a perpetual stress test. Caught in a years long legal battle with a former business colleague, he lives his life in a never-ending nervous fit. His heart pounds along at a resting heart rate above 110, his blood pressure is high, but the worst symptom, the one that brought him in 2 weeks ago, is how very, very hot he feels. He can scarcely stand indoor heating; his secretary suffers the open office windows while his wife piles on the covers in their breezy bedroom.

I have seriously entertained the notion that this poor fellow has an adrenal tumor, so intense are his symptoms. While waiting for his first round of tests to come back, I wondered if we might give him, his secretary, and his wife a break with beta blockers.

Originally developed for blood pressure troubles, beta blockers have since been tapped to control abnormal heart rhythms, protect heart muscle after a heart attack, and to combat performance anxiety. They work by competitively blocking cellular receptors for beta-sympathetic adrenal hormones such as norepinephrine which set off the 'fight or flight' response. As such, they can slow down the pulse and blood pressure response to stress. The problem with earlier versions of beta-blockers is that they blocked both beta-1 receptors responsible for cardiovascular changes and beta-2 receptors which, among other things, relax smooth muscle and dilate the airways (so you can get more oxygen to run away from lions, tigers, and meetings, oh my).

As my patient also has asthma in addition to more stress than any human should have, I needed a beta-1 selective agent that would not contribute to an asthmatic constriction of his airways. Lucky for us, the sales rep from Forest Pharmaceuticals had just left a big supply of Bystolic (generic name nebivolol) in our drug closet. I gave him a bottle and hoped that there would be no unexpected beta-2 blockade.

Here's the phone message I received 2 days later:

Said the pill you gave him works wonders. His heart rate went from 160 to 78, no more body heat, has not been using his inhaler, and his BP has gone down. He also has been working all day.

Now that is a wonder drug! I wonder why I didn't take one before the meeting from hell.

Tuesday, February 19, 2008

Flow-mediated vasodilation

They're not just passive pipes anymore. No longer do scientists view our blood vessels as mere conduits that carry blood from heart to bod and back again. The worthy endothelial cells that line our arteries and veins not only respond to signals from the kidneys and adrenal glands to dilate and constrict, they actively produce substances themselves that affect their functioning.

One way that researchers test the health of blood vessels is through an indirect method called flow-mediated vasodilation (FMV). This test, an indirect measure of the ability of the arterial system to respond to increased demand, is performed by pumping up a blood pressure cuff on the subject's arm to some intolerable level for a few minutes, releasing it, and then calculating the subsequent surge of blood flow through the brachial artery at the elbow with ultrasound technology.

A small study from Italy looked at the effects of a high-fat meal on blood vessel reactivity in ten postmenopausal women. The ladies were invited down to the lab for an 'oral fat load,' doubtless a large piece of tiramisu. At two hourly intervals thereafter, their FMV was measured. At baseline, the ladies sent nearly 8% more blood coursing through their fingertips after the cuff was removed. Two hours after the high-fat treat, this number fell by two-thirds, meaning that their blood vessels' capacity to dilate in response to increased blood flow fell by over 60%.

Theoretically, then, a high fat meal, whether consumed in a fast food joint or as part of an Atkins diet, can wreak havoc in an individual with unsuspected coronary artery disease. A burst of activity after the feast, say a sprint up the block to catch a bus, calls on diseased arteries to provide extra blood flow at a time when they are clamped down from a load of Nacho Belle Grande. When blood supply can't keep up with demand, the oxygen-starved portion of the heart can be damaged.

Air pollution, cigarette smoke, and early morning hours all can muck up your FMV. Vitamin E, oatmeal, dark chocolate, green tea, JuicePlus, and ACE inhibitors (a class of blood pressure meds that includes lisinopril and enalopril) all support your endothelial cells to expand on demand.

Sunday, February 17, 2008

A new drug for alcohol dependency

College campuses are filled with kids who drink for kicks. Statistics suggest that some of these early drinkers will go on to become alcoholics for the feel good, addictive thrill of it all. The majority of adult alcoholics, however, drink to relieve stress and anxiety.

Currently, two drugs are available that are supposed to alter a drinker's response to alcohol in a way that makes ongoing use less appealing. Naltrexone is an opioid receptor blocker believed to prevent the release of dopamine (a feel-good neurotransmitter) that occurs with drinking. A 2006 study reported in JAMA found that naltrexone plus behavior therapy was significantly successful in preventing relapse in abstinent alcoholics. On the other hand, this same study found no benefits from Campral, another drug used for abstinence support. Campral is believed to block the effects of glutamate on brain cells. Glutamate is an activating neurotransmitter which, in some individuals, promotes anxiety and agitation.

So what can be done for alcoholics who drink to calm themselves? Researchers at the U.S. National Institute on Alcohol Abuse and Alcoholism went looking for other substances that would modulate stress reactions in the brain. They pulled LY686017 off the back shelf of drugs tested for depression but discarded for less than perfect efficacy. Ex-alcoholics who scored high on anxiety scales were given LY686017 or placebo, then given questionnaires about just how much they craved alcohol. Those plied with LY686017 were notably less likely to long for a drink.

But these Maryland scientists did not just stop with questionnaires. They subjected the subjects to mock interviews and math tests with scowling assistants in intimidating white coats. Afterwards, the group was tested for levels of the stress hormone cortisol. All subjects also got to sniff and caress a vial of their favorite beverage and were asked just how badly they wanted to drink it. Again, LY686017 triumphed, squelching the hormonal stress reaction as well as the urge to drink.

Says neuroscientist Selena Bartlett of the Ernest Gallo Clinic and Research Center at the University of California, San Francisco, "It feels like we're heading for a sea change for new therapies for alcoholism."

Excess weight and cancer risk

I woke up later than usual this a.m. (my morning lark has migrated south these gray, snowy days). The thought of racing around to get ready for step aerobics was nearly more than I could face.

Face it I did, and this research report from the current issue of The Lancet(1) makes me glad that I ventured forth. Epidemiologists from the Universities of Manchester and Bern knew that obesity increased the risks of some cancers. Using 41 years of data found on MEDLINE and Embase, they correlated incidence of 20 cancers with BMI(2).

They found that the risk of excess poundage relative to cancer varied with sex. For the overweight guys, every 5 point increment in BMI significantly raised the risk of esophageal, thyroid, colon, and renal cancers. For women, esophageal, gallbladder, endometrial, and renal cancers were most strongly associated with increasing weight.

Lest you think achieving a 5 point drop in your BMI is a daunting task, I accomplished that 6 years ago with a single one hour kickboxing class per week. Just sixty minutes of a hot, sweaty workout each week. Research suggests that the best way to shake pesky, longterm fat off is with high intensity exercise.
1) The Lancet 2008; 371:569-578.
2) To calculate your BMI, divide your weight in kilograms by your height in meters squared. Got it? If that is too much for you to face this snowy Sunday, let someone else do it at BMI calculator.

Friday, February 15, 2008

What's going around?

Illness #1: Starts with a tickle or tiny cough. Patient thinks must've been exposed to perfume, smoke, cat, smog, or perhaps a minor illness. Within hours to two days, patient develops sore throat, hoarseness, and a cough that is painful, compelling, deep, possibly productive of small amount of yellow guck. Body feels toxic, aching all over and fatigue so severe that patient debates with self whether or not it's worth getting up to bathroom or perhaps better just to hold it. No one wants to be around patient, including doctor.

Illness #2: Rather abruptly develops deep cough, body aches, chilling, fever, headache. Maybe sore throat. Eyes are glassy and no one doubts patient is ill. No one wants to be around patient, including doctor.

One illness is probably croup, the other influenza. Both are nasty and highly contagious. The flu shot, as you may have heard, was not a good match for the circulating strains of influenza this season. The viral part of these illnesses lasts for a week or more, the cough lingers for weeks (or even months in Denver's cold, dry, dirty air). While we can sort of take the edge off the misery with codeine cough syrup and Advil, antibiotics won't help a bit.

Getting better involves a slow return of energy. Remember, the cough may well outlast the illness by weeks. If you succumb to one of these bad actors, look out for phase 2 of the illness. If a week or more into the illness, you feel worse instead of better, and that which you cough or blow out is colored and disgusting, you may be developing bronchitis or sinusitis. We can talk about antibiotics.

If this onslaught keeps up, I may start wearing a mask during close encounters of the contagious kind. Please don't take it personally!

Thursday, February 14, 2008

Concierge service AND medical care

I was nearly out the door today (quiet schedule due to the weather and Valentine's Day) when my middle-aged patient dropped in. I treat her for high blood pressure and high cholesterol, both of which are well-controlled. This afternoon, however, she began experiencing chest discomfort, shortness of breath, and dizziness.

Her blood pressure was up but her pulse below sixty. She was nervous and breathing rapidly. On EKG, she had evidence of a lack of oxygen to the front wall of her heart. To the ER, I said, Now! But I've got a brisket in the oven at home, she countered, and no one to turn it off. It hardly seemed prudent to let her drive home through the cold to save the brisket at the expense of her heart. So I dropped her off at the ER, then went to her townhouse and turned off the oven, leaving the brisket to cool on the counter.

The report so far is so good--her cardiac enzyme levels do not indicate any damage, but her story so suspicious for angina that they will keep her overnight and stress test her tomorrow. My only regret? The thought of that delicious smelling brisket spoiling uneaten on her kitchen counter.

Monday, February 11, 2008

A patient came in today wondering if an inexpensive test would tell her the state of her coronary arteries. When asked why she wondered about her heart, she replied that she experienced an unpleasant pounding sensation in her chest for hours each day and worried that she would soon have a heart attack. In fact, she'd recently been exploring some difficult past experiences with her therapist who had suggested she consider medication for her depression and anxiety. She was afraid, as so many people are, to try antidepressants.

I told her it was possible that she might not even know what it's like to live without anxiety as she'd apparently not been free of it for her adult life. I wished I'd had a copy of this poem with me to share with her. Here's an excerpt; it's written by a man who is undepressed for the first time in his life after starting Paxil:

I feel more like myself,
a feeling that can hardly be true
after 60 years of prowling
outside the fence, with the gates
locked, or scarier still, open,
swinging and I would stand there
paralyzed, afraid to step in
my feet starved for affection
and serotonin shooting itself
in the foot each time a foot perked up
and started to dance. But that can
hardly be true, the way I feel today,
so vividly myself, so grounded
you might say the first draft is done.
I'm in the process of revision.
Metabolic syndrome a lifesaver

Metabolic syndrome and lifesaver are rarely seen in the same sentence. The metabolic syndrome is a cluster of high risk conditions which greatly increases the chances of developing diabetes and heart disease. If you've got waisted fat, your silhouette more apple than pear, plus two of the following:

  • Elevated blood pressure
  • Low serum HDL-cholesterol
  • Elevated fasting serum triglycerides
  • Elevated fasting glucose

it's time to undertake serious lifestyle changes. My middle-aged patient clearly had trouble in a metabolic syndrome sort of way--she came to her appointment late last year in overalls because she'd packed so much fat round her middle that jeans were yesterday's dream. Her problem, however, was upper right abdominal pain.

There was no telling whether or not she had a mass in her abdomen as her central fat mass was as round and tense as a full-term pregnancy. Her lower right ribs were tender to touch, and I concluded that she was suffering from the same sort of ribcage discomfort as an expectant mother might have just before giving birth. But this lady was so uncomfortable that I felt we'd best do a CT scan to check for an internal problem such as gallstones.

The CT results were bad news--she had a large mass on her right kidney. A cancer was found at surgery, completely contained within the kidney, with no evidence of spread. She was cured by a nephrectomy. But a month later she was back in the office, her abdominal pain unchanged from her original visit. The pain, in fact, was from her expanding waistline pressing out on her ribs. The kidney cancer was a most fortunate 'incidentaloma' found in passing by a just-to-be-sure-we're-not-missing-something CT.

Saturday, February 09, 2008

A rare complication of MRIs

I had an MRI last year as a screening test for breast cancer. MRI scanning with a contrast material called gadolinium is the best screen currently available for the cancer, and I received my negative results with a deep sense of satisfaction that, for the moment, I was free and clear.

While I have an internist's enthusiasm for ingested substances*, I have an abiding distaste for things injected. I will think long and hard about getting another MRI--I didn't mind the noise, no problem with the confined space, and I don't really mind IVs, it's the thought of another IV injection that stops me cold. And now, here's news of a new disease, rare but icky, we've created with gadolinium imaging technology.

Nephrogenic systemic fibrosis (NSF) was first described in 1997. Case series confirmed that NSF was confined to patients with renal insufficiency (diminished kidney function), and later determined to affect only those kidney patients who had undergone radiological imaging with gadolinium in the several months prior to developing hardened leathery skin. The fibrosis or connective tissue thickening and scarring associated with NSF binds up joints, lungs, heart, and diaphragm as well as the skin. The systemic involvement can be fatal.

By the time your kidney function is low enough to be at risk for NSF, you have already come to the attention of a specialist. Hopefully, no cases of NSF will appear in people not known to be at risk. This emerging syndrome reminds me, however, that there's no such thing as diagnoses for nothing' and MRIs for free**.
*Coupled with a coming-of-age-in-the-'60s mentality
**Sorry Dire Straits!

Friday, February 08, 2008

Oncotype DX Breast Cancer Assay

Many years ago, two of my patients in their early 40's had abnormal mammograms. In both cases, the films showed suspiciously clustered spicules of calcium. The biopsy on one showed invasive ductal carcinoma; her subsequent work-up confirmed no spread of the cancer to lymph nodes or beyond. The other one's biopsy was negative.

Prevailing wisdom at the time was to administer adjunctive chemotherapy to nearly all patients no matter whether their cancer was localized or not. My previously well patient, a professor at a local university, underwent chemo and died from an infection shortly after receiving her first dose. The other lady was found to have the exact same suspicious cluster of calcifications on her mammogram several years later (the first biopsy had missed the area) and underwent another tissue sampling which was positive for cancer. She had a lumpectomy, but no chemotherapy was recommended. Now two-plus decades later, she just retired from her law practice.

Fast forward to two months ago. Another abnormal mammo followed by another biopsy on another lady. This cancer was also localized by all tests, but her tissue was then examined for hormone receptors and genetic content post-lumpectomy. This DNA analysis known as the Oncotype DX Breast Cancer Assay revealed that the chances that her cancer would return without follow-up chemo were "off the charts." No dithering over whether or not chemo is appropriate; in her case it is essential and life-saving.

On average, the outlook for most women with node-negative, estrogen-receptor positive breast cancer treated with estrogen-blockers post-surgery looks good. Overall, these patients have a 15% risk of recurrence in the 10 years after diagnosis. This means that 85% of the women who underwent a course of chemotherapy for this diagnosis in the past could, in fact, have skipped these difficult treatments and still done well. Up until recently, however, we had no good way to counsel these women about which path to pursue.

In 2004, the Oncotype DX test was developed to test for the active expression of tumor-related genes in breast cancer surgical specimens. The results were used to develop a Recurrence Score which predicts the likelihood that the tumor will return in the future. Now women diagnosed with estrogen-receptor positive breast cancer are candidates for more individualized treatment based on these 'biomarkers of recurrence.'

To develop this test, the researchers sorted through 250 candidate genes from a DNA library of genetic material. They then analyzed clinical studies of cancer patients and the genetic nature of their tumors looking for a correlation between the expression of these 250 genes and the likelihood of cancer relapse at a later date. The scientists chose a panel of 21 genes for the final assay based on the strength of association between their expression and risk of recurrence. The Recurrence Score also correlates with the length of time until relapse and overall survival.

The test was lauded at the time by senior investigator JoAnne Zujewski, MD as having "the potential to change medical practice by sparing thousands of women each year from the harmful short- and long-term side effects associated with chemotherapy." Furthermore, those who could benefit most from opting for chemo, like my current patient, can feel more assured that they've made the right decision.

Tuesday, February 05, 2008

Marijuana withdrawal

Using marijuana (way, way back when and never,ever inhaling!) made me as fumble-mouthed as an evening news anchor and rather forgetful, so I gave it up before college. I've been surprised to learn, however, in my role as privileged exam room confidante that quite a few people continue to smoke up daily. Before they even go to work! Very few express any desire to quit, and no wonder considering new evidence from Johns Hopkins University researchers.

In a small series, the Baltimore psychiatrists found that subjects withdrawing from regular marijuana use suffered from withdrawal symptoms equivalent to those which occur on giving up cigarettes. The symptoms included irritability, anxiety, difficulty in focusing, and insomnia.

The problem I've come up against in helping those few who'd like to walk away from the marijuana habit is a lack of available medical adjuncts to shore up their will power. We have alternative nicotine delivery systems such as patches, lozenges*, and gum for those giving up cigarettes. A newish drug called Chantix* acts as a weak nicotine analogue in the brain, working on nicotine receptors to release a little bit of the feel-good neurotransmitter called dopamine but not so very much as to perpetuate the addiction. Naltrexone helps alcoholics give up drinking, as, theoretically, does Campral although efficacy data on the latter is not so very convincing.

But, alas, there are no legal marijuana analogues on the market FDA-approved for withdrawal purposes. Marinol (generic ronabinol) is a synthetic version of the active compound in marijuana called delta-9-tetrahydrocannabinol or THC. It is indicated for suppression of nausea associated with cancer chemotherapy or as an appetite stimulant for persons with AIDS. Its use could perhaps supply THC to marijuana addicts in much the same way that Nicoderm provides nicotine to withdrawing cigarette smokers.

Acomplia*** or rimonabant is an endocannabinoid receptor blocker which was developed to help persons with a prediabetic condition called the metabolic syndrome get a grip on their elevated blood fat levels and weight. It would probably take the fun out of smoking marijuana as the THC could not meet up with its receptors if Acomplia was already sitting in place, but it is not available in the US.

The bottom line is that quitting addictions is a lot of unpleasant work. I quit smoking 30 years ago this month, and I'd never care to have to motor my way through another withdrawal experience.
*A patient recently told me about a nicotine lozenge called Ariva. Sold behind the Walgreen's cigarette counter, 20 lozenges for about the same price as a pack of cigarettes, Ariva was very helpful in her quest to quit. I gave a pack to a near and dear one who wished to cut back on his habit, and the product set off powerful and painful gagging. Great, gagging or smoking, which would you pick?

**A pesky little post-release problem with Chantix has the FDA re-examining safety data. Apparently partially blocking nicotine receptors sets off suicidal depressions in some people.

***Acomplia is also linked with suicidal depression. Apparently, you can't block the body's feel good receptors without making some people feel bad.

Monday, February 04, 2008

Lap banding in Denver

...if I were going to have a weight loss operation...there's no doubt I'd have the lap band. Why? Cheaper, safer, faster, doable as an outpatient procedure, quicker recovery, equal weight loss in the long run.
---Sid Schwab, MD, from his Surgeonsblog

During laparoscopic gastric banding, an inflatable silicone band is places around the upper portion of the stomach. This creates a pouch above the band just beneath the point at which the esophagus enters the stomach. After the first few bites of a very small meal, this little sack of stomach is full, overweight eaters feel satisfied, and they begin to lose weight.

Doctors down under recently found in a small series that morbidly obese patients with diabetes who underwent a lap band procedure for weight loss lost significantly more weight than a control group who followed a diet and exercise plan. And 2 years post-op, 22 of 30 in the lap banded band had their type 2 diabetes go into remission compared with 4 of 30 in the control group.

And if I were going to have weight loss surgery in Denver, I think I'd sign on for banding with Dr. Matthew Metz. This surgeon is not only a genuinely nice and personable fellow, he was also a bariatic surgery fellow at the Cleveland Clinic. He's a bariatric surgery nerd (that's what you want in a specialist), fully trained in all the latest surgeries and completely ready to repair and revise out of date bypasses that no longer work.

Check out

Friday, February 01, 2008

The dewy glow of a morning lark's skin...

My son called me at 6 a.m. today. Lest you think 'what an early bird that teen!', let me tell you he'd not yet been to bed. He'd just pulled one of those college all-nighters, and was calling me to request a noon wake-up call so that he wouldn't miss his 12:30 class...yet again.

Researchers have devised an innovative way of finding out whether folks are morning larks or night owls (as opposed to, say, just asking them). European biochemists recruited a group of willing subjects* who self-identified as morning or evening persons. The scientists then nipped a couple of skin samples from the group and cultured the cells in the lab. They then minced up a few fireflies, and inserted the gene that makes the insects glow into the gene that regulates the internal clock of human skin cells.

The purpose of melding human DNA with that of fireflies was to get a visual on the cells' 'inner slave clocks', that part of our body that responds to the brain's call to bounce out of bed or snooze onward. Indeed, these skin samples began glowing like a Midwestern summer's eve at a time determined by the subjects reported biorhythms. Now how bizarre must that have been--these cell communities in petri dishes switching on and off there in the lab based on the behavior of their previous human owners.

Interesting, but what's the point? Says chronobiologist Achim Kramer who helped design this study, "Pinpointing individual clock cycles could pave the way for personalized sleep and drug therapies." If they can pave a way to get my son up in the a.m., that is scientific progress at its best.

*I used to dub them volunteers, but discovered in a recent New Yorker article that many of these experimental subjects are 'professional guinea pigs,' often making an adequate living from payments for participation in studies like this.