Back away from the computer, ma'am!

Received from a patient today:

"I am still having a very upset stomach and some episodes of diarrhea (3 to 4 a day now). They are happening after each email now instead of just in the evening."

Elderberry juice and H1N1 flu

I posted some time ago about a potential influenza complication known as a cytokine storm. While this violent immunological over-reaction is known to occur with H5N1 or 'bird flu,' it has not proven to be a problem thus far with this current epidemic. In fact, the adults (I see few teens and no children) in my practice, while not enjoying their bouts of 2009 A(H1N1) flu, are finding the one week course more a matter of misery than serious disease.

I only just got my H1N1 shot last week--the Denver Public Health Dept. did not feel that internists were a high risk group! As I've been seeing cases of this flu for months, I started taking elderberry juice concentrate about a month ago. An article published in July of this year(1) used spectrometry to determine which elderberry molecules bound to the influenza particles thus inhibiting their ability to penetrate and infect host cells. Two compounds were identified that, in fairly low concentrations, stopped the little flu buggers dead in their tracks. In fact, their ability to inhibit H1N1 infections in lab conditions compared favorably to that of Tamiflu.

I ordered my elderberry concentrate from wyldewoodcellars.com. Per my favorite naturopath Dr. Jacob Schor, I take 1 tablespoonful in water each morning. I won't kid you, I don't love it, but it's palatable and better mixed with OJ.
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1. Roschek, B. et al. Elderberry flavonoids bind to and prevent H1N1 infection in vitro. Phytochemistry 2009 Jul;70(10):1255-61. Epub 2009 Aug 12.

Oil pulling testimonial

I've written before about oil pulling, an ayurvedic practice that involves swishing a mouthful of oil around in the mouth for 10-20 minutes first thing in the a.m. One web-site proclaims that "regular application of this treatment by reversing [this natural bodily intrusive element evinced by the microflora] so that wellness is the dominant state of the human body is likely to increase the average human lifespan to approximately 150 years, double the present life expectancy."

Well I don't know about that, I don't even get what this authority is talking about. A small study from India(1) concluded, however, that oil-pulling daily for 10 minutes caused a significant decrease in oral Streptococcus mutans (the bacteria that promotes tooth decay) within 1 week of starting the practice.

I recently visited my dental hygienist for a check-up and cleaning. I have practiced daily oil pulling with sesame oil for 5 of the 7 months since my last visit with her. The conclusion? Less stain despite daily coffee, no difference in plaque, very healthy gums, and--best-of-all for me--no sensitivity in the lower teeth to her merciless probing. She was so impressed by the sparkle of my front teeth (so shiny, per her, "they look like glass") that she plans to recommend the practice to others.
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1. Asokan, S et al. Effect of oil pulling on Streptococcus mutans count in plaque and saliva using Dentocult SM Strip mutans test: A randomized, controlled, triple-blind study. J Indian Society of Pedodontics and Preventive Dentistry 2008. Vol 26, Issue 1, pgs 12-17.

Hydrosal, Drysol, and hyperhidrosis

I can now wear tops TWICE and can wear regular shoes. DrySol, you're the best!
--Comment from satisfied user on drugs.com

I had the mixed pleasure of dining at Red Robin recently. Always a pleasure to not cook dinner and not clean up afterwards, but the burger was just so-so. I was briefly alarmed to note as the host seated us that he had enormous sweat rings below his armpits, but then I realized that some misguided RR fashion designer had put darker panels of red material down the sides of the staff's red t-shirts.

Some people, of course, do suffer from axillary hyperhidrosis or excessively sweaty pits. And they suffer terribly, choosing clothing colors less likely to broadcast their problem, keeping their arms close to their bodies. Never raising their hands because they're sure it would be an embarrassing mistake.

Enter Drysol, one of medicine's best kept secrets. Part of the problem, my problem anyway, is the don't ask/don't tell mentality of hyperhidrosis. If I don't ask, patients mostly don't tell me that they suffer from sweaty pits, hair, hands, or feet. Last month, however, I had a patient ask for Drysol by name--he'd heard about it from his nephew. And now he says "It's changed my life."

Those are strong words indeed, praise I most often hear applied to antidepressants, anti-anxiety, and anti-acne medication. Drysol or aluminum chloride hexahydrate is strong stuff. It doesn't always work, and it stings like crazy if applied to wet or newly shaved skin, but when applied with care according to the directions, many hyperhidrotics lose their drip.

Hyperhidrosis is a disorder of sudomotor nerves or those nerves that hook up to and activate sweat glands in response to heat or emotion. While thermoregulation (keeping body temperature in a healthy range) is controlled by the hypothalamus deep and central in the brain, sweaty response to emotion is under the control of the anterior cingulate cortex behind the rational frontal brain and heavily connected to our fear-directing amygdala.

A new preparation of aluminum chloride hexahydrate has been released called Hydrasal which is in a salicyclic acid gel formulation rather than pure alcohol. Small studies recently released at the March meeting of the American Academy of Dermatologists show this product is better tolerated than the Drysol preparation and is also useful in patients who are undergoing Botox injections for hyperhidrosis with incomplete relief of excessive sweating.

Bacterial contamination from toilet flushing

I recently completed a long car trip, and thus spent more than a moment in public restrooms. Once in the stall, purse and road atlas in hand, I faced each time the dilemma of where to stow my gear whilst completing my business. Some facilities have elegant shelves to hold these items, others a hook on the door, some no place at all but the more or less unsavory floor. Imagine then how floored I was to read this item in the latest issue of Health Magazine(1):

"Don't put your purse on the bathroom floor; E coli in spray droplets following a flush may land on it. Hang it in the stall, and clean it inside and out weekly with a disinfecting spray or wipe."

Flushed with doubt, I wondered if this was all some sensationalist piece of journalistic nonsense designed to sell magazines and Wireless Wipes. But alas, check this out and think it over the next time you set your bag on the only dry spot on the tiled floor of a public can:

Microbiologists in the UK (2) contaminated "the sidewalls and bowl water of a domestic toilet to mimic the effects of soiling after an episode of acute diarrhoea." In other words, they dumped a gelatinous turdoid sort of matter containing fecal pathogens into the toilet bowl. Cultures of the bowl water and porcelain surfaces confirmed that significant colonies of the little darlings were clinging for dear life therein. They then flushed, and subsequent testing of the toilet AND the surrounding air confirmed that the bacteria had diminished in numbers in the actual toilet (thank heavens) but that a significant number of them had been jettisoned into the air on aerosol droplets of toilet water.

Dr. Barker and company concluded: "Many individuals may be unaware of the risk of air-borne dissemination of microbes when flushing the toilet and the consequent surface contamination that may spread infection within the household, via direct surface-to-hand-to mouth contact. Some enteric viruses could persist in the air after toilet flushing and infection may be acquired after inhalation and swallowing."

Think about it. Your toothbrushes sit how far from your toilet? My bathroom cup is inches away from mine. Do you close the cover before flushing? All this dainty hand washing, was it before or after you picked up your purse from the bathroom floor?

Yech.
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1) Health. November, 2009. p. 20.
2) Barker, J, Jones, MV. The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet. J Appl Microbiol. 2005;99(2):339-47.

Diagnoses at Denny's

I've mentioned before that I tend to diagnose the passers-by that I see around town and on the road. I was eating breakfast at the Denny's in Moab, Utah this past week when a middle-aged couple lumbered to their seats.

They were both quite wide in the middle, carrying way too much visceral fat packed around their waistlines. Doubtless two cases of metabolic syndrome, a high risk constellation of central obesity plus two of the following: high blood pressure, low HDL cholesterol, diabetes or elevated fasting blood sugar, and elevated triglycerides. Of course, I have no idea about their lab findings, but he no sooner sat down but he pulled out a ziplock baggy jammed with pill bottles.

He was unnaturally red in the face contrasting with his pale arms and legs sticking out from t-shirt and shorts. Sunburn? Shoot, that's a med. student's diagnosis. Idiopathic erythema? Rosacea? Polycythemia vera? His legs, however, had none of the swelling or skin changes associated with venous insufficiency which is a good sign, but his calves and thighs were scrawny which may be a bad sign per a recent report that a low thigh circumference is associated with a higher risk for heart disease!

As they sat, unaware of my clinical musings, she leaned forward, grinning, and said something to him in a low voice. His face immediately crinkled with amusement and softened with affection.

My final diagnosis? They were in love!

Fun with the flu

My patient no sooner sat down when she grabbed a Kleenex, said "Hold on!" and quickly turned away, coughing wetly into the tissue.

"Oh gad," I thought unhappily, "She's going to show it to me."

At that moment, my patient dabbed delicately at her lips, looked over her shoulder, and said, "Don't worry, I'm not going to show it to you."

We both burst out laughing.

C. difficile and diarrhea

Clostridium difficile (C. diff) is one of many reasons to stay out of the hospital. This bacteria is not a normal inhabitant of the human gut, but once it gets a toe-hold therein, it invades the colon wall, produces toxins, and causes serious illness with bloody diarrhea. Long classified as a nosocomial infection (acquired as a result of being under hospital care for another medical problem), C. diff is now showing up as a community-acquired infection.

The classic patient profile for C. diff sufferers is someone who is old, rather ill, and receiving heavy duty antibiotics such as clindamycin, cephalosporins (which are routinely given before surgical procedures), and fluoroquinolones such as Cipro and Levaquin. Several times a year, I see a patient who has none of those characteristics but has big-time diarrhea due to C. diff. Here's disconcerting news about possible sources of community acquired C. diff.

1. Meat in Tucson: Researchers there sampled both raw and "ready-to-eat" meat from supermarkets. 42% of the product tested was positive for toxigenic c. diff.(1)
2. Ready-to-eat salads in Scotland: 7.5% of these "healthy choices" harbored virulent c. diff.(2)
3. Meat in Canada: 20% prevalence, and more common in winter.(3)

Denver infectious disease specialist Dr. Mary Bessesen theorizes: "I suspect that animals carry it in their gut and on their skin when they arrive at the packing house." She goes on to note that no one knows for sure whether C. diff in the commercial meat supply causes human disease but "what we have thus far is suggestive only--not proof--but it is concerning."

Yuck.
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1) Songer, JG et al. Emerg Infect Dis. 2009 May;15(5):819-21.
2) Bakri, MM et al. Emerg Infect Dis. 2009 May;15(5):817-8.
3) Rodriquez-Palacios A. et al. Emerg Infect Dis. 2009 May;15(5):802-5.
4) Vujia, DJ et al. Emerg Infect Dis. 2009 Jan;15(1):69-71.

"Using the daylight"

Wise words from a century ago(1):

When illumination was poor, people went to bed shortly after nightfall and arose at daybreak. As illumination has become better, they have gone to bed later and later, especially in the cities; and the hour of rising has grown later until, in the summer at least, many persons sleep as much during daylight as in the dark.

This is of course unfortunate. Sleep is never so restful--at least for most persons--during the hours of light as when it is dark. Everyone knows this from personal experience. The old saw was that two hours of sleep before midnight were worth twice that amount afterward; and while this might not be literally true, the truth in it is that if sufficient sleep is to be obtained after midnight, then much of it must be secured after darkness has ceased. Everywhere one hears the complaint that people are becoming more nervous and are losing the power to rest thoroughly. Undoubtedly, some of this--probably much more than we suspect--is due to the fact that so much of sleep in city life where the increase in nervousness is particularly noticeable must under present conditions be obtained during hours of daylight.

The article goes on to make a case for the establishment of daylight savings time. So now we have daylight savings time, and people are still going to bed too late but now they're also getting up too early, getting insufficient sleep whether it's dark or light. And ever more, they're also becoming more nervous and are losing the power to rest thoroughly.

You cannot flick off bright lights, computers, or TVs and just pop into bed expecting to fall directly to sleep. A case could be made for turning down the wattage in preparation for bed, perhaps reading with just an Itty Bitty Book Light turned onto the page instead of a table lamp flashing our brains. Less Ambien and more common sense.
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1)The Journal A.M.A., July 31, 1909, liii, 383, 387.

Influenza, antibiotics, and procalcitonin

Sure, I know what procalcitonin is, namely that which is not yet but will be calcitonin or the hormone produced by the thyroid which shuts off bone breakdown. Salmon calcitonin (Miacalcin) nasal spray used to be the only drug available for treatment of osteoporosis before Sally Field and other aging baby boomers elevated this condition to a status worthy of new and better compounds.

So what's this got to do with antibiotics? Nothing that we knew about back when I was in med school, I can assure you of that. An article and editorial in a September issue of JAMA(1), therefore, was quite an eye-opener on just how important it is to continue on with continuing medical education.

First, a word or two about lower respiratory tract infections (LTRI) and antibiotic use, a subject that impacts my patients and my decision-making processes every day, especially as swinish flu slams the Denver area. Why do I closet myself several times an hour with some miserable coughing wretch at great personal risk to my own lower respiratory tract? To distinguish ordinary, show-stopping/week-ruining influenza from its many complications, particularly secondary bacterial bronchitis and pneumonia. Often it's me (don't want to overprescribe antibiotics to avoid complications to the patient and antibiotic resistance to the public) vs. them (No time for this! Need antibiotics! Big test/presentation/trip/wedding coming up! Need antibiotics!).

I check out: how sick are they, how long have they been sick, are they having trouble breathing, is their O2 level low, how do their lungs sound, what color are their secretions. Knowing all the while that they feel miserably sick, any days with flu are too many days, their airways are swollen so of course they feel short of breath, and, of course, their secretions are doubtless gross because flu-sloughed cells in the airway plus gobs of white cells will make that which they hack out green.

Surely there must be a better formula other than my experience + intuition + observations. Enter procalcitonin(PCT), and it's not just for regulating calcium anymore. While the thyroid C-cells make PCT and turn it into calcitonin depending on the biochemical need to drop calcium levels in the blood, all sorts of other tissues release PCT when the body is fighting bacterial attack. Under normal conditions, PCT is barely detectable in the blood but levels can soar 100,000-fold with widespread sepsis as bacteria invade the bloodstream.

So here we have a wonderful demonstration of theragnostics (another concept that's new to me) wherein a diagnostic test--say PCT levels--identifies patients likely to be helped by a certain therapy, and then targeted drug therapy is given--e.g.antibiotics--based on those results. And I, with my expensive cognitive skills, am cut out of the equation thus making therapy not only more scientific and less intuitive, but also more accessible and affordable!

Now of course this is not yet anything you'll find in a Walgreen's TakeCare Clinic (until perhaps a handheld PCT-O-Meter is developed) but the possibilities are exciting. Not only could we know just when to treat acute bronchitis or pneumonia with antibiotics because PCT levels indicate a bacterial source, we could use this test in other puzzling situations such as whether or not artificial joints are infected or a patient with worsening chronic lung disease has an infectious complication.
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1) Schuetz, P et al. Effect of Procalcitonin-Based Guidelines vs Standard Guidelines on Antibiotic Use in Lower Respiratory Tract Infections. JAMA Sept. 9, 2009 Vol 302, No. 10 1059-1066.

Emotion and Memory

My friend got lost years ago while on a cross-country skiing trip. The morning paper and the evening news reported search efforts in daily, discouraging detail. Time passed, and the possibility that my friend and her skiing partners lived on became less and less likely. One day, however, while driving home with the car radio on, a breaking-news bulletin announced that they had been found, alive and well if a bit frost-nipped on fingers and toes. I had to pull over and get a grip on my teary emotions.

I can tell you the exact spot I pulled over, the weather, and where I had been. This all quite remarkable as, on average, I've a big picture sort of mind while the details leak before storage in long-term brain files (no surprise this to my husband). My friend later told me that everyone invariably related the minutiae of the moment in which they'd heard of her rescue--this after I'd supplied her with my experience as if it were the most fascinating tale.

So what's with this emotional boost to memory? If you were alive at the time, you can doubtless remember where you were when Kennedy was shot or the moon landing occurred. Likewise for the World Trade Center tragedy and perhaps Princess Diana's death.

Japanese neuroscientists studied emotion and memory in patients with Alzheimer's Disease (AD) following the devastating Kobe earthquake of 1995.(1) They performed brain MRIs on all the subjects, then checked out who remembered the earthquake and who remembered the MRI. The patients were much more likely to remember the quake, suggesting that intense emotions reinforced the memory.

The researchers went on to correlate the ability to remember the temblor with the residual size of the subjects' hippocampus (the brain's memory center) and amygdala (emotional center). Victims of AD are known to suffer from brain shrinkage. Those who retained the emotional memory of waking up to a significant earthquake were much more likely to have a normal-sized amygdala no matter the size of their hippocampus, and, likewise, those with impaired emotional event memory had more intense amygdalar damage.
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1)Kazui, H. Emotion and memory. Four studies of the emotional memory in Alzheimer's disease. Japanese Journal of Neuropsychology. VOL.18;NO.3;PAGE.150-156(2002).

Can Prednisone make me feel crazy?

If you've ever taken it, you already know the answer is an emphatic YES!! Here's a visual from my friend and artist Rose Kelly about her trip to the "Prednizone" while undergoing chemo.

Advanced glycation end products

That which is truly tasty, like make the hair stand up on your neck and shiver over the full delicious tastiness of it all, may prematurely age your blood vessels, your nerves, your kidneys, and your joints.

These advanced glycation end products or AGE are the end-products of reactions that bond sugar to protein in the absence of water. Think sugar steaks (too bad you won't want to try one at Bastien's Steak House on Colfax after reading this), the brown sugar/Jack Daniels crust on baked ham, browned cookies, the caramelized surface of creme brulee. So let's just say you avoid AGE in foods, and I'm not necessarily saying you should because, after all, life is meant to be enjoyed, well turns out you can glycate your own darn sugar once its ingested or produced. And fructose (that which sweetens your bottled drinks) is very prone to glycation.

So AGE along with ALE (that would be advanced lipoperoxidation end products or metabolized fat) are very proinflammatory molecules. AGE hooks up with specific cellular receptors called RAGE and the combo acts as a 'master switch' that activates nuclear factor kappaB(1) and creates high levels of dysfuntional proteins among other things. The sort of dysfunctional proteins that gum up your brain, your peripheral nerves, and your arteries.

Well we're all going to rust and glycate and peroxidate eventually, and we may as well do it with the satisfied smile of the occasional gourmand. But, as in all things, a little is good but a lot is not, and if you want to keep your cells functional, some things are best done in moderation or not at all.
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1) NF-kB is a good thing if you happen to be injured or infected as it amplifies the immune response but a bad thing if you happen to drink Coke and eat browned chocolate chip cookies on a regular basis.

New Diagnoses, New Behavior

Can't look for what you might find
Once more you're running around in circles just to prove
You knew the answers all the while
Can't figure why no matter what you say or do
Things stay the same you will remain
Day late a dollar short
Day late a dollar short
--The Acro-Brats(1)

There's nothing like a new diagnosis of diabetes to get a patient's attention. Suddenly, all those discussions about diet, exercise, weight loss, soda consumption, etc. make sense. Well better late than never (perhaps The A-B's have a song about that too) but there's also the day late dollar short thing too because this is a condition that you are far better off without.

Yale scientists actually set out to prove what I already knew from years of consultations with the newly diagnosed. They checked out data from the Health and Retirement Study panel on over 20,000 people who were overweight or smokers.(2) The odds of weight loss or smoking cessation were hugely increased among individuals newly diagnosed with serious illnesses such as diabetes, smoking, heart disease, or COPD. Those who'd just learned they had heart disease were 5 times more likely to throw away the smokes than persons just counseled to do so just because it was the right thing to do, and new diabetics sent their BMI's plunging compared to the merely overweight.

Can't figure why no matter what I say or do
Things stay the same patients will remain
Day late a dollar short
Day late a dollar short

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(1) I actually listened to this song on You-Tube. Definitely not my thing--the metallic thrum made my amygdala cringe-- but I appreciate the edgy frustration expressed by the Acro-Brats. I feel it myself, everyday, in exam room encounters.
(2) Keenan, PS. Smoking and weight change after new health diagnoses in older adults. Arch Intern Med. 2009 Feb 9;169(3):237-42.

Too close for comfort?

I recently attended my 40th high school reunion. I talked for awhile with one old friend I hadn't seen in years. But I was distracted during the entire conversation by her preferred conversational distance which was close, darned close! Not a breath problem--hers was fine and apparently mine was too--just my problem with her 'in my face' proximity. A new study may indicate why, and it implicates my overactive amygdala.

I've mentioned before that the amygdala, an almond-sized region at the base of the brain, is nerve cell center for coordinating response to threat. If yours is on overdrive like mine, you may over-respond to horror movies, scary books, and phones ringing in the night.

Neuroscientists had the opportunity to study the biological underpinnings of personal space in a patient known as SM. She had a genetic disorder that took out her amygdala, and as a result, she could not recognize fearful facial expressions in others, and was very outgoing and far more trusting than average. And she cozied up in conversational situations such that she--Ms. Red above--let an experimenter get twice as close to her as the other Ms. Blues did without expressing any discomfort in the situation. (1)

Scientists went on to study preferred conversational distance with functional MRI scanning.(2) They socked away average persons with intact amygdalae in the machine, then got closer and closer to the subjects, measuring their brains for activity. When they invaded that person's comfort zone, the amygdala lit up with activity.

"Our findings support the idea that the amygdala functions as the brakes in social interactions, If you take away the amygdala, it seems like you are less tuned to ... social [behaviors] that can cause discomfort," says neuroscientist Richard Davidson of the University of Wisconsin.(1)
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1) ScienceNOW Daily News, August 31, 2009
2) Kennedy DP et al. Personal Space Regulation by the Human Amygdala. Nat Neurosci 2009 Aug 30.

Antibiotic resistance and beyond

Almost all the drugs that we consider as our mainline defense against bacterial infection are at risk from bacteria that not only resist the drugs but eat them for breakfast.
--George Church, geneticist, Harvard Medical School

What's eating you may eat drugs too! Church and company dug up this unhappy piece of news while digging in a cornfield fertilized with manure from antibiotic-fed cows. They compared the locals (soil microbes) in the corn patch to their bacterial colleagues from the dirt of a pristine forest and several other locales more or less contaminated with druggish waste.

So you'd expect those bugs inured to manure to be antibiotic resistant and the au naturel bunch to die when cultured with drugs, right? Unfortunately, wrong. Bacteria from every sampling included strains that could survive "with nothing to eat but antibiotics." Not only did these little hummers not die from the drugs, they devoured them.

For those of us who think antibiotic resistance is not a huge and looming danger, Gerry Wright, a chemical biologist from McMaster University, sums it up in words that can't be ignored: "Soil bacteria pass around resistance-conferring genes like teenagers swap downloaded music files, and pathogenic [disease-causing] bacteria could likewise pick up antibiotic-digesting genes, particularly from a closely related microbe.

Great.

Health care debate

If you live in the Denver area, consider attending the Great Debate on Health Care this Thursday, Sept. 17th at South High School. Conservative talk show host Hugh Hewitt and C.U. law professor Paul Campos, both articulate proponents for their respective sides, will debate current proposals for health care reform. You can order tickets online at 710knus.com or purchase tickets at King Soopers.

Denver Doc now on Twitter

I've made the technological leap to Twitter for those medical pearls of wisdom from me to you that fit in 140 characters or less. No updates on my dentist appt. or the weather here in Denver, just good health-related information from reliable sources. This blog will continue to be published on a regular basis as well.

If you're interested in Twitter updates from Denver Doc Online, you can sign-up at
www.twitter.com/docofages. Thanks!

The amygdala and PTSD

I can hardly bear to watch violent or scary movies. I walked out on The Ring the moment the dried-up little girl was found in the closet (thankfully, the movie was 'showing' at the time in our living room). And the opening scene of The Exorcist in which Father Merrin finds the creepy little statue, the wind blows, and a couple of dogs fight still can interfere with a good night's sleep for me.

Research suggests that an overactive amygdala (the brain's VP in charge of processing emotional experiences and fear) may predict how an individual handles stress, be it in pictures or for real. Israeli scientists used functional magnetic resonance imaging (fMRI) to scan the brains of 18 year old subjects undertaking training as paramedics(1). They scanned the trainee's brains while showing them photographs of graphic medical scenes specifically looking for activation in the amygdala region. They also screened the recruits for stress symptoms including anxiety and insomnia.

After 18 months and a grisly load of combat experience, the researchers found that those paramedics with the largest increases in stress symptoms were the ones with the greatest amygdaloid activity on the initial scan. Study co-author Talma Hendler says that the amygdala may be an "a priori biological marker" for individual susceptibility to post-traumatic stress disorder.

Rather than use a fancy, expensive fMRI as a screening test for fitness under fire, I suggest a less expensive showing of Inglorious Basterds. Check the subjects' heart rate and blood pressure by the movie's end, and you'll know who's ready for the field and who should stick to the office.
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1. Proc Natl Acad Sci USA. 2009 Aug 18;106(33):14120-5.

H1N1 vaccine--one dose will do!

This just released today on the New England Journal of Medicine web-site. Results from the H1N1 vaccine trials indicate that one dose of the soon-to-be-released shot results in a good response from most adult subjects. Furthermore, no serious adverse effects occurred--just the usual sore arm and the vague flu-ish sort of feeling that is commonly occurs as a result of the immune reaction to the shot.

Vaccine demand is expected to exceed supply through the fall, so this one shot news is good news indeed.

Who should get Tamiflu for H1N1 flu?

If this past weekend is any indication of phone calls to come, I will be busy fielding requests for Tamiflu for suspected 2009 A(H1N1) which is what we're calling swine flu these days. Patients are understandably nervous for themselves and their families with regards to the spread and severity of influenza illness.

There are 2 available antivirals which are active against 2009 A(H1N1)-- oral Tamiflu (oseltamivir) and inhaled Relenza (zanamivir). For some reason, I've always reached for Tamiflu, and a brief search for a comparison of one antiviral to the other suggests that I am just another victim of an effective marketing campaign by Roche Pharmaceuticals. Nevertheless, be it Tamiflu or Relenza, one of the biggest fears per flu-ologists is that the novel H1N1 flu will become resistant to these worthy drugs, and they will be rendered powerless against the bug.

So what does the CDC have to say on the subject? They along with the WHO (the World Health Organization, that is, not the '60's band) recommend that antiviral treatment be undertaken in accord with the following guidelines:

1. Treatment is recommended for all hospitalized patients with confirmed, probable or suspected 2009 H1N1 or seasonal influenza.
2. Treatment generally is recommended for patients who are at higher risk for influenza-related complications.
3. Treatment should be initiated empirically when the decision is made to treat patients who have illnesses that are clinically compatible with influenza. Treatment should not await laboratory confirmation because laboratory testing can sometimes delay treatment and because a negative rapid test does not rule out influenza.(1)

In other words, if the patient is sick enough to be hospitalized with flu-like illness, initiate treatment immediately. While these antivirals work best if initiated in the first 48 hours of illness, evidence suggests that hospitalized patients with seasonal flu fare better with respect to risk of death and length of hospitalization if Tamiflu therapy is started even if it's more than 48 hours after onset. Those known to be at higher risk of flu-related complications include pregnant women, persons who are immunocompromised (undergoing say chemotherapy or treatment for rheumatoid arthritis), or those with underlying medical illnesses such as diabetes, asthma, or heart disease. And finally, if we providers determine that a patient meets one of these criterion, get 'em going on it and don't wait for final proof!

These recommendations highlight the urgency with which certain subgroups of flu victims should be treated. The CDC, therefore, goes on to make further suggestions as to handle the upcoming flu season and the avalanche of requests for antiviral medications. These include:

1. Provide information for patients at higher risk for influenza complications about signs and symptoms of influenza and need for early treatment after symptom onset.
   
2. Ensure rapid access to telephone consultation and clinical evaluation for these patients as well as patients who report severe illness.
3. Consider empiric treatment of patients at higher risk for influenza complications based on telephone contact... if this will substantially reduce delay before treatment is initiated. In selected circumstances, providers may consider giving a prescription for an influenza antiviral to selected patients who are higher risk for influenza complications.
4. Request that patients at higher risk for influenza complications contact the provider if signs or symptoms of influenza develop, obtain the medication as quickly as possible and initiate treatment.
   
5. Counsel patients about influenza antiviral benefits and adverse effects, the potential for continued susceptibility to influenza virus infection after treatment is completed (because of other circulating influenza viruses or if illness was due to another cause).(2)

What about antiviral chemoprophylaxis wherein antivirals are given to at-risk persons exposed to someone who is fluish? Please note in no case do these recommendations include giving Tamiflu to any old person traveling and worried regarding flu exposure except as outlined in the 3rd guideline above.

1. Persons who are at higher risk for complications of influenza and are a close contact of a person with confirmed, probable, or suspected 2009 H1N1 or seasonal influenza during that person’s infectious period.
2. Health care personnel, public health workers, or first responders who have had a recognized, unprotected close contact exposure to a person with confirmed, probable, or suspected 2009 H1N1 or seasonal influenza during that person’s infectious period.
3. Antiviral agents should not be used for post exposure chemoprophylaxis in healthy children or adults based on potential exposures in the community, school, camp, etc.
4. Chemoprophylaxis generally is not recommended if more than 48 hours have elapsed since the last contact with an infectious person.

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1. http://www.cdc.gov/h1n1flu/recommendations.htm
2. This is an abbreviated list. See above web-site for the full printed version.

H1N1 and severe respiratory failure

Scientists are ferreting out clues to the ferocity with which this new swinish flu attacks the lower airways in some of its victims. Ferrets demonstrate a susceptibility to influenza A very similar to humans and therefore are used as an animal model in flu investigations.

The above picture(1) shows microscopic sections of ferret airways (that is not a goose!), comparing seasonal H1N1 flu (the usual variety that circulates each winter season) on the left to tissue infected by the 2009 A/H1N1 flu on the right. Violet coloration indicates affected surface cells, and both varieties make a mess out of noses with sloughing sheets of dead nasal tissue full of violet-colored intruders as seen in the top pair of slides.

Moving on down to the trachea (which is the largest central airway lined with rings of cartilage that you can feel in the front of your neck), the ferret with seasonal flu middle picture on left is free of viral invasion but the swine-flu ferret victim on the right has dots of violet flu violation throughout its trachea. Finally, and of importance to this discussion, slides from the bronchioles of both ferrets are pictured at the bottom. This tissue was obtained from the smallest airways that go directly into the alveolae or air sacs that hook up oxygen with blood. Seasonal Flu Ferret has normal bronchioles, flu bug free, but Swine Flu Ferret's tiny air passages are teeming with the little buggers.

What's this got to do with the upcoming flu season? One of my patients, an ICU nurse, shared a disturbing report with me yesterday. She said that her unit has been busy this entire spring to summer with youngish patients suffering from severe swine flu-related bronchiolities (inflammation filling these airways with fluid) requiring ventilator support until the infection started to clear. Her information jibed with an August report from the World Health Organization entitled "Preparing for the second wave: lessons from current outbreaks." Per the WHO document:

"Clinicians from around the world are reporting a very severe form of disease, also in young and otherwise healthy people, which is rarely seen during seasonal influenza infections. In these patients, the virus directly infects the lung, causing severe respiratory failure. Saving these lives depends on highly specialized and demanding care in intensive care units, usually with long and costly stays."

This information highlights not only the importance of widespread immunization against the 2009 A/H1N1 flu (which creates so-called herd immunity, slowing down or preventing the lateral spread of flu from person-to-person due to the large number of vaccine-protected people) but also the paramount importance of immunizations for persons with underlying illnesses, particularly asthma, cardiovascular disease, diabetes, and immunosuppression.
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(1) Munster, VJ, et al. "Pathogenesis and Transmission of Swine-Origin 2009 A(H1N1) Influenza Virus in Ferrets." Science 24 July 2009: Vol. 325. no. 5939, pp. 481 - 483.

Why should I get a flu shot?

Well, there's a hack of a lot of flu coming our way. Consider this:

• Flu viruses reproduce every 8 hours.
• That's a three times daily opportunity to meet and mate with other influenza viruses in the neighborhood.
• If seasonal A(H1N1) rolls in the tracheal hay (that's your airway!) with swine-origin 2009(H1N1), the latter could develop an even more effective way of passing from human to human.

Conclusion? You do NOT want these bad actors fooling around together in your nose and throat. In order to prevent such airway orgies, you need two shots. The CDC currently recommends that you get the seasonal flu vaccine now to prevent crazy long lines in late October when the swine flu vaccine rolls off production lines and into your neighborhood Safeway. So roll up your sleeve, and get shot 1 now.

H1N1 flu shots

Coming soon to your neighborhood supermarket: An ounce of prevention against H1N1.

More precisely, .0000005 ounce of prevention which is the teensy-weensy amount of killed viral material that scientists from the CDC, National Institutes of Health, and various licensed pharmaceutical companies inserted into syringes as they launched clinical trials of newly manufactured H1V1 vaccine earlier this month. They expect to analyze study results from mid-September to mid-October and then begin the first public immunization programs before Halloween. The trials will provide important information on the vaccine's safety, efficacy, and whether one or two doses are needed to provide optimal protection. (Study results released 9/10/09 indicated that one dose for adults is sufficient.)

We already know that H1N1 influenza, first identified in Mexico in late winter of this year, is the most common cause of flu-related illness throughout the world at this time. While this new viral strain continues to cause low-levels of new cases in all 50 states, it is currently 'widespread' in Maine and Alaska. But the regular flu season has not even started yet, and once the usual seasonal blend of influenzas A and B hits, we can expect a double whammy of flu-driven illness this fall into winter.

Quite a few of you have called our office with logistical questions about how best to protect yourselves and your families against this onslaught of respiratory crud. Here's the latest information:

What can we expect?

We know that H1N1 flu is quite contagious, easily passed person to person via contaminated secretions from coughs and sneezes, and able to survive on surfaces for up to 8 hours. While the initial reports from Mexico were quite disturbing with respect to the severity of illness caused by this strain, the illness lately has been acting a lot like seasonal flu. It does disproportionately affect persons under 60 and and can be unusually virulent in those under 25. Per Dr. Jay Butler of the CDC, "75% of the [H1N1]hospitalizations are in those aged under 49 and 60% of the deaths are in those under age 49." Studies showed that no young adults demonstrated circulating antibodies to H1N1 at the start of this pandemic whereas many older adults apparently encountered a similar influenza variety in the past and were found to have some immunity to this strain.

Experts are unable to estimate the community prevalence of H1N1 as many cases are too mild to come to medical attention. In addition, as H1N1 becomes more prevalent, the CDC no longer recommends that such mild cases be tested to confirm the presence of this specific virus.

As I've mentioned in previously posts, influenza is a tricky and changeable foe which can mutate rapidly. Thus far, thankfully, studies of the virus from recent cases in the southern hemisphere demonstrate no significant genetic change from northern cases investigated earlier this year.

What's the difference between H1N1 and the seasonal flu?

H1N1 is a novel strain originating in swine (but not caused by consumption of pork!) that developed in North American pigs through the mixing in their respiratory tracts of genetic material from swine, human, and avian flus. It is antigenically distinct from seasonal flu which means that its proteins and genetic material are completely different than the ordinary influenza types that circulate each winter season.

Will I need shots for both?

Absolutely. Separate shots will be available for seasonal and H1N1 flu. Preliminary information released in an online version of The New England Journal of Medicine 9/10/09 indicates one dose will be sufficient for adults; the proper dosing for children is not yet available.

The seasonal flu shot and the H1N1 shot can be taken on the same day--but different arms please! The seasonal shot is already available, however, whereas the first H1N1 vaccines will not be distributed until late October. While the optimal time to receive the seasonal flu shot is October or November to assure that immunity lasts through the entire season, the CDC currently recommends that persons receive the seasonal vaccine as soon as possible to assure that both flu shots can be administered to the largest number of people.

How can I get the H1N1 vaccine?

While the CDC was hopeful that ample vaccine would be available by October, production delays will slow delivery of adequate vaccine until later on in the year. For this reason, certain groups have been assigned top priority for the first wave of vaccinations, chosen due to their risk for more serious disease. These include:

• Pregnant women
• Persons who live with or provide care for infants aged <6>
• Health-care and emergency medical services personnel with direct patient contact
• Children aged 6 months--4 years, and
• Children and teens aged 5--18 years who have high risk medical conditions

What about college-aged children?

The CDC and universities are implementing various programs to limit the spread of H1N1 disease on campus. Some Colorado schools will offer alternative housing for dorm residents whose roommates become ill.

Stay tuned for up-to-date information on the use of anti-viral medications such as Tamiflu for H1N1 prevention and treatment.

Triple Reassortment Swine Influenza*

*aka Triple Reassortant Swine Influenza

"Six of the eight genetic segments of this virus strain are purely swine flu and the other two segments are bird and human, but have lived in swine for the past decade."
---Raul Rabadan, PhD, computational biologist at Columbia University

And that is why pigs are dubbed "mixing bowls" for influenza viruses. While humans are susceptible to human influenza viruses and somewhat less so to the swine varieties (at least up until now), our airways don't provide particularly good handholds for those influenza subtypes that seek out birds. Pigs, on the other hand, have receptors on the surfaces of their tracheal cells that welcome strains from all three species. From porcine throats and lungs, therefore, emerge new flu varieties with the potential to cause dangerous human disease.

These new flus are called triple-reassortment swine influenza A viruses as they contain genetic material from bird, human, and pig influenza viruses. Until recently, the pigs of North America kept their flu to themselves with sporadic reports of human infections generally limited to those most exposed to pigs in their daily work. Now, however, with another flip of their surface proteins--and flu viruses reproducing every 8 hours have 3 opportunities per day to mix, match, and mutate their DNA in a promiscuous sort of way--the little swinish devils have brought these reassorted flus to human airways. Furthermore, this newest genetic triple threat passes easily from one infected human to another.

With all this mating and mutating, therefore, epidemiologists are finding it hard to predict what's in store as the swine flu (and it is a swine flu no matter what it's called, passed at first from live pigs not pork meat) makes it way back to the Northern hemisphere big time. Fortunately, vaccine production is underway, and immunization programs should begin next month. More on that soon.

What's a Phase 6 pandemic?

WITHOUT A VACCINE, CDC ESTIMATES GRIM FOR SWINE FLU Denver Post, July 25, 2009

Grim?!? Whoa, that's a pretty strong word. In this weekly flu update, we'll check out the ease with which the H1N1 (formerly known as swine) flu spreads from person to person, and why the CDC is hoping for a timely vaccine against the virus.

What's a Phase 6 pandemic?

Sounds serious, and indeed it is insofar as it speaks of the ease with which this little hummer spreads from one human to the next.

The World Health Organization (WHO) has developed a 6-tiered approach that classifies the worldwide threat from strains of animal influenza newly arrived in human airways. Each higher level indicates an increased penetrance of the virus into human populations. By Phase 6--the current global level of the H1N1 flu--the virus has shifted into a lean, mean, human-to-human infecting machine in at least two countries of one WHO region and with spread detected in at least one country of a different region. This particular influenza virus, therefore, reached Phase 5 once it spread from person to person in Mexico and the United States; its subsequent spring '09 appearance in the Southern hemisphere then raised the threat to level 6.

Experts agree so far that this variety of influenza has a 'substantially higher' rate of transmissibility than the usual seasonal flu although this in itself does not mean that it's more lethal.

So what's transmissibility and what's the H1N1 score?

Influenza is quite contagious as it thrives in infected respiratory secretions and effectively spreads those viral laden droplets into the environment via juicy sneezes and coughs. The smaller the droplet, the longer it floats through the air and the further it penetrates into the airway of the unlucky recipient who inhales it. If the virus is novel--meaning that large portions of the population have never encountered this particular bug before--the risk of contagion is even higher.

Epidemiologists express transmissibility as reproductive number (R0 or R-zero) which is the number of cases caused by one infected person. If the R0 is less than one, the disease fades away, whereas rising R0 numbers mean that the spread of the disease is increasingly harder to contain. Experts think that an R0 more than 2 renders such measures as closing schools and screening visitors from other countries for signs of the disease as virtually useless.

So what's the R0 of H1N1? Compared to the seasonal flu with an average R0 of 1.3, estimates for H1N1 vary between 1.3 to more than 2. Calculating an accurate R0 for novel H1N1 flu is very complicated considering the many unknowns about this pandemic such as the incubation time and the percentage of cases mild enough to escape official notice. But we must assume that H1N1 is sporting a fairly robust R0 considering its current worldwide status, and, for that reason, we desperately need a vaccine to slow the spread of infection.

Upcoming info

The important thing in containing this pandemic, therefore, is the development and widespread use of an effective vaccine. More on that subject next week.

The end of private health insurance?

I generally don't mix politics with medicine, but I ask you to consider this article from Investor's Business Daily published July 15, 2009:

It didn't take long to run into an "uh-oh" moment when reading the House's "health care for all Americans" bill. Right there on Page 16 is a provision making individual private medical insurance illegal.

When we first saw the paragraph Tuesday, just after the 1,018-page document was released, we thought we surely must be misreading it. So we sought help from the House Ways and Means Committee.

It turns out we were right: The provision would indeed outlaw individual private coverage. Under the Orwellian header of "Protecting The Choice To Keep Current Coverage," the "Limitation On New Enrollment" section of the bill clearly states:

"Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day" of the year the legislation becomes law.

So we can all keep our coverage, just as promised — with, of course, exceptions: Those who currently have private individual coverage won't be able to change it. Nor will those who leave a company to work for themselves be free to buy individual plans from private carriers.

From the beginning, opponents of the public option plan have warned that if the government gets into the business of offering subsidized health insurance coverage, the private insurance market will wither. Drawn by a public option that will be 30% to 40% cheaper than their current premiums because taxpayers will be funding it, employers will gladly scrap their private plans and go with Washington's coverage.

The nonpartisan Lewin Group estimated in April that 120 million or more Americans could lose their group coverage at work and end up in such a program. That would leave private carriers with 50 million or fewer customers. This could cause the market to, as Lewin Vice President John Sheils put it, "fizzle out altogether."

What wasn't known until now is that the bill itself will kill the market for private individual coverage by not letting any new policies be written after the public option becomes law.The legislation is also likely to finish off health savings accounts.

Washington does not have the constitutional or moral authority to outlaw private markets in which parties voluntarily participate. It shouldn't be killing business opportunities, or limiting choices, or legislating major changes in Americans' lives.

A blogger from Maine, participating in a conference call with the President, said he kept running into the above article that claimed Section 102 of the House health legislation would outlaw private insurance. He asked: “Is this true? Will people be able to keep their insurance and will insurers be able to write new policies even though H.R. 3200 is passed?” President Obama replied: “You know, I have to say that I am not familiar with the provision you are talking about.”

Bystolic testimonial

I wrote some time ago about a medication called Bystolic, a beta-blocker used for hypertension and irregularities in heart rhythm. Beta-blockers also have been used for years to calm the body manifestations of anxiety such as a racing heart, and they are, therefore, useful for stage fright. I have several lawyer/patients who use beta-blockers when they must speak in court. Another patient was having panic attacks that were difficult to diagnose as they manifested with symptoms quite similar to TIAs. After completing a detailed cardiac work-up, I put her on a small dose of Bystolic (2.5 mg. or 1/2 of the smallest available tablet) which controlled both her attacks and her blood pressure.

Here is an e-mail I received from Cheryl on her experience:

I have been using Bystolic for over a month. I love it. Not only is it controlling my anxiety and fast heart rate, my blood pressure is down and I have a generalized good feeling. Things don’t get me worked up like before. And, I’m breaking the 5mg in half. I did have to stop taking it in the evening because my sleep was restless. But, I start my day with a cup of coffee and half a Bystolic and it’s a good thing. I was reluctant after trying samples of Diovan that almost killed me. (Yuk on that one….Poison*).

If I had known how great I would feel on Bystolic, I would have taken it a long time ago. I’m not a pill-popper and dodge it, but this works! I am a health freak and have fought taking meds, but my doctor prescribed it for my racing heart. The benefits make my life happier and healthier.

*This is Cheryl's reaction to Diovan. It often works well for others, and is a good drug for hypertension.

Onsolis

My dear friend is dealing with enormous post-op pain following a prolonged surgery for a bowel blockage. She's still in the IV drip phase of pain control, snowed under by varying doses of ketamine, hydromorphone, and methadone. The surgical team has called in anesthesia and the pain team to help manage her case, so we are once again dealing with multiple docs who, we hope, are more than less keeping in touch with one another.

Ways to control pain that don't require swallowing pills are important to surgical pain control as well as in situations where oral meds aren't tolerated or aren't enough. I was interested, therefore, to learn today about Onsolis, newly approved by the FDA, as an entirely new approach to the problem. Onsolis uses BioErodible MucoAdhesive (BEMA®) drug delivery technology to deliver Fentanyl across the tissues of the inner cheek into the bloodstream. Up until now, Fentanyl has been available as a skin patch which sometimes causes local irritation and occasionally results in overdose if patients apply heat to the body area on which the patch is stuck.

Gotta be careful with these heavy duty narcotics though, they are not for the uninitiated or narcotic naive patient whose liver is not muscled up for processing these drugs. I once had a patient with dreadful arthritis in her neck. She was prescribed morphine for pain control, and in an effort to be painfree, took way more than she tolerated and died in respiratory arrest. For patients like my friend, however, who have been using narcotic analgesia for some time and cannot reliably use or absorb oral meds, this little patch may be a great boon to their comfort.

Of cockatiels and trumpets

Some of my patients are 'difficult' insofar as I am stumped as to what they need and how to improve their health situation. One such customer was a middle-aged lady plagued with pain, poverty, and depression. She was a large lady, and part of each appointment was spent in the slow walk from the waiting to the exam room which she negotiated one tedious step at a time with the help of two canes. She always arrived with copious pencil-written notes about her days spent doing little other than getting by.

What her notes never included, however, were tales of her cockatiels. Who knew she raised birds? I certainly didn't. I'm not sure how it even came up, but once we discussed her birds, everything seemed to change. She still came armed with those torn notebook pages full of complaints, but she was also the person who brought pictures of her birds and their tiny little-finger sized hatchlings. She was now, for me, the bird lover who struggled with pain rather than just the pain.

Yesterday's new patient was a nervous young man who at 23 had an engineering degree and spent his working days making sure that the calculations made by his firm on bridge design were correct. I remember a magazine article on school standards (and their increasing laxity) that asked the reader whether or not they would care to drive across a bridge designed by someone in the lowest quartile of their engineering class. My first impression of this fellow was that he'd be a good one to have beneath the bridge upon which we drive with nary a thought as to its safety.

At the end of the physical, I asked him if he planned to go on to a higher degree in engineering. He answered that he felt that engineering was going to be the job that supports his real loves in life, namely playing the trumpet. I'd like, I thought, to drive across bridges designed by this engineer who plays the trumpet. No need anymore for either of us to be nervous.

Abilify testimonial

I wrote recently about a patient whose 'delusional parisitosis' was ruining her life. She felt that bird mites had invaded her home, her car, and her siblings' homes, making her too anxious and distracted to work or carry on any semblance of normalcy. A psychiatrist started her on Abilify last month during a brief involuntary hospitalization orchestrated by her frantic family.

She came in today, 5 weeks into her Abilify treatment. She looked well--rested and tear-free. She declared that things were 'almost back to normal'; she was back in her home, no longer experienced abnormal skin sensations, and had returned to work. I didn't ask her if the mites were gone, nor did she volunteer anything along the lines of 'what do you suppose that crazy business was all about?' I didn't feel like she needed to acknowledge whether or not the mites were real or imagined; it was more than sufficient that they were no longer front and center in her mind and her life.

I hope her insurance pays for this medication. It's four-plus expensive, but what an amazing difference it's made for her.

Bacteria, bad breath, and oil pulling

I've been thinking about bad breath and mouth hygiene lately (and as soon as I get the big "L" off my forehead, perhaps I'll think about something fun). First of all, I wonder what to do about patients with bad breath--not the ones who complain of it who frankly never have bad breath on examination, but rather the clueless ones who have bad breath and don't know it. Should I say something to them? Perhaps I could include "Do you have bad breath?" in my review of systems during the annual physical, and if they answer "No," tell them "Not so fast on the negative buster!"

My latest foray into alternative medicine includes a month-long experiment in the Ayurvedic practice of oil-pulling. I'm not quite sure where I came across it, but it seemed like an intriguing way to use up a bottle of organic sesame oil sitting in my 'frig. First of an a.m. on an empty stomach, I sip but don't swallow a tablespoonful of sesame oil. As I bring in the paper, make coffee, empty the dishwasher, and do the little morning chores, I 'pull' the oil through my teeth or poke at the mouthful with tongue against teeth for (theoretically) 20 minutes or until my mouth is too full and I'm too grossed-out to go on which got up to 14 whole minutes today. Spit and rinse follows, then on to breakfast.

Testimonials abound on the Internet in support of the practice which, among other things, is supposed to enhance oral hygiene, and lessen tooth decay, bad breath, and dry lips. So far, one week into it, it only dampens my enthusiasm for breakfast and seems to make me less prone to eating the crap that drug reps bring in to the office (despite new Pharma regulations against the practice!).

An article in the Journal of the Indian Society of Pedodontics and Preventive Dentistry reported a study wherein 10 adolescent boys were somehow convinced to oil-pull in the a.m. for 10 minutes, and then their levels of streptococcus mutans (a bacteria associated with tooth decay) were compared with another group of 10 who swished instead of a morning with chlorhexidine mouth wash. Both groups experienced the same drop in levels of those s mutans bad boys.

But...I dare you to find a bunch of health nuts waxing poetic over the morning use of chlorhexidine mouthwash! Consider this on oil pulling from Molly of SanFrancisco: The really bad stuff that forms plague [sic], is very attracted to the acids in the oil. So it melts this bad stuff and then you spit it out. That's why your teeth get much cleaner than by conventional means, like alcohol based rinses. And so, when you melt this bad stuff, you simply spit it out..buh bye.

On now to my real story here which is breaking news from the first ever symposium on the microbiology of odors held last month in Philadelphia. Israeli microbiologists have developed a new saliva test called OkayToKiss that tests for the presence of certain enzymes produced by gram-positive bacteria (such as s mutans) that make it easier for gram-negative bacteria in the mouth to break protein into malodorous compounds.

The doc-in-charge of the research, Dr. Mel Rosenberg, is described as an "international authority on the diagnosis and treatment of bad breath." He invented a two-phase mouthwash (containing saline and oil) based on his studies of petroleum microbiology wherein he discovered that oral microorganisms from dental plaque when mixed with nontoxic oils became bound to the oil. Voila! Does that not sound like a variation on oil-pulling to you? Check out melrosenberg.com if you want a ton of technical on the process. And the 1-2 mouthwash known as Assuta bested Listerine with respect to longterm control of halitosis.

So back to this OkayToKiss test. Due out next year, this pocket-sized test I gather is a treated piece of paper that you lick and check. If it turns blue, keep your mouth to yourself. This Dr. Rosenberg is a kick--don't miss his smellwell site for more ideas on keeping fresh as a daisy.

September, 2009 update: Still oil-pulling. I can last 15 or more minutes at it, no problem. Teeth so white that my 20-something year old daughter who commented below about how gaggingly gross this sounded is now doing it herself. My first visit with the dental hygienist post oil-pulling is next month; I'll let you know how I fare.

Dying for D

A lot of you, it seems, have not yet gotten the memo. All this sun-phobia has caused an epidemic of vitamin D deficiency. The latest articles I've seen go by implicate low levels of D as a contribution to non-melanoma skin cancers (thought you were ducking that by avoiding the sun, did you?), bacterial vaginitis(!), and depression. Now this from the Archives of Internal Medicine:

Researchers sorted through the mountain of data generated by the Third National Health and Nutrition Examination Survey looking at D levels as compared to the incidence of dropping dead in some 13,000 participants followed from 1988 through 1994.

Those participants with D levels lower than 17.8 ng/ml (and at least half my patients test into this range!) had a 26% increased risk of dying compared to those more D-endowed. The likelihood of being D-ficient was higher in those who were older, female, nonwhite race (darker skin is not as efficient at producing D when exposed to sunshine), diabetic, smokers, overweight, and in those who did not take D supplements. I have found many who rely on the D added to dairy products or calcium supplements and/or the D in multivitamins are also often deficient.

Take D. Take it everyday. Get a little sunshine on your unsunblocked self.
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Melamed, ML, et al. 25-hydroxyvitamin D levels and the risk of Mortality in the general population. Arch Int Med. 2008; 168(15):1629-1637.

Brain centers in charge of voice recognition

In everday life, we automatically and effortlessly decode speech into language independently of who speaks. Similarly, we recognize a speaker's voice independently of what she or he says.(1)

My first call of this holiday weekend was a real jaw-dropper. The youngish man was most put out; he'd been assured that his prescription was called in and, on arriving at the pharmacy, found that they had no record of it. In language worthy of a drunken sailor, he anonymously expressed his deep unhappiness, and concluded that my staff and I were copulating pieces of excrement but in different words.

Now I certainly appreciate his aggravation--been there (at the pharmacy as a customer) done that (felt my blood pressure rising that the pharmacy staff had no knowledge of any script) myself. As often as not, it's an oversight or delay at the pharmacy, but I do know (as do you my patients) that we also have system failures at the office. That said, this tirade was inappropriate done anywhere but in the privacy of one's own brain or car, and I would like to know the identity of the caller so we can discuss whether or not he should continue as our patient if he even cares to do so.

So now we're on the topic du post: voice recognition. I remember a much more pleasant call nearly two decades ago when my front desk assistant announced I had a personal call on line 6. I didn't recognize the name she gave me (remember--we do admit to system failures) but I instantly knew the voice of my freshman college best buddy whom I'd lost track of for 17 years. Now scientists have identified the bit of gray matter that lights up with delight or dismay at the sound of a familiar voice.

Using functional MRI scanning, researchers from the Department of Cognitive Neuroscience at the University of Maastricht located an area of the auditory cortex that hums with activity as test subjects decipher the message and the messenger of spoken stimuli. In order to establish the identity of my anonymous caller, I need to find a staff member whose right anterior superior temporal sulcus (this STS is a brain bit located roughly behind and slightly above the right ear) along with the nearby Heschl's gyrus roars with recognition (and righteous indignation) when the message is replayed.

And Mr. No-Impulse-Control, get this, Pat at the front desk has a highly developed STS, and we will smoke you out. And know that a plainly worded message, even one expressing anger appropriately over lost time and effort, would've resulted in a prompt call by me to your pharmacy!
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Formisano et al. "Who" is saying "What"? Brain-based decoding of human voice and speech. Science. 7 November 2008, Vol 322, pps. 970-973.

Lest you think that I don't observe my own health habits, here's the latest. I've developed a juicy head cold since I got back from South Dakota, so perhaps I got in the line of fire of infected droplets from Mr. Sneeze-in-the-hand who passed not five feet away from me at the Rushmore Memorial. On the plus side, however, I logged well over 4,000 steps* at the office today, leaving the exam room every time I needed to sneeze or cough and then, of course, washing my hands. Unfortunately, I joined the chunky mom and child in the Keystone, SD restaurant by snacking through the day on Milky Way bites (dark chocolate covered!) and chips.

My bro', whom regular readers know as a strict grammarian and my sharpest critic, wrote a limerick in response to my previous post:

A very old guy in Custer
Said it's not beer that loses your luster;
Read your own blog,
Be a stick, not a log,
(And drink coffee to make certain, buster.)

Last week, I received an endoscopy report (complete with color pictures) on one of my patients who underwent the test two days prior to evaluate her upper abdominal pain. She had a mass in her duodenum that looked scary, like something you might see growing on the Great Barrier Reef. The comment section of the report said "Pt. should call the office in 7 days for the report."

Seven days waiting for a biopsy report? Sounds like the week from hell as there's nothing worse, I think, than waiting for test results on a mass found where no mass ought to be. An hour later, the path report came over the FAX--no cancer!! I called her to let her know, although I advised her to call the GI doc to find out what the next step should be. Her response reminded me of a line from Dennis Prager's "Happiness is a Serious Problem":

"...ideally, 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."
_____
*I wear a pedometer every day. I'll refund the co-pay of the first person who shows up in my office for their physical wearing one! People tell me all the time that they don't need exercise as they 'run around all day at the office' or 'park at the end of the lot.' I've often wondered how many steps are involved in said running and parking.

My father was a psychiatrist. When my friends came to visit, they would ask me--half-joking--if he thought they were crazy. I know for a fact that he passed no judgments on our crazy adolescent antics, but I'm here to tell you that the internist in me is always on alert to the health habits of others. Here's several observations from my just-completed trip to South Dakota:

--The young man sneezed mightily into his hand as he walked away from Mt. Rushmore. He looked with distaste at his mucous-slicked hand, then wiped it half-heartedly on his jeans. Remember, this guy (or his cousin) touched that door knob just before you did.

--This fellow (a dead ringer for TweedleDee's silhouette) jockeyed for position at the toaster during the crowded, freebie breakfast service at the Dew Drop Inn in Rapid City. He was reaching for the whole wheat bread when the little serving lady brought in a heaping stack of chocolate muffins. To heck with bread, he nabbed two fresh muffins.

--This chunky young mom walked into the restaurant with her overweight daughter in tow. They placed their orders, and shortly thereafter the waitress brought a plate of onion rings for mom and a platter of fries for the young lady. Hmm, I thought, but oh well, they're on vacation and going for a treat before dinner. Alas, their second course was ice cream parfaits for all.

--A very thin, very old guy sat at the bar in Custer, SD, reading the paper and nursing a beer before dinner. We discovered that he was a World War II veteran, a banker, a cattle rancher, and the jeep tour driver for the lodge. He regaled us with stories from all his various careers.

I'm having whatever he's ordering!

Delusional parasitosis

The ones that crawl in are lean and thin
The ones that crawl out are fat and stout
Your eyes fall in and your teeth fall out
Your brains come tumbling down your snout

No lighthearted matter, these creeping mites, for two of my patients. The first middle-aged lady came in last summer toting a small aquarium full of water. Floating within were numerous diaphanous strands that trembled and tumbled as she heaved the case onto the table.

"Bugs," she declared, "the things that are crawling into my nose and making me crazy."

She was not kidding; she was in tears. She didn't say I think I'm going crazy because I imagine bugs, she said these are bugs.

The second lady came with her brother and sister in tow. He was carrying a crystal wine glass filled with alcohol and covered with saran wrap. Within floated three 'mites' captured as they scurried up someone's arm; I can't remember which one of the sibs caught the little buggers. I carefully poured off the alcohol and managed to snag the tiny particles onto a slide.

"Two clumps of fiber and pile of skin cells," I declared on returning to the exam room. "C'mon back and have a look."

Did they say "Oh my goodness, how foolish we feel now?" Nope, they just shrugged and said "we must've missed them which is amazing as they swarm by the thousands up our arms and legs." Lady #1 didn't go so far as to pin down the species of her infestation, Lady #2 was quite clear the pests were bird mites.

This is not only a psychotic syndrome, but the ability to pass the delusion along to others is a known phenomenon dubbed Shared Psychotic Disorder (SPD) which occurs in as many as 15% of cases of Delusional Parasitosis (DP). Must be a huge delusional exaggeration of the way one starts to itch when someone near by starts to scratch.

Per Wolfgang Trabert(1), when SPD patients are separated from the 'inducer,' a significant number of them undergo a spontaneous remission. Indeed, the brother and sister of this patient pulled back from their personal mitey troubles and had Lady #2 involuntarily admitted for psychiatric evaluation. She emerged slightly less upset due to the use of anti-psychotic meds, but still convinced that her house (that she's abandoned), her car (which she still drives but coats herself before doing so in olive oil as mites don't care for the taste), and her new apartment all continue infested.

Helping Lady #2 try to regain some semblance of a normal life is the hardest thing I've ever attempted in 28 years of practice. Her major source of information is birdmites.org. Check it out; is this fact or a web-site run by a bunch of SPD patients?
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1. Trabert, W. Shared Psychotic Disorder in Delusional Parasitosis. Psychopathology 1999;32:30-34.

Heart attacks and low cholesterol

Can you have bragging rights cholesterol and still suffer a heart attack? You bet, read on:

My patient sat relaxed and smiling in the exam room. He was here, per my schedule, for 'follow-up."

"So, what's going on?" I asked.

"Well, haven't you heard?" he asked. "I just had a heart attack a week ago Sunday."

There he sat, tan, comfortable, the only visible sign of less than perfect health in his 61 year old self was a little bit more belly than ideal bulging out at his midriff.

"You're kidding, right?"

"Nope," he replied, "to make a long story short, I had a heart attack while reading the morning paper and drinking my coffee. I started having severe chest pain, told my wife that this was the real deal, and within 78 minutes I was on the table getting a stent placed in my heart"

Gad, this guy has perfect blood pressure (110/72) on a low dose of heart-healthy lisinopril, 'walks some' for exercise which is not enough but more than many people, and has an LDL cholesterol of 80 on no meds. His dad had diabetes and died of coronary artery disease at 73.

The cardiologist found a complete blockage of his left anterior descending artery--the so-called 'widow maker-- on catheterization, which means no blood whatsoever was getting to the front wall of his left ventricle prior to stent placement. An echocardiogram after the procedure showed that only a small part of the apex of his heart was damaged.

When I was in med school, this fellow would've gone straight to bypass surgery followed by a prolonged post-op stay in the CCU. Yet here he was, scarcely a week later, already starting a cardiac rehab exercise program.

Two lessons here: prompt access to modern medicine is grand, and none of us can rest assured in our low cholesterol numbers.

"Why don't we do it in our sleeves?"

I feel an enormous amount of compassion for the sick people in my exam room. But my fountain of understanding abruptly runs dry when some infectious chucklehead lets loose an unrestrained cough or sneeze as we sit together in that tiny space.

So please, one and all, as we pass through this scary, fluish time in close quarters, check out this video . Give your family, your co-workers, and your doctor a break!

Cytokine storm and the H1N1 swine flu virus

At a time when the flu season should be winding down in North America and Mexico, scary reports are emerging from our Southern neighbor of a new swine flu variant whose victims are primarily young. Not only does this influenza A strain appear to be a previously unknown combination of bird, swine, and human genetic material, but the course of fatal illness caused by this bad actor seems to be marked by a 'cytokine storm' that leads to grave lung damage in those affected.

Well shoot, who wants to be in the eye of a cytokine storm? Cytokines are worthy molecules that various body immune cells make in response to an infectious invasion. This is generally a good thing insofar as these various chemicals amplify the body's attack on unwanted intruders. As is true of so many physiological functions, however, a little is good but a lot is destructive.

At the heart of the stormy matter are macrophages ('first responder' white cells activated by damaged cells or foreign invaders such as bacteria or viruses) and CD8+T-lymphocytes (circulating white cells that leap into killer mode the moment they get a whiff of flu viral proteins nearby). These white knights in cell membrane clothing produce a whole host of cytokines--including Tumor Necrosis Factor (TNF)-alpha, Interferon (IFN)-gamma, IFN-alpha/beta, Interleukin (IL)-6, IL-1, MIP-1 (Macrophage Inflammatory Protein), MIG (Monokine Induced by IFN-gamma), IP-10 (Interferon-gamma-Inducible Protein), and MCP-1 (Monocyte Chemoattractant Protein) to name a few. H5N1 influenza (bird flu) happens to be a particularly strong inducer of this cytokine over-production due to the virulence and enthusiasm with which it enters human tissues. Whether or not swine flu and this newest swine version causes this kind of cytokine mess is still not known.

So the human lung and too many cytokines is way too much of a good thing, causing swelling, hemorrhage, and tissue death which are, ironically, more a result of the body's defense mode than a primary flu-generated injury. Scientists theorize that young people may have a more robust cytokine response and less H1N1 immunity from previous exposure compared with older populations.

As of today, 8 cases have been reported in the US from California and Mexico that have been identified as the swinish H1N1 flu but mild and self-limited illnesses in those affected. Remember, increasing evidence suggests that robust body levels of vitamin D are flu-protective, so this might be a good time to get your blood tested for vitamin D and step up your supplements under advisement with your physician.

For up-dated information on the H1N1 flu, see Triple Reassortment Swine Influenza, H1N1 flu shots, Why should I get a flu shot?, and What's a Phase 6 Pandemic?

These glasses have got to go!

I've just returned from a round trip drive to the East coast. Don't ask why, just know that the last time I did that journey, I was 19, and it's quite a different matter to sit in a car that long that far nearly 4 decades later.

We were equipped with snacks, books on tape, and my favorite pair of sunglasses. When I tried them on at the sporting goods store, I was impressed with their style and comfort. I wore them for six months before I noticed that they had skulls embossed on the ear pieces--perhaps some sort of extreme sports insignia? Actually my son brought the look to my attention.

Well I can live with the skull thing, but I discovered during hours of driving into the late afternoon Kansas sun, these shades simply don't fit. The beskulled left ear piece digs painfully into my very own skull just above and behind my ear. So what misery to pick--squinting into the sun (wrinkles! cataracts! an inability to see the road!) or incessant fiddling with the way glasses meet head?

On top of that, my left shoulder began hurting terribly. I'm picturing my aging, degenerating neck sinking into my torso, pinching a nerve on its way to the bucket seat, and I add massaging the shoulder to sunglass fussing to my general in-car fidgets. After ripping the stupid things off when the sun went behind a cloud, I discovered that my shoulder pain resolved within minutes.

I've always told my patients that muscle tension in the neck can easily cause a headache. Apparently pounding plastic into the temporalis muscle on the side of the head can reverse the pain flow down the neck to the shoulder.

Bilateral shingles

I wished recently for a consult with Dr. House (in the form of Hugh Laurie with the patience of Mother Theresa). My patient felt awful for a week or so. She was having palpitations, her chest hurt terribly with any position change--say with settling back into bed--or with deep breathing, and the skin on the back of her neck hurt terribly. Her appetite was down, she had no pain with swallowing nor acid reflux, and generally felt unwell due to her newly diagnosed rheumatoid arthritis and Crohn's disease.

Her blood pressure was low and her pulse was up, no fever, her chest wall was not painful to touch, her lungs were clear, and her abdomen wasn't tender. Any movement of her torso caused her to cry out in pain. Her blood count and lab work were normal except for an expected elevation in her sedimentation rate (a non-specific measure of inflammation or infection in the body) due to her arthritis and colitis. A chest x-ray was clear, her thoracic spine films looked good, and the EKG showed no evidence of heart troubles.

Yikes, what on earth? Perhaps yeast in her esophagus? Yet she had no trouble swallowing food. Costochondritis (inflammation where the ribs meet the sternum)? No pain on pressing those joints. Acid gastritis? Her pain was positional and not affected a bit by eating. Heart pain? Nope, the pain was totally atypical. Pre-shingles nerve pain? Maybe in the neck, but not on both sides, and what did that have to do with her chest pain.

Two days later she broke out in shingles--on both sides of her head behind and on her ears. So much for conventional wisdom that shingles only affects one side. In fact, 4% of patients break out on both sides of their bodies. Meanwhile, she researched the side effects of Asacol (a medication used to decrease the inflammation of colitis) and found chest pain on the list. She quit the medication, and, within a day, her pain was gone.

So who needs House when patients use the Internet? I regret that I didn't start her right away on one of the drugs that work against shingles (Valtrex, Famvir, or acyclovir). House would've done that.

Meat-related mortality

I just finished a liverwurst sandwich (delicious with dijon mustard and sliced purple onion); it was 'to die for' but not exactly my definition of health food. Imagine my dismay when to die for took on a more literal meaning as I opened the March 23rd issue of The Archives of Internal Medicine to this headline news: "Meat intake and mortality: a prospective study of over half a million people."(1)

So what do 500,000 meat eaters have to teach us about the guilty pleasure of a liverwurst sandwich? Namely that the consumption of red meat and processed meats (and liverwurst, while not red, is oddly pink in a processed, not-found-in-nature sort of way) is associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality.

In other words, too much meat and you're so much dead meat. My sandwich sits like a guilty lump in my stomach. An accompanying editorial goes on to indict me further: "Far too few clinicians speak out on topics such as this. What the public hears is the side of the profession that is preaching vegetarian diets and not the side of the profession that is discussing moderation as a healthy option." So I'm telling you now, the very occasional processed meat treat may be good for your soul, but mostly you should emulate my favorite dinner--which I had last night--namely a bowl of Bear Naked Granola.

And just to further fuel my discomfort with meat, I have just ordered "Dying for a Hamburger: Modern Meat Processing and the Epidemic of Alzheimer's Disease" wherein the authors make a case that Alzheimer's Disease is spreading like an infectious disease which, per them, is carried in cow meat meals contaminated by prions, the proteinaceous particles associated with mad cow disease. Lovely. I'll let you know if this sounds cutting edge or lunatic fringe.
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1) Arch Into Med. 2009 Mar 23;169(6):562-71.