Tuesday, March 31, 2009

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.

Sunday, March 29, 2009

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.
1) Arch Into Med. 2009 Mar 23;169(6):562-71.

Saturday, March 21, 2009

Flector patch

Looking for the anti-inflammatory relief of Advil or Aleve without the stomach distress? If you're injured and hurting, check out Flector Patch for a brand new alternative in pain control

Monday, March 16, 2009

How gross is this ad?

Actual advertisement on London bus--does this stud muffin do Pap tests?
(from copyranter.blogspot.com)

Sunday, March 15, 2009

Fatty liver disease

"As the nation gets heavier, our livers will get fatter."
---Chin Hee Kim, MD

Nonalcoholic fatty liver disease (NAFLD) is the most common form of liver disease AND it affects 20-30% of the US population per Drs. Kim and Younossi writing in the Cleveland Clinic Journal of Medicine(1). NAFLD can range from no big deal fat in liver through inflammation and liver cell damage (nonalcoholic steatohepatosis or NASH) to cirrhosis, liver cancer, or liver failure.

The standard, automated laboratory blood profile includes a panel of liver enzymes. These transaminases(2) which are involved in the production of amino acids are part of the biochemical equipment within liver cells. They are normally present in the bloodstream in small amounts, but disruption of liver cells causes their blood levels to rise. A case of hepatitis skyrockets transaminase levels into the 1,000s and beyond, but even very low level elevations found on lab screening are worthy of follow-up because they may indicate an ongoing, asymptomatic inflammatory liver process that can ultimately lead to cirrhosis and liver failure.

Often, elevated liver enzymes or liver function tests (LFTs) in overweight persons demonstrating signs of metabolic troubles (fat concentrated around the waistline, elevated blood pressure, elevated triglycerides, low HDL, or high blood sugar) are the first sign of NAFLD. This fatty liver business is usually asymptomatic and only noted on lab testing. In order to chase down the cause of abnormal LFTs, we next order tests to check for chronic hepatitis B or C infections, auto-immune liver disease, or metabolic diseases such as abnormally stored copper or iron in the liver. An ultrasound of the liver is fairly accurate in assessing the presence of fat in the liver.

Liver biopsy is the best way to determine if the fatty liver troubles are benign or carry a risk of progression from nonalcoholic steatohepatosis to scarring and permanent liver damage or failure. Once diagnosed, the best approach to treating fatty livers is the same strategy that improves overall health in overweight persons on the road to diabetes or heart disease. These include weight loss (including use of bariatric or gastric bypass procedures), trials of various drugs that promote insulin sensitivity such as metformin, Actos, or Avandia or drugs that lower triglycerides and raise HDL levels such as statins and gemfibrozil. Fatty livers are more sensitive to damage from regular alcohol intake.

If you tend to pack the pounds around your waistline, be sure to ask your doctor to test your liver enzymes.
1) Kim, HK and Younossi, ZM. Nonalcoholic fatty liver disease: A manifestation of the metabolic syndrome. Cleveland Clinic Journal of Medicine. October, 2008, Vol 75, pp 721-728.
2) Aspartate transaminase (AST) and alanine transaminase (ALT) levels generally range up to 40 or so. In mild NAFLD, AST <> ALT.

Saturday, March 07, 2009

Cures for the red face?

And who wants a red face? I had a new patient in yesterday who specifically complained of a red nose, and indeed, the tip of her nose was red with tiny enlarged blood vessels visible on its surface (but only seen by me with reading glasses assist!).

Thanks again to TheDermBlog.com (and I highly recommend this site to you), I am able to bring you a little more info on the subject. One of the most common causes of a red face is rosacea, an inflammatory skin condition that often causes red cheeks and nose (and occasionally eyes), that gets redder yet with alcohol consumption, and responds to topical antibiotics like Metrogel. Sun damage also permanently dilates the superficial blood vessels in our skin, particularly visible in those with Type I sun-sensitive skin (as in fair, easily burned, often in red heads and persons of Northern European ancestry). Dr. Benabio notes on his blog that laser treatment can take away those enlarged capillaries at the skin surface.

I also see persons with acne succumb, as did I, to overscrub syndrome, using washcloths and various exfoliants in a vain attempt (in both senses of the word vain) to liberate the pores from pus and oil. I have been following Dr. Benabio's advice to wash the face less often, but it still goes against my basic impulse to scrub early, scrub often and dab with astringent in between.

He recommends anti-inflammatory, anti-redness skin products for the those who carry the red badge of sun damage/acne/rosacea front and center on their face. In particular, he mentioned Aveeno calming lotions with the herb feverfew. Aveeno apparently has gone to some trouble along with a host of phytochemists to remove the pesky parthenolide component of feverfew (which sensitizes the skin i.e. makes it redder) leaving behind its beneficial anti-inflammatory components. In particular, the parthenolide-depleted feverfew inhibits 5-lipoxygenase, a pro-inflammatory molecule that is the target of a new anti-arthritis medication working its way through clinical trials. Maybe feverfew should join the A-list of herbals that we smear on and swallow (it's supposedly good for migraine prevention as well) along with vitamin C and green tea.

Well, of all my skin troubles, redness is not one. Testimonials for Aveeno (and Eucerin) anti-redness creams abound on the internet. Let me know if you try it and like it!

Sunday, March 01, 2009

Vitamin A supplements and cancer risk

A little is essential, a lot, apparently, is too much of a good thing.

Enamored with the potential of anti-oxidants in fruits and vegetables in cancer prevention, scientists theorized that concentrating these worthy phytonutrients in supplement form might be even better yet. Several studies through the years designed to test this theory on vitamin A derivatives such as carotene (that substance which imparts the orange color to carrots, sweet potatoes, melons, etc.) have been abruptly halted when smokers enrolled in the trials who took the real deal beta-carotene preparations developed lung cancer at a significantly higher rate than those on placebos.

University of North Carolina researchers took another tact and arrived at the same conclusion. They examined data from 77,000 Americans over 10 years--correlating use of dietary supplements with subsequent cancer diagnoses. Note that these subjects were not assigned to a certain vitamin or placebo but rather self-reported their use of over-the-counter vitamin pills.

Not only did beta-carotene again prove problematic in a cancer-causing sort of way for the smokers in the study group, but retinol and lutein demonstrated a potent total dose-related association with lung cancer risk. The longer a person took these supplements, the greater their risk compared with those smokers who did not use them--53% for retinol and 102% for lutein!

Lutein, of course, is recommended to help prevent macular degeneration, an age-related eye condition that can result in significant vision loss. The researchers did not comment on the conflicting reasons to take or pass up lutein, but perhaps persons who smoke should pass up the lutein.