Sunday, November 21, 2010

"Turn your DNA into art"

The perfect personalized gift this holiday season--a work of art based on the recipient's unique genetic sequence. If you can only figure out some sneaky way to swab their inner cheek without raising suspicions, you then mail off the sample to Yonder Biology who will turn it into a "beautiful genetic image" on photographic paper, stretched canvas, or acrylic face mount at prices ranging from $99-$1,199. Add a "Me" t-shirt for an extra $34!

Whether or not you choose this route to self-expression, it's a fun web-site. Check-out:
Yonder Biology.

Sunday, August 01, 2010

Rose Kelly

Rosellen Kelly, 8/20/52-7/31/10

I lost my dear friend Rose yesterday to cancer. Mom, wife, friend extraordinaire, writer, artist, and Assistant Head of School at St. Anne's Episcopal here in Denver, she was a treasure to all who knew her. She collected friends like an endless strand of pearls--like the ones she wore at a time when our generation was mostly through with such traditional adornment.

Gracious, hilarious, and soothing, she told me that she viewed death as "just showing up for my next assignment. An angel in life, she has ample experience for her upcoming gig.

Sunday, July 25, 2010

Duke wants picky eater info

Well, I've heard it all. The patient who ate her way past the benefits of gastric bypass surgery by eating a bag of Hot Tamales candy each day. A man who has eaten the exact same meal three times daily over the five years that I've known him. Another who drank 18 colas a day supplemented by cereal in the a.m. and a hamburger in the p.m. My daughter who scraped anything larger than a grain of rice off her tongue for the first 2 and 1/2 years of her life.

Researchers want to hear from you if you are an adult picky eater. Apparently, experts now classify this as an eating disorder, and they are seeking data on the effects of finickiness on health and social situations. Per Marsha Marcus, a psychologist involved with the study, "We want to define the boundary between normal weird eating and real problems."

Would you like to participate in the quest to find the cutting edge of 'normal weird' as it extends into 'real problems'? Log onto The Food F.A.D. Study and contribute to medical science.

Saturday, July 24, 2010

Of Busyness and Chocolate

"We show in two experiments that without a justification, people choose to be idle; that even a specious justification can motivate people to be busy; and that people who are busy are happier than people who are idle.”(1)

The past few days have been stressful, so last evening I set to work on my kitchen, wiped down cabinets, sudsed up countertops, and then got down on my knees to hand scrub the floor. This was a Friday night, mind you, but I was content if more than a little sweaty, completely calmed by my whirlwind of activity. As a result, I've been thinking about busyness, and, my conclusion-- based on encounters with people both happy and un--is that humans enjoy being busy. Researchers from the University of Chicago’s Booth School of Business concur that busyness is a source of happiness.

As you know from this blog, scientists will study just about anything, and their most willing and available subjects are college students. Researchers at the University of Chicago theorized that "People dread idleness, yet they need a reason to be busy." So they grabbed a group of undergrads, hooked them up with a bogus survey, and here's what they found about idleness, chocolate, motivation, and happiness.

The students were asked to complete the survey then offered various strategies for turning it in. All involved the choice between a 15 minute sit-around-and-wait versus a 15 minute walk to another location. Without a chocolate inducement, the majority of subjects chose to wait. If offered a choice of milk chocolate on site vs. walking for dark, however, significantly more subjects opted to ambulate. The final test group was forced to walk or wait as a condition of the experiment. In every case, those who walked judged themselves happier than their lazy-bone colleagues. The researchers concluded, as stated above, that while people might choose to be idle, they’re willing to get moving for rewards as ‘specious’ as chocolate, and they’re always glad to be busy.

I talked this all over with a psychologist friend, and we agreed that this research is adrift in specious reasoning. Did the walkers, in fact, become happy due to walking or did they walk because they were happy? Or did they become happy while walking because it was such a nice break from their busy schedules to slow down and walk through the beautiful campus (if indeed the U. of Chicago campus is beautiful). Or is this the healthy person bias, meaning are people who choose to walk for chocolate on average people who are optimistic about the future and happily seeking healthy choices?

Other research confirms another obvious fact, namely that active people derive satisfaction not necessarily from busyness so much as from being valued and needed as a result of that which they accomplish in their work. And too busy, frantically busy, is a known detriment to health. Stay tuned for more busy research in upcoming posts.
(1) Hsee, CK, et al. "Idleness aversion and the need for justifiable busyness." Psychol Sci. 2010 Jul;21(7):926-30.

Wednesday, May 05, 2010

Don't cool your jets!

I get daily discount deals by e-mail. Nothing wrong with these bargains, but who on earth writes their ad copy? This one was too rich to keep to myself:

When pilot lights go out, it is because they lack ample
core strength, a failure that results in uncooked pilots.
Keep your pilot light burning bright with today's deal
at "X" pilates studio.

Wednesday, April 21, 2010

Caffeine plus exercise

I am preparing a talk on exercise, and I figure I can't just say "You should," thank the audience, and head for the gym. On perusing articles on exercise and breast cancer (you should do the former to decrease risk of the latter!), I followed one of those delightful internet link trails and came across this interesting study on New Jersey mice (1).

Imagine being offered three choices: two weeks of daily Starbucks plus an obligatory work-up with a personal trainer (both free of course!) that same Starbucks sans gym work-out, or a caffeine-free opportunity to exercise only if you care to but never mind if you don't. These Jersey rodents were assigned the mousy equivalent of these choices, then all underwent tanning sessions under UV lights. Oh yeah, and then followed by skin biopsies...

All lost some of the fat lurking just beneath their furry hides, but the exercise plus caffeine group lost twice as much as the indolent coffee drinkers. Better yet for those buff little fellows that enhanced their exercise-enhanced physique with tans, those who drank caffeine-laced water AND exercised exhibited apoptosis of sun-damaged skin cells. In other words, caffeine inhibited DNA damage from UV light--and therefore tumor formation-- by promoting the destruction of UV-damaged cells.

If we're at all like mice, which we more or less are, caffeine plus exercise may equal some sort of cancer protection.
Yao-Ping, L et al. Voluntary exercise together with oral caffeine markedly stimulates UVB light-induced apoptosis and decreases tissue fat in SKH-1 mice. PNAS July 31, 2007 vol. 104 no. 31 12936-1294.

Friday, April 09, 2010

The changing face of primary care

I ran into one of my patients today at the grocery. We chatted in the bread dept. about footwear and fiber, then met again in books. I was there considering whether or not I could justify adding yet another book to my 'to read' pile, she was just browsing on her way up one aisle and down the other. By the time we parted, I'd learned that her older son, once my patient, had moved home again and was struggling with depression. Her younger was now in his 7th year battling an HIV infection. Who knew I could learn more about her personal life at King Sooper's then ever I knew from our not infrequent exam room encounters?

This small town sort of intimacy in the middle of a moderately big city represents all that I love about my practice of medicine. Alas, it looks like things will change mightily in the coming year as my partner and I strike out in new directions in order to continue practicing medicine at all.

Strange how primary care is front and center in the middle of health care reform, yet remains undervalued and underfunded in ways that will soon completely preclude the sort of Mom and Mom shop that she and I run. In the face of falling reimbursements and rising expenses, here's what we view as our two choices:

The first is to become employees of a large hospital corporation. Economy of scale and deep pockets will remove the agony of the overhead--buying medical supplies and injectibles in quantities and at per unit prices of which we can only dream in our current situation. Being able to negotiate with insurance companies for contracts that two docs in a 1950's style little medical box could not begin to command. more funky offices adorned with antiques and artwork (and leaky basements!), no more elevator-free hop, skip, and jump from parking lot to office door, January 2011 would find us working out of a medical building reeking of disinfectants and cleaning products instead of coffee and popcorn.

The other option is a gradual shift to a membership practice. Many dollars short of a concierge version which requires an annual fee of $1,000 or more, this concept involves a much smaller cost, say $25/month, which not only brings in the sort of yearly revenue that covers property taxes and hazardous waste disposal, but also benefits members with 24/7 ask-a-nurse access, wellness and nutritional counseling, as well as e-mail access and same-day appts. While there is no requirement to join in order to remain our patients, this nominal-ish sort of fee would be each patient's affirmative vote that small practices reap big satisfaction for all.

Obviously, my language screams of my preference, but we worry, rightly, about 'willingness to pay.' Particularly in light of the new health care legislation, there is increasing belief that health care is a right for which one should not have to pay much at all. Our time frame here is short in terms of decision-making; I'd love to get your opinion--especially from my patients but honestly, from anyone who'd like to chime in--about what you'd like your future relationship to be with us or whomever your PCP may be. Feel free to use my e-mail address or to leave anonymous observations.

Sunday, April 04, 2010

Other people's motives--How do we judge?

As soon as I learned to drive, my parents instructed me to 'lock your doors' when driving at night or through 'certain neighborhoods.' When I moved to Cleveland for internship, my uncle advised me to forget locking my doors in those riskier parts of that city but rather DO NOT drive through them under any circumstance, night or day.

With such precautions drummed into me at an impressionable age, I remain ever alert to shady pedestrians at downtown intersections. To my son's dismay, I'll lock the doors if I judge a sketchy passerby likely to open the door and grab my purse or, worse yet, to hop in the passenger seat and abscond with me and/or my car (Oh like that would ever really happen Mo-om!).

Call me paranoid or over-sensitive, but never deny that I have a highly trained right temporoparietal lobe aka the temporoparietal junction (TPJ). Scientists now know that this section of our brain, seated just above the right ear, is vice president in charge of judging other people's motives. Here's how they figured this out.

Patients with brain damage to the TPJ are known to have trouble inferring moral intentions. Social scientist Liane Young and colleagues at MIT decided to test normal subjects with their TPJs intact and turned off. Now who on earth would volunteer for an experiment that involves turning off a section of their brain? Perhaps MIT undergrads feel they have neurons to spare.

Anyway, Young and company used "transcranial magnetic stimulation (TMS), a technology that uses a tightly focused magnetic field to temporarily disable individual regions of the brain." Before and after a magnetic zap to their TPJ, the volunteers read scenarios in which subject A accidentally kills subject B or narrowly misses killing the hapless B on purpose. As opposed to their righteous pre-TMS states of mind, the group post-TMS were much more forgiving of attempted murder.

So what? Well, we know that the TPJ continues to mature through adolescence and beyond, so someday my son will 1) be more forgiving of my heightened sense of other people's malevolent motives, 2) will lock his own darn doors, and 3) will make better choices in general (I hope). In addition, the MIT social scientists are now turning their attention to the TPJs of persons with autism spectrum disorders, conditions in which the ability to 'read' other people is seriously impaired.

Wednesday, March 24, 2010

Pain perception

Some people are stoic and some aren't. … Maybe there's a plausible biological reason for that difference.
---Dr. Geoffrey Woods, Medical geneticist, Cambridge University

My patient's face was all pinchy with pain, an expression not generally seen in a 20-something year old lady. She'd visited Walmart the previous day (an outing that always makes me pinchy with impatience as my husband meanders through every last aisle). While there, she bent over to examine some wonderful find and skewered her forehead on a metal hook.

"Ew," you're thinking, which is what I would've thought if there had been a ragged tear in her face, or any kind of mark whatsoever. Her forehead, however, was completely smooth and unblemished.

"So," I said, "where did it snag you?" And I touched the indicated spot, sending her recoiling in pain, pinchier than ever. The area wasn't red, abraded, swollen, or bruised. I told her that while I appreciated she was in a lot of pain, my examination indicated no serious injury. I then assured her that her pain should diminish greatly in the following days.

As usual, when confronted with pain reports that seem to far outstrip apparent injury, I wished I could walk a mile in her forehead. What was she really feeling in there? Real pain, real drama, a need for sympathy, worried sick, or what?

Dr. Woods and company also wondered why humans demonstrate such a wide spectrum of pain perception. They already knew from previous research that three rare mutations in the SCN9A gene are a serious problem insofar as such genetic changes can cause persons to be either too sensitive or completely oblivious to painful stimuli. In the first case, the faulty SCN9A gene allows sodium ions to flood through channels in the surface membranes of cells in the central nervous system. As a result, these neurons painfully overfire in response to minor daily occurrences such as bumping a shoulder against a wall when taking a corner too close. At the opposite extreme, SCN9A gone haywire in a different way prevents the perception of pain altogether. Affected persons, consequently, receive no signals say from a fracture or sprain and, therefore, have no cue to stop moving and get off the injured joint.

The Cambridge team went looking for subtle, more common mutations in the SCN9A gene, namely substitutions of a single nucleic protein (SNP) in the gene's sequence(1). They studied a group of subjects with osteoarthritis of comparable severity to see if these SNP variations correlated with differing levels of pain perception. One variation present in a small subset of the group was indeed associated with the highest pain perception in those who carried it. The scientists then looked in other people with other common pain syndromes such as sciatica and lumbar disk disease, again finding that "the statistical link between having the rare SNP and feeling more pain was impressively strong." In other words, those persons with lower pain thresholds were significantly more likely to have this particular SNP variant.

The researchers found that just under 20% of their subjects carried one copy of this particular SCN9A mutation, but only 2-3% had two defective copies, and these were the people most likely to react strongly to their painful conditions. Further testing suggested that this mutation renders them incapable of squeezing their sodium channels shut so wave after wave of pain news just keeps rolling in.

Obviously, this genetic test is not available for clinical use, and there's nothing to be done about it anyway. Those of us in the medical business and everyone involved in the sympathy business can now appreciate, however, that some persons are hard-wired for more pain than others; for such persons, that 'stiff upper lip' advice may be harder to follow. And my hapless Walmart shopper was back two days later, her forehead no longer tender but her head now clamped in the vise of a secondary tension type headache brought on by scrunching her brow over the original hooking.
1) Woods, GC, et al. "Pain perception is altered by a nucleotide polymorphism in SCN9A," Proceedings of the National Academy of Sciences.

Sunday, March 21, 2010

Probiotics and clostridia difficile

I noticed a disturbing item in this a.m.'s paper--diarrheal illnesses caused by clostridia difficile are increasing in number and virulence. This serious intestinal condition is now more common than disease caused by methicillin resistant staph aureus aka MRSA as a cause of serious hospital-acquired infections.

C. diff tends to be a nosocomial infection, i.e. one that results from medical treatment, specifically, in this case, from the use of potent antibiotics. C. diff is not normally present in the gastrointestinal tract but moves into the territory after antibiotics kill off the good little bacteria who normally call our colons home. Increasingly virulent strains of c. diff can cause life-threatening colitis which occasionally requires emergency surgery, sepsis (overwhelming infection), and death.

While community-acquired C. diff rarely causes serious illness, it can run on and on in unpleasant and debilitating ways. Research suggests that the use of probiotics --preparations available over-the-counter that contain live bacteria of the intestinal-friendly variety-- can decrease the risk of antibiotic-related diarrhea including C. diff. While the use of these supplements is not recommended as the sole treatment of the condition, they may in fact promote a healthier micro-environment in the colon which increases resistance to a C. diff invasion.

I often recommend probiotics to my patients starting antibiotics for acute bacterial illness. I was interested, therefore, in a recent review by Consumer Lab of the various products on the market. Consumer Lab conducts testing on various over-the-counter nutritional supplements, including a review of the scientific literature for supporting information on their legitimate uses as well as a summary of testing results for purity and truth-in-labeling. Their nominal annual fee is well worth the price for consumers interested in using such products.

In the "you can't always get what you think you do" world of label-reading, I discovered that two of the probiotic products I recommend by name--Culturelle and Align--did not deliver the promised organisms per capsule. There is quite an in-depth discussion of probiotics on this site, and I recommend it to you as vital information concerning the increasingly perilous world of microbes, anti-microbes, and the pro-microbes that defeat them.

Sunday, March 14, 2010

Cigarettes and cognition

I was just visiting Mauigirl's blog; she's been struggling with the declining health of her aging mom. Between a hospital stay followed by a move to a nursing home, MG's mom has been one month without a cigarette. MG notes that research suggests that nicotine has favorable effects on cognition and wonders if the notable change she's seen in her mom's mental functioning might be, in part, due to the lack of nicotine. I've often told my patients that people like to smoke for good reason, that, in fact, cigarettes are not only calming but wonderful for concentration and focus.

Cigarettes--or rather the nicotine within--may be neuroprotective. While I'm all in favor of saving the brain, I won't be prescribing cigarettes to anyone wishing to keep their marbles. But there's interesting evidence suggesting that nicotine is not without its benefits to brain.

Scientists have noted that persons who smoke have lower rates of neurodegenerative diseases such as Parkinson's and Alzheimer's. Korean rats were encouraged to smoke via an automatic smoking machine. After four weeks of 'automatic smoking' for ten minutes per day, the rodents were significantly protected against the seizure-inducing effects kainic acid. Apparently, if you want to dip your head in kainic acid (whatever that is), you might consider smoking too.

Kainic acid exposure aside, researchers have other theories why nicotine is good for the brain. The brain is full of nicotinic acetylcholine receptors; activation of these cellular switches has a number of beneficial actions. This effect of nicotine has been compared to "turning up the volume of a radio signal." As acetylcholinergic brain cells are in charge of memory and executive functioning--i.e. planning and carrying out complex tasks--turning up the volume is a good thing. No wonder people enjoy the clarity and focus of a Marlboro.

Neuroscientists at the University of Florida have discovered still another mechanism as to why nicotine might promote brain health. They found that nicotine prevents overactivation of little neuron-supporting cells called microglia. When the microglia get all hot and bothered with overactivation, they can set off events toxic to their neuronal buddies unto death. Well who wants that? Check out what Florida's Dr. Douglas Shytle has to say about that:

Microglia can be your best friend or your worst enemy depending on the signals they receive. The analogy is that you keep talking to them they will take care of you, but if you stop talking they are more likely to get aggressive and have a toxic effect on the brain.

If all this makes you want to take up smoking again, hang on. The Southern investigators realize that they must "now develop drugs that mimic the beneficial action of nicotine without its unwanted side effects."

Sunday, February 28, 2010

Occipital neuralgia and Lyrica

Maureen periodically flinched while we talked as searing pain shot up the back of her head. Short but severe, these jolts of pain were diagnostic of neuralgia, a condition wherein a single nerve-- the greater occipital in this case-- seizes with pain. As a result, my patient was experiencing show-stopping discomfort from the base of her skull over the back of her head, sometimes on the left and other times on the right.

She spent her days hunched, like so many of us, over a computer and desk. On standing, she carried her head forward and her shoulders rounded reflecting the anterior thrust of her daily activities. All this was aggravated by breasts so large that her bra straps had dug permanent grooves in the top of her shoulders.

No easy fix for Maureen. I assumed that she, like many people, would not embrace the idea of medication, particularly over the long haul. I told her my plan--a short term fix to improve things quickly with a medication called Lyrica coupled with a larger plan to improve her posture, strengthen her supporting abdominal and back muscles, and perhaps consideration of breast reduction surgery.

Lyrica (pregabalin) is indicated for the treatment of seizures, diabetic neuropathy, nerve pain following seizures, and was recently approved for the treatment of fibromyalgia. Its use for occipital neuralgia, therefore, is 'off-label' but experience confirms that it soothes hypersensitive nerves no matter their location. Unfortunately, it's not without side effects, causing sedation, dizziness, and dysequilibrium, but its analgesic benefits can far outweigh these problems in patients whose daily lives are completely turned upside down by pain.

Maureen headed out with samples plus referrals to a physical therapist and a plastic surgeon and a written copy of the plan. Here's the phone message I received the next day:

Patient doesn't want to take Lyrica over a long period of time, was looking for a quicker working solution to pain. Advise.

Argh. Message back to patient:

Lyrica is a quicker working solution. Physical therapy, posture work, and possible surgery is the longer term answer.

The next message from Maureen sent the following day:

Pain free for the first time in weeks!

Friday, February 26, 2010

Fear Factor

"Get over it!"

Those who fear not are fond of telling the overwrought amongst us to face our fears and move on. If you're a hot reactor who barely copes with scary movies or prefers to watch TV's "24" through slits between your fingers, here's some interesting news. You may, in fact, be genetically wired to startle and gasp and burst into tears.

Anxiety is a good thing, an unpleasant emotion that warns us against potential danger. Anxiety run amok can be a show-stopper--ask anyone who suffers from phobias and struggles with fear of crowds, riding in cars, flying in airplanes, visiting the doctor, or other situations that most people plunge through with nary a second thought. Neuroscientists are hot on the trail of the biological bases for various behaviors and the genetic codes that determine why we act the way we do.

Investigators at Weill School of Medicine in New York noted that mice with a small change in the gene sequence for a brain chemical called brain-derived neurotrophic factor (BDNF) are wimpy little things. BDNF is an important protein in mice and humans alike that supports brain cells to thrive and multiply especially in the brain regions responsible for learning and memory. These scaredy mice have DNA coding for BDNF that is just one molecule different from that of their intrepid colleagues. The cringing rodents with genetically skewed BDNF are not only anxious but known to have difficulty overcoming their fears and are resistant to treatments such as Prozac that decrease anxiety.

Dr. Fatima Solimon and her fellow psychobiologists at Cornell brought human and mouse volunteers with both normal and variant BDNF down to their lab for a psychological workout. Fear responses are prone to 'extinction' when subjects are repeatedly exposed to the threatening stimuli without any consequences. Psychologists use such exposure therapy to help people overcome phobias. Mice freeze and humans sweat when fearful, and the researchers checked how long it took subjects to quit freezing and sweating as correlated with their genetic type. In addition, the humans underwent functional MRI scans looking for high activity in brain regions known to be associated with both fear as well as the ability to master emotions through conditioning.

Their experiments confirmed that humans with variant BDNF coding have no problem learning that which is threatening but have a terrible time unlearning the cues that first signified danger. The people kept sweating and the mice kept freezing in their tracks long after the fearless subjects with the hardy BDNF were dry, calm, or scampering about their cages. And MRI scanning confirmed that those with the anxious variety of BDNF had trouble turning off their fear centers and turning on their learning centers.

Solimon and company whose findings appeared in a January, 2010 issue of Science Magazine are hopeful that their findings may ultimately translate into better understanding and treatment of persons with anxiety disorders, phobias, and PTSD. Those who suffer so are indeed eager to get over it.