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.