...the only funeral you can be sure your physician will attend will be that of his or her own.
--George Lundberg MD, Editor-in-Chief of MedGenMed

Not me. I try to attend all the funerals of my patients who die, every one. I not only love a good funeral, I need a good funeral to come to grips with the loss of these dear people who trusted me with their life...and death.

J was a fifty-something year old lady who had a chronic pain thing that defied explanation or treatment. A bright psychologist, she was her own best advocate. At the beginning of each visit, she would hand me a typed agenda for the appointment. We often covered her latest round of specialist visits which ultimately included a complete evaluation at the Mayo Clinic. A dear woman, but I dreaded her visits, in part due to our mutual frustration over the lack of progress.

She died suddenly and unexpectedly one day while napping in her rocker. Her funeral was packed with people from varied walks of life. The music? J's own recordings, her voice so beautiful it makes me shiver still to recall its full-bodied beauty. Did I know she sang? Sadly, I did not.

E, who struggled in the end with a vicious cancer after years of diabetes and congestive heart failure, was stunning in her pictures displayed at the funeral, pictures from a much younger time before I ever knew her. At K's funeral, a poster board displayed the glorious sunrise pictures shot by her young nephew on the day of her death BEFORE he even knew she was gone. At D's funeral, I met her baby granddaughter whom D met briefly at the end of her life. At MJ's funeral, his family came back to where I sat and insisted I move up to the family row. R's funeral was hardest of all--she had died of an overdose of medication I gave her to ease her intractable pain.

I would have missed an important part of my patient's journey here on earth if I'd missed a single one of these and other sad good-byes.

A 17th century pitch for exercise:

Better to hunt in fields for health unbought
Than fee the doctor for a nauseous draught.
The wise for cure on exercise depend;
God never made his work for man to mend.

--John Dryden

Ziana

One of the benefits of aging is the end, finally!, of acne. That doesn't mean that zits are not a topic of discussion in the household here, so I read with interest that a new twofer gel is available for those of us young enough to still breakout.

When I got my first zit, unkindly pointed out by Susan Millicent on a 6th grade field trip, the best my pediatrician had to offer was a suggestion to leave soapsuds on my face for a minute each evening. Red and scaly became the order of the decade, whether from soapsuds, sunlamps, or Retin-A. No matter the cause, though, red and scaly always preferable to pustules.

Enter lyrically labeled Ziana. Google Ziana, and you will find she will read your Tarot cards OR it will cure your acne. Per Dr. Wortzman of Medicis Pharmaceuticals, the gel version was more effective and produced less erythema and skin scaling as well as patient-reported burning and itching in clinical trials than use of its component parts. "Very little skin irritation," says he.

Ziana combines the antibacterial punch of topical clindamycin with the zit-digging power of tretinoin (Retin-A). Pricey though per one dude on acne.org:

Well guys...ixnay on the Ziana. I just found out that not only does it cost $250 WITH the $35 rebate the derm gave me, but that my parent's health care plan won't cover it because it's too damn expensive!!!

Sick Lit

Whatever you've got, chances are good that someone else has not only been there, suffered that, but that they've also written about it, painted it, or filmed it. For an extensive catalogue of hundreds of works of art and literature with medical connections, check out The Literature, Arts, and Medicine Database.

Chlorthalidone for blood pressure

I'm not joking about this issue. It is easier for doctors to write HCTZ than to write chlorthalidone, even though study after study has shown that chlorthalidone is a better drug...if you want to prescribe chlorthalidone, you have to write out all 14 letters.
---William Elliott, MD Rush Presbyterian St. Luke's Medical Center in Chicago

So are we docs really that lazy that 10 letters come between us and better care for hypertension? Sort of, that and habit--always have written for the water pill HCTZ (hydrochlorothiazide) and always will. Also the lack of recent literature on the superiority of chlorthalidone (man I don't even like typing that sucker) AND the fact that all the standard twofer drugs for hypertension as in two drugs in one tablet are HCTZ plus whatever. Except for Tenoretic which is now known as atenolol/chlorthalidone which is even a bigger drag to write out.

At least three large studies have shown that patients on CTD (there, see, it can be abbreviated) have better outcomes than those on HCTZ with respect to blood pressure control and, more importantly, 58 percent less coronary heart disease and 41 percent fewer deaths.

Am I going to start writing for CTD? Not only does that mean all those extra letters all day long, it means pulling out the other med (lisinopril, Diovan, Cozaar to name a few) and writing out all those letters in a separate script along with the one for CTD plus asking patients to cough up an extra co-pay as the twofer becomes two.

Where did humans get the extra energy to support their large brains?

Actually, I've been wondering some busy afternoons where I'm going to find the energy to hold my head up much less support the brain within. Harvard University primatologist, Richard Wrangham has been wrangling, however, with this long-standing riddle in human evolution, namely what allowed Big Head Todd and friends to rise from the lower primates in order to paint in caves, play rock music, and blog on the Internet.

One word, per Dr. Wrangham: Cooking. Big old brains require big time energy; a resting adult's noggin uses 25% of his/her total energy output. If you have to spend the day picking nits out of each other's fur for supplemental protein, you hardly have time to work with your opposable thumb or to invent Folsom points.

On the other hand, if you cook the nits you pick, you in effect predigest your food, so less energy is spent on digesting and more sugar is available to the brain. Per Wrangham, cooking paved the way for the dramatic expansion of the human brain. He notes:

No human foragers have been recorded as living without cooking, and people who choose a 'raw-foodist' life-style experience low energy and impaired reproductive function. The possibility that cooking is obligatory is supported by calculations suggesting that a diet of raw food could not supply sufficient calories for a normal hunter-gatherer lifestyle.
_____

Wrangham R etal. Comp Biochem Physiol A Mol Integr Physiol. 2003 Sep;136(1):35-46.

More produce does not produce more cancer protection

No more bolting more blueberries which, when eaten in a hurry and underchewed, come out looking about like they did going down. Apparently the daily five as in five servings of fruits and veggies is good breast cancer prevention, but more is not better.

While my medical partner is a star when it comes to packing a little lunchbox full of baby carrots, cherries, grapes, etc., my produce produces mold and turns to slime in my crisper bin. I was pleased, therefore, to read the results from this study of 3,000 breast cancer survivors. One group followed the five per day formula while the other half were schooled in the more the merrier philosophy of vegan fare. There was no statistically significant difference in breast cancer recurrence between one group or another.

Lead author John Pierce of the University of California, San Diego concluded "You don't need to go overboard." He did note that daily exercise remains clearly associated with better outcomes in breast cancer survivors. And, as Susan Gapstur of Northwestern University adds, "At the end of the day, it's never wrong or bad to eat healthfully."
_____

Pierce JP et al. JAMA July 18, 2007.

Courtesy waves

I wrote two days ago about warm glow motives. This warm and fuzzy feeling occurs when the ventral striatum deep within the brain lights up with activity as you do unto others as you would have them do unto you.

Well what better way to follow the Golden Rule than to allow some chump trying to get out of a driveway a chance to enter your lane of traffic. Life's contentious enough, and little traffic niceties might make everyone's day a little easier. I've discovered, however, no electrical hum generates out of my ventral striatum unless said chump gives me a little wave as he zips in front of me. No wave, no glow.

If courteous drivers have no dopamine flowing out of the ventral striatum, road rage follows. Remember to give a little sign to your fellow drivers that you appreciate their help.

Where's the Acomplia?

This drug, generically known as rimonabant, is an endocannabinoid receptor blocker. Do you recognize that word in there--cannabis as in marijuana?

All that is pleasurable in an illegal sort of way mimics some function in the body that causes good vibrations through the central nervous system. As some of you who once inhaled your way through your youth may remember, marijuana not only feels good but causes enormous craving for and pleasure in eating. Block those cellular receptors that hook up with marijuana, and research suggests you can mash the munchies and lose the weight.

Acomplia looked like just what the doctor ordered for those expanding midlife waistlines resulting from years of overeating. Studies suggest that not only can weight be lost, but the metabolic syndrome, a dangerous body state contributing to diabetes and heart disease, can be reversed as well through use of this drug.

Unfortunately, we've got endocannabinoid receptors for more reasons than just enjoying the occasional funny cigarette. Data now suggests that blocking those feel-good receptors increases risk of depression and suicide. The FDA continues to investigate these unwanted outcomes of the drug, and Acomplia's approval is not expected in this country any time soon.

The glow of giving

My friend J enjoys paying for the person behind her in line at the Starbucks drive-through to the everlasting delight of her daughters. If she carried a function MRI machine in her van, a recent study out of Oregon(1) suggests that we could see the girls' brains light up with philanthropic pleasure.

This neuroeconomic study stuck volunteers in just such a machine and scanned their noggins while they played a 'dictator game.' The subjects received $100 and then made decisions about whether or not to donate money to the game's food bank.

The investigators correlated the subjects' self-reported satisfaction of giving with activity in their ventral striatum, a structure deep within the brain known to produce a feel-good sort of reward response. The area was fired up whether or not the giving was voluntary vs. mandatory taxed transfers, but glowed hotter when the altruism came from the heart and not the government.

The researchers dubbed this response the warm-glow motive. This may explain, they say, the economic puzzle: If money is a good, why are people willing to give it away?
_____

Harbaugh WT et al. Science 316 (2007)1622-1625.

Posterior tibial tendon dysfunction

Overstretched and going to ground. Doesn't that about sum up this aging thing? Well here's another thing going wrong in the half-century set.

The posterior tibial tendon basically comes from the calf around the back of your inner ankle bone where it stretches over the inside edge of the foot and holds the arches up. Injure yours through overweight, overstress, or just plain too many years of living, and the little darling stretches or tears and poof! arch hits the floor. The loss of the arch stresses your ankles and drags your knees inward along with the feet and the ankles. The result? Foot pain, lateral knee pain, and an inability to stand on your toes.

Shoot, who knew? If you're wondering about the state of your arches, check out your wet footprint. Or look for the "Too many toes sign." Get a buddy to stand behind you and look at your feet. A positive 'too many toes sign' is present if more than the pinky toe can be viewed from the back. This toeful look is created by the outward splay of a foot caving inward due to a fallen arch.

And it's not necessarily just the midlife women suffering from PTTD. The other day, a phys.ed. teacher, male, 30 y.o., came in complaining of right ankle pain. This developed after he walked all day long on a trip in flip flops (no arch supports in those) carrying a backpack. Sure enough, this young fellow had 'too many toes' on his right foot and had injured his posterior tibial tendon through overuse/misuse during his daylong trek.

Practicing what I preach

Well it wasn't exactly stalking a saber-tooth tiger across the tundra. But it was a whole lot like air-boxing to overloud music with a bunch of women half my age.

I've signed up for a trial membership at 24-Hour Fitness, and went today to their Turbo Kickboxing class. Very humbling--I consider myself fit enough, but these women, especially the buff little instructress, have taken fit to entirely new levels.

Here's wise words by FW Booth from the Journal of Physiology:

In sedentary cultures, daily physical activity normalizes gene expression towards patterns established to maintain the survival in the Late Paleolithic era.

The cute little membership rep asked me what my goals were for my 24 Hour Fitness work-outs. I told him "Staying alive," and I meant it.

A bad pancreas day

That would be yesterday. Three patients in for discussions on their newly diagnosed type 2 diabetes, and two more for the 'you're on the way there' talks.

I gave them all my 'right genes/wrong eon' lecture. Basically, here's the scoop when our 'Ice-Age genome' meets the 21st century:

• The human genome evolved within an environment of high physical activity.
• Our cultural evolution has proceeded too rapidly for genetic accommodation.
• This mismatch between biology and lifestyle fosters development of chronic disease such as diabetes and heart disease.

In other words, our physiology was perfected during the Ice Age for cold, famine, and high activity. Now, we're not cold, we're not hungry, and we're triumphant if we park the car at the far end of the grocery store lot before we go 'hunting' through the aisles to supply our family with food.

Our bodies, meanwhile, are storing our extra calories for the coming famine which never comes. All that fat to waist sets up a metabolic nightmare that takes high intensity physical exercise to unravel. Those of us whose ancestors were clever enough to take down mammoths (and that would be all of us) are most likely to go down this road.

This diabetic news was not news to any of my patients with whom I spoke yesterday. They all had screaming warning signs for years on their lab printouts and around their midriffs. If you have elevated triglycerides as in more than 150 on a fasting sample, an abnormal fasting blood sugar (100 or above), and/or your waistline is the first part of your anatomy to walk through the door, don't wait for a bad pancreas day, eat less and move more now.

MD: How's your blood pressure been?
Pt: Good, as far as I know.

This means patient hasn't checked it.

MD: How often are you getting out for exercise?
Pt: Not as often as I should.

This means not at all.

The upside of bipolar disorder

I had a delightful young lady in my office today. She caught my eye in the waiting room even before I called her name due to her engaging smile, the kind of person you'd like to hire to work your front desk and win over your public.

She, however, was not particularly happy today, having been recently diagnosed with bipolar depression. Despite her successful career in public relations, she worried that her future would be bleak due to her condition.

I assured her the upside of bipolar was the creative energy and outgoing personality she brought to her life, her work, and her relationships, all qualities easily visible during our brief encounter. I just e-mailed her the following quote from Dr. Peter Whybrow of the Department of Psychiatry and Biobehavioral Sciences at UCLA. He is responding to the question as to why genes for bipolar disorder would persist in the human genome:

I think there is much in the energy and excitement of what one considers hypomania* that codes for excellence, or at least engagement, in day-to-day activities. One of the things that I've learned over the years is that if you find an individual who has severe manic depressive disease, and you look at the family, the family is very often of a higher socioeconomic level than one might anticipate. And again, if you look at a family that is socially successful, you very often find within it persons who have bipolar disease...

So I think there is an extraordinary value to those particular genetic pools. So you might say that if you took the bipolar genes out of the human behavioral spectrum, then you would find that probably we would still be -- this is somewhat hyperbolic -- wandering around munching roots and so on.
_____

*Hypomania is the high energy state short of outright mania that can be seen in persons with bipolar tendencies in the course of their normal functioning

Builds stronger bodies 2 ways

If I had it to do over again, which thankfully I do not, I would take two specific supplements during pregnancy along with the old standby prenatal vitamin: vitamin D and omega-3 fatty acids.

The former improves bone health in a woman's offspring. British researchers studied nearly 200 children for bone mineral content at age 9 years correlated with their mother's vitamin D levels during pregnancy.(1) Those with D-ficient moms (defined as blood levels of 25(OH) vitamin D <11mcg/L) had significantly lower lumbar spine bone density compared with children of D-replete moms (vitamin D >20).

As most women get most of their bone mineralization in place by age 20, D supplementation in pregnancy can improve peak bone-mineral acquisition, perhaps reducing the risk of osteoporotic fractures in later life.

So D covers the bones, and omega-3 fatty acids improve developing brains. We're all fat-heads insofar as 60% of our brain is made up of lipids. Intake of DHA or docosahexaenoic acid during pregnancy, especially during the final trimester, pumps that baby's brain full of DHA which becomes an integral part of the neuronal or brain cell membranes. Rat moms rave about the cognitive and attentional abilities of their DHA-primed offspring.(2) Evidence suggests that such a strategy works well for humans too.
_____


1. Javid MK et al. Lancet. 2006;367: 36-43.
2. Levant B et al. Lipids. 2006 May;41(5):407-14.

No MAM

There are so many reasons to dread the onset of menstruation--crabby, irritable, teary ones. For many women who suffer from migraines, those plummeting estrogen levels associated with the start of the flow also bring on a menstrually associated migraine or MAM.

One strategy to duck the MAMs has been to use birth control pills continuously over three cycles, cutting a year's load of periods from 12 to 4. Several pill types are currently available specifically designed for this purpose, including Seasonique which includes a small amount of estrogen in the pills taken during the quarterly week off.

Endo Pharmaceuticals has just completed another Phase III clinical trial on Frova, an Imitrex-like drug typically used to rout a migraine in the early stages. When Frova is taken twice daily beginning three days before the usual onset of a MAM and continued for six days total, study subjects experienced less intense MAMs, or no MAMs at all!

Thyroid dosing: Too low is too slow

I definitely learned that initiating thyroid replacement therapy in persons profoundly hypothyroid should be done slowly and carefully to avoid heart complications. I never learned, however, the proper starting dose for your average, semi-sluggish, hypothyroid woman. This is important as statistics suggest that 15% of adult women ultimately become low in thyroid.

Leaving no problem left unstudied, Dutch docs conducted a study that compared a full starting dose of levothyroxine (1.6mcg/kg which is the equivalent of a .1 mg Synthroid or Levoxyl tablet for a 130 pound woman) to a weensy, sissy little dose of .025 mg with respect to the speed with which thyroid levels returned to normal on follow-up testing.(1)

Whether or not the 50 study participants received the big deal or the teeny bit, no one complained of palpitations, chest pain, nor keeled over dead of a heart attack.

The notable difference between the two groups, however, was that nearly half the full dose group was euthyroid (normal levels) within 2 months of the study's start but only 3 in the low and slow bunch had achieved normalcy by then. In a way, it matters not one way or the other as quality of life with respect to symptoms improved at the same rate in both groups.

On the other hand, each dose adjustment requires a trip to the lab to check levels followed by 3 to 4 frustrating calls to the physician's office to get the results and get the new prescription called in, so aggressive dosing may work better for all in the short and long run.
_____
Roos A, et al. Archives of Internal Medicine 2005;165: 1714-1720.

I recently had a slim and fit sixty-something year old lady come in for a discussion on her elevated cholesterol. While her total and LDL-cholesterol were notably high, her protective HDL-cholesterol levels were elevated as well in a satisfying sort of way.

The first step in determining whether or not she should be on cholesterol-lowering meds involved totaling up her risk factors for coronary artery disease according to guidelines issued by the National Cholesterol Education Program(1):
__________

Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals

* Cigarette smoking
* Hypertension (BP greater than or equal to140/90 mmHg or antihypertensive medication
* Low HDL cholesterol (<40 mg/dl)*
* Family history of premature CHD (CHD in male first degree relative <55 years; CHD in female first degree relative <65 years)
* Age (men greater than or equal to45 years; women greater than or equal to55 years)

* HDL cholesterol greater than or equal to60 mg/dL counts as a "negative" risk factor; its presence removes one risk factor from the total count.
__________

According to our calculations in her situation, she had zero risk factors as her HDL-cholesterol of 87 canceled out her age of 62. Her goal LDL-cholesterol was less than 60, and the recommended level at which to use medication was greater than 190.

Her LDL-cholesterol was 197. She, as so many people are, was reluctant to start drug therapy. Off she went, instead, to Colorado Heart & Body Imaging for a $395 CT scan of her heart. The news was not good--she had a fair amount of calcifications in her coronary arteries, correlating with more plaque in those vessels than 90% of women her age.

She started treatment with Lipitor yesterday.

_____
1. See NHLBI, ATP III At-A-Glance for the complete algorithm.

Physician Self-disclosure

Rochester MDs wondered about the extent to which primary care docs take the Enough about you, what about me? attitude during office visits. In addition, they investigated whether or not physician self-disclosure (MD-SD) has a positive effect on patient/doctor interactions(1).

They analyzed 113 undisclosed 'standardized patient' visits with 100 volunteer physicians for the number and content of MD-SDs. One-third of the investigational visits contained an MD-SD. Of these, 40% were unrelated to the topic under discussion and a mere 21% of the visits returned to the previous conversational thread after the MD burst in with his/her information.

Whoa, this is sobering food for thought. I certainly have been known to bring up personal or family information when I feel it is pertinent to the visit at hand, particularly when something about that experience may help the patient to feel less odd about their symptoms or less nervous about trying a therapeutic strategy. In particular, I've brought up my experience with panic attacks while driving on the highway in order to decrease the patient's suspicion that I am easily dismissing their panic-driven symptoms as 'all in their head.'

Occasionally, however, I must admit that I go too far with what I consider a particularly amusing or fascinating story of a personal nature, but always related to the topic at hand. I recall telling myself "Time to shut up and listen," on more than one occasion.

The authors of this article conclude: There was no evidence of positive effect of MD-SDs; some appeared disruptive. Primary care physicians should consider when self-disclosing whether other behaviors such as empathy might accomplish their goals more effectively.

Point well taken!
_____
1. McDaniel, SH, etal. Physcian Self-disclosure in Primary Care Visits. Arch Intern Med. 2007;167:1321-1326

The price of peace of mind

Priceless, I suppose. But nearly $2,000 is what I just spent to attain it.

I was delighted to be approved by my insurance company for a breast MRI as part of my high risk screening. I've mentioned before that dense breast tissue increases the risk of breast cancer nearly six-fold. First of all, dense breasts are extremely difficult to image by mammography which makes cancer more likely to be missed. Plus, dense breasts are caused by increased amounts of glandular and supporting tissue, all of which is more likely to be stimulated into some sort of unwanted, carcinogenic DNA mutation.

Recent information confirms that MRI imaging is much more likely to catch a cancer in a set of dense breasts. Since I happen to own a pair, and I also have a family history of ovarian cancer, I definitely fall into the high risk category.

I was relieved to get the all clear notice from Rose Medical Center's radiology department. I was not so pleased to get the bill from Anthem--$3,682 for the undertaking, over half of it mine to pay. As my medical partner pointed out, Anthem's stance was "Sure get a breast MRI. Get two. We don't pay much of anything on those."

Another less expensive screening test which is useful for dense breasts or really any kind of breast is thermography. Whereas mammograms and ultrasounds rely on differences in density of breast tissue (thus not so good a test for the 'all dense all the time' set), thermograms use infrared technology to find temperature differences in breast tissue.

On average, breasts hang off your chest in a cooler sort of way, showing up in shades of greens to blues on thermograms. Cancers recruit blood vessels early on to fuel their nefarious growth and show up orange to red. Breasts remain thermographically stable over time, so yearly thermograms are one more way to screen for cancer.

One more reasonably-priced way that is. I have gotten thermograms at Pristine Health in the Denver Tech Center for a mere $195. I picked up a price list from Colorado Heart & Body Imaging in Cherry Creek on Friday--thermography (called a Sentinel BreastScan by them) is merely $145!

Coke for breakfast?

I spend a lot of time asking people about their personal health habits, and this one always astounds me. Lots of people drink coffee in the morning, and, fortunately, coffee has been cleared of such awful consequences as pancreatic cancer and heart disease. Instead, recent evidence positively links its consumption with a decreased risk of diabetes, Parkinson's, and Alzheimer's disease.
.
Some people don't like the taste of coffee, and I don't entirely trust this group. In place of it, they might start the morning with tea (that's good!) or soda. That's bad, really bad.

Wrapping their hands around a comforting, chilly can of Mountain Dew, these misguided souls get their caffeine hit along with the equivalent of 1/4 cup of sugar. Worse yet, they are setting themselves up for ATHEROGENIC DYSLIPIDEMIA.

Now there's a little something you could live without. A cholesterol profile so destructive that they couldn't just call it high cholesterol, but rather a fancy name meaning deranged blood fats that actively promote atherogenesis or the birth of nasty, cholesterol-rich deposits on the blood vessel walls.

Atherogenic dyslipidemia is a triad of bad actors: high triglycerides, low HDL-cholesterol, and small, dense particles of LDL-cholesterol. While labs do not routinely measure the size of your LDL particles, if you've got the first two, rest assured you've got destructive little LDL particles. (for an explanation of LDL particle size, see Bullets to Beach Balls.

The trouble with soda and many other sweetened drinks is fructose, a corn syrup derived sugar. It's sweeeter and less expensive than sucrose making it an attractive additive to popular drinks. And overweight persons experimentally persuaded to drink a lot of fructose-sweetened drinks took their normal cholesterol profiles to atherogenic dyslipidemia within two weeks of having their way with all that free soda.

Atherogenic dyslipidemia not only raises risk of heart disease, it also promotes central obesity (wearing your weight front and center like an unwanted late life pregnancy), the metabolic syndrome, and diabetes.

I find myself urging patients to drop the pop and brew some coffee instead for their first drink du jour.

This was a big year for coughs. And a big year for big coughs, muscle-straining, sleep-robbing, gagging, back-twisting coughs that went on and on for weeks.

Studies suggest that much of what makes adults cough through the winter season is pertussis or whooping cough, the so-called childhood disease that's not just for children anymore. We now know that the final booster shot administered to teens against diphtheria, tetanus, and pertussis is not a lifelong boost against this disease that causes the cough from hell.

The next time you get a tetanus shot, sign up for the new version that includes protection against pertussis. If you're not so sure whether or not you want to get a shot against a disease that may well rob you of weeks of peaceful sleep and quiet work-days, consider this from Richard Irwin, MD of the University of Massachusetts Medical School:

While kids could die from pertussis, adults feel like they're going to die.

For more info, check out Adacel.

The adenoma-carcinoma sequence

Colorectal cancer is the 2nd most common cancer in developed countries. A person's lifetime risk of ending up with this tumor is 1 in 20. Virtually all colon cancers arise from a pre-existing polyp, a phenomenon known as the adenoma-carcinoma sequence.

So here's the deal on colonoscopies. Much as you do not want to go through the icky prep, and much as you do not want someone touring your colon via a tube stuck up your backend, the fact is that colonoscopies are one of the most effective cancer screening tools we have. If a polyp (aka adenoma) is found during the procedure, it's removed on the spot.

Adenoma snagged, cancer averted. It's that simple. I've had mine, go have yours.
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Check out the fun at Colonoscopy city!

Greetings create a first impression that may extend far beyond what is conventionally seen as 'bedside manner.'
--Gregory Makoul, PhD, Northwestern University

In the 'what-will-they-study-next' category of medical research, this Chicago group set out via telephone to discover how patients would like to open that first appointment with a new physician.

They found that "415 survey respondents reported that they wanted the physician to shake their hand, 50.4% wanted their first name to be used when physicians greeted them, and 56.4% wanted physicians to introduce themselves using their first and last names."

Well score, score, and score. Been there and do that, all that, every time a new patient arrives at the office. My medical partner and I always troop out to the waiting room to meet and greet. And now its medically proven to work!

Smelling like a doctor

Probably smelling like a doctor means not smelling at all. Maybe a touch of lemon, or a soapy clean sort of scent, but certainly not oh de' garlic.

I've mentioned that I love my supplements, and I love www.puritan.com for ordering my dietary substitutes. Right now they're running a 3 for 1 sale. When I accidentally ordered garlic from them, it was buy 2 get 3. So I now have 1,250 capsules of garlic oil, and dear heaven how this stuff reeks. Puritan's Pride supplements generally get thumbs up ratings on Consumer Lab testing, but I knew that WYSIWYG just from the smell and the aftertaste.

While Consumer Lab reviews are a bit lukewarm about the good of garlic, a glance at the medical literature through a MedLine search is almost convincing enough to get me to take this stuff. Garlic promotes the healthy function of blood vessels, inhibits the formation of those pesky nanoplaques (itty bitty deposits of LDL-cholesterol in the arterial walls), and best of all for me because I personally fear dementia worst of all, garlic prevents neuronal apoptosis which is aging brain cell suicide.

But gad, I just can't do it. I suppose I could chuck these smelly capsules and by the scent-free kind, but instead they sit in my cupboard and I save my neurons with crossword puzzles instead.

Dressing like a doctor, Part III: Eyebrows and Exercise

I've mentioned in two previous posts my difficulties in achieving that look of professional insouciance, particularly when I have zero fashion sense whatsoever.

I recently saw an article on the well-groomed brow, not sure where, Good Housekeeping perhaps? This model had impeccably shaped eyebrows, lush and burnished. I neglected to note how she achieved them, but thought perhaps just a touch of brown color would take mine there.

Think Frida Kahlo with a stethoscope. No one actually was so bold as to ask me what the heck happened to my eyebrows, but then again the only two people who actually take notice of my appearance--Jean at my office and my daughter--weren't there to check the look. I've decided to chuck that look.

In a second fashion foray, I sought a new outfit for exercise class, no more wearing my son's cast-off t-shirts. I found the perfect accessory in the Univ. of Northern Colorado bookstore as I whiled away two days at freshman orientation pretending I did not know my son. For his sake.

A perky little Northern Colorado tee, gray with blue lettering, just the match for my sassy, blue exercise capris. Even if my co-exercisers did not mistake me for a co-ed, surely they'd think me a physician in the know.

Damn, I don't know how the college girls fit in these tees. I bought the large size and spent the entire class today tugging it down in front. I'm going to send the shirt to my daughter and resurrect Mike's hand-me-downs out of the ARC bag.

Dietary supplements

If you've been reading my health news for any amount of time, you know that I am a fan of supplements. I've got that came-of-age-in-the-'60's sort of attitude--got pills? I'll take 'em. Actually, I hope that they will counter-balance my somewhat less than perfect diet, as in this a.m. bing cherries, yogurt, and Krispy Kreme doughnuts. I didn't buy the latter, however, they came free from an imaging facility seeking my referrals. Imaging company bribery calories don't count.

If you also like your supplements, and judging from the patients I speak with daily, many of you do, remember that supplements are not a WYSIWYG (pronounced wizzywig and meaning 'what you see is what you get') situation. The FDA has bowed out of supplement supervision, so these companies could put in floor sweepings and call it alpha lipoic acid if they wanted to.

Enter ConsumerLab.com. Their stated mission is "To identify the best quality health and nutrition products through independent testing." Beholden to no one, they sample a myriad of supplements, then 1) tell you the evidence behind the product, and 2) tell you whether or not WYSIWYG, comparing label claims to actual content.

Let's say that you're one of many who fuss about overloading your liver whose job it is to clear the schmutz you put in your mouth before it poisons your body. Mine, right now, is wringing its liver-spotted hands over big globules of Krispy Kreme doughnuts that would have their way with my blood vessels if left to their own fatty ways.
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In support of your ever-loving liver, you might choose to take Milk Thistle supplements. According to Consumer Lab info., the evidence in support of this supplement is full of mights, maybes, and so-so significance. Nevertheless, they tested eleven brands and found that only two delivered the amount of active ingredient (silymarin) listed on the package. One delivered a bit of lead contamination on the side, but what the heck, your liver will probably take care of it.

There is a nominal annual fee for access to this information which is available on their web-site and regularly delivered via e-mail as well.

Bad news skills revisited

I've just received an e-mail from a reader that suggests my that using the telephone to deliver those ghastly diagnoses is quite simply that...bad news. I think I have a lesson or two to learn from those on the other side of the desk or phone line receiving this information.

If you have personal experience in receiving bad news and wish to comment on the way in which it was delivered, please share it! You can reply here or to my e-mail address judy.paley@femailhealthnews.com.

I'd like to include your stories in an article written for other primary care physicians. These would include only your first name. Let me know if I have your permission to do so.

More interesting facts about fingers

A reader noted in response to my item on finger length, specifically the ratio of Ms. Index to Ms. Ring, that she'd heard of a correlation between this ratio and sexual orientation. Indeed, there are several studies to that effect, the latest one published in the July, 2006 issue of Neurobiology.

Doctors in Zurich knew that longer 4th fingers are associated with higher levels of prenatal testosterone. This embryological hormonal climate influences the developing brain with respect to sexual preference. They measured the ratios of finger 2 to finger 4, and found that the higher the ratio, the less likely the Swiss miss to prefer lesbian relationships.

A previous study out of NYU looked at finger lengths in identical female twins with different sexual preferences. They found that the 2:4 ratio was lower in the lesbian twin compared to her heterosexual sister, suggesting some difference in their prenatal environments because their genetic make-up was exactly the same.

Blood clots and cancer

My grandmother developed phlebitis (blood clots and inflammation in the veins of the legs) in her mid sixties. She was treated for the clots, however clots were treated in the 1960's, and no further investigations were undertaken. Within a year, she was dead from metastatic ovarian cancer.

So when my very healthy (tanned, fit) fifty-something patient came in with tender, swollen veins in her right calf, I thought of Grandma and alarm bells went off. One week of testing later, the results showed metastatic pancreatic cancer. She too was dead within the year.

My Mom always felt guilty that she hadn't pursued further work-up for her mom after those clots popped up. A study in the Archives of Internal Medicine suggests that prompt follow-up wouldn't have helped Grandma any better than it did my unfortunate patient.

Over half a million cancer cases were culled from the California Cancer Registry to identify cases of common malignancies correlated with spontaneous blood clots. While the incidence of blood clots preceding localized cancer was not significantly elevated, the risk of being diagnosed with metastatic cancer post-phlebitis was more than double.

So no guilt here for cancers discovered after the clot-fact. Per the authors, "Given the timing and advanced stage of the unexpected cases, it is unlikely that earlier diagnosis of these cancers wwould have significantly improved long-term survival.

Trust in God...and tie your camel securely.
--Muhammad of Arabia

Medicine can be likened to the strong rope that tethers the wandering camel.
--Shobi Ahmed, JAMA, 10/19/05

From a public-health perspective, if you can
improve the health of 5% of 50 million people,
that's a lot of people.

Keith Norris, MD on inexpensive vitamin D supplements
to prevent diabetes and obesity.

Data from the National Health and Nutrition Examination Survey (NHANES) was analyzed to correlate serum vitamin D levels with the incidence of diabetes and obesity. Those subjects in the lowest quartile of D levels were twice as likely to develop these high risk medical conditions.

Note to my pasty white D-ficient patients: How many more D-tales do you need?

Bad News Skills

Oh right, my son picked up a lot of those in high school. This particular study, however, did not deal with THOSE kind of skills, but rather the skill with which doctors deliver bad news.

The researchers ran a 4-day communications workshop called Oncotalk for medical oncology fellows. These doctors were in the last phase of their training as oncologists, and soon to be cancer specialists who doubtless would face bad news deliveries on a regular basis.

During the 3-year study, the fellows were observed pre- and post- workshop participation talking with standardized patients, as in "I'm not a patient, but I play one during this study." Postworkshop, participants gained an average of 5.4 bad news skills. The number of doctors mentioning the word cancer in bad news encounters rose from a paltry 16% before the skills practicum to 54% after.*

Being a reluctant bad news deliverer on a regular basis, I've given a lot of thought to this. That "C" word cancer is sitting in on the conversation whether you mention it or not, and I think it becomes a bigger presence if left unmentioned. I used to think that delivering bad news on the phone was wrong, then I saw how people freaked out when called by my office staff to come in to discuss test results. No one is calling anyone to come in and hear that their mammogram was normal.

Equally important is delivering good news the instant it is known. When test results come back to our office, they are immediately reviewed for critical information that needs to be conveyed immediately. But good news or bad, there is one anxious person waiting by the phone to hear about those negative scans and those benign biopsies.

*Can you imagine an oncologist NOT saying the word cancer when they tell a person that they have it or that the tumor is now out of control?

Upright Imaging

A new era in MRI comfort:
Walk in,
Sit down,
Watch TV.
--Ad for Fonar upright imaging system

I've ordered a lot of MRIs for patients. I've watched patients hauled out of the MRI screaming, seizing, and hemorrhaging on the TV show House. This past week, however, was the first time I actually had an MRI. I expected the tiny space, but no one warned me about the noise.

The doctors on House usually discuss their sex lives while monitoring their patients' procedures. In fact, no one would be discussing sex or anything else in the vicinity of an MRI due to the racket of the machine. I'd imagined a coffin, but never knew about the jackhammer working just over my head. The earphones and piped-in music are just a pre-procedure ploy of no use whatsoever during the exam.

So now the Fonar Upright advertises itself for my patients uptight. They note their machine allows "imaging a child without anesthesia because the child can sit on his or her mother's lap, imaging claustrophobic patients, and overweight patients, who fit right in...The patient simply walks in, sits down, and watches TV during the scan."

Best of all, apparently, these upright scans can image the back with the spine fully loaded with the weight of the body which creates real-life pressure on squashy discs as opposed to scans done when the patient is lying flat. This enhances the ability of this MRI imaging technique to pick up pain-producing pathology.

Hmm, watching TV, that implies they've also squelched the noise. Maybe patients can watch reruns of House.

Fun facts about fingers

If you're wondering whether or not your male acquaintances are mathematically inclined and interpersonally challenged, have them give you the finger. No, not that finger, rather two fingers--index and ring--and more specifically, check the length of the former compared with the latter. Now of course if you need to measure finger lengths to figure out whether or not your man friend relates well to others, perhaps you'd better measure your own fingers.

In the 'whoever thinks of these studies' category of studies, researchers theorized that the length of the 4th finger, which apparently correlates well with testosterone levels in a man's remote embryological life when he first came to life in his mother's womb, might predict male traits such as strong visual/spatial talents but weak people skills. They measured a host of 2nd:4th finger ratios, and found that those men whose ratios were less than or equal to .98 (meaning 4th finger looms larger than 2nd) did indeed score high in math but couldn't read non-verbal cues.

The exaggeration of these traits (male intellect to the max) is autism, although the researchers did not measure the digits of autistic persons. Women tend to have 4th fingers equal to 2nd in size, but when they don't, no predictions as to mathematical or relationship skills can be made. This finger length stuff is totally a guy thing.

ACE inhibitors

We've got a lot of drug choices availble to lower high blood pressure. Some older drugs that effectively lowered pressure have fallen by the wayside because, while they enable patients to reach a satisfying 'numbers' goal, that success did not translate out into a decrease in risk of future heart attack or stroke which is really the point of treating hypertension.

The ACE inhibitors are a class of blood pressure meds that remain on the "A" list. These drugs work by inhibiting a cascade of events initiated by the kidneys that result in the constriction of blood vessels. When blood vessels narrow, the same amount of fluid (your blood volume) is now in a smaller space, and pressure rises. These angiotensin converting enzyme inhibitors partially block the conversion of an inactive substance produced by the liver--angiotensinogen--to an active vasoconstricting molecule called angiotensin.

Not only do ACE inhibitors lower pressure and thus lower risk of heart attack and stroke, they also promote normal blood vessel behavior independent of their effect on blood pressure. Furthermore, new evidence suggests that several drugs in this category help peope hold onto their marbles through the years.

Several ACE inhibitors cross the 'blood-brain barrier,' the tight junction between the blood and all the good and bad things coursing through it and the delicate nerve cells in the noggin. Persons of age taking these drugs, including captopril, lisinopril, ramipril, and fosinopril, were followed over six years time for the development of dementia as a function of their blood pressure medication choice during the Cardiovascular Health Study.

Those oldsters on brain active ACEIs were 50% less likely to demonstrate a decline in mental functioning during the study. The lead investigator concluded, "If an ACE-inhibitor is indicated, I would recommend using one that crosses the blood-brain barrier."

At a time in our lives when we are intent on getting all parts to the finish line, going for the 'three-for-one' action of these drugs seems like a great strategy.

Where is Femail Doc?

Over at my mom's house, getting us both through life, one day at a time. Check for progress notes at Doc of Ages. Loook for more up-to-date medical news here sometime in the future.

I wrote last week in Doc of Ages (www.vintagefemail.blogspot.com) about the increasing evidence that regular use of aspirin can prevent cancer versus the pesky little problem of gastric hemorrhage which may occur without warning in aspirin users.

Over 5,000 British physicians and some 2,500 TIA victims in the UK just added the weight of their evidence on aspirin use and colon cancer risk. The conclusion? Five years of daily intake of 1 standard asprin tablet (325 mg) resulted in a 37% decrease in incidence of colorectal cancer, and 10 or more years led to an impressive 74% risk reduction.

Investigators noted that these studies showed a more robust chemopreventive effect for aspirin compared with earlier trials because the daily dose was higher. They also note that nothing has changed about that annoying little stomach bleeding thing from regular aspirin use, but perhaps these strong statistics mean that cancer prevention benefits outweigh those risks for high risk patient populations.

In our study, if every woman ate a healthy diet, exercised a half hour a day, was not overweight, did not smoke, and drank a small amount of alcohol, over 90 percent of diabetes cases would have been eliminated...This is, of course, a hypothetical concept.
--Frank Hu, HSPH, Harvard School of Public Health

There you have it, diabetes 90% eliminated with a few small lifestyle adjustments. This analysis is based on data from 80,000 nurses followed over 16 years for the development of diabetes as correlated with their daily habits.

The new rusty nail?

Yech, tongue piercing, can't imagine how anyone could go through with it. An article in Head & Neck several years back wonders if the metal barbell through the tongue could become the 'new rusty nail' based on a case report of tetanus that developed post-piercing in one young lady.

Doctors in Italy reported that an 18-year old woman developed episodic 'electric shock' sensations in her face due to inflammation in a facial sensory nerve from a tongue stud. Other complications noted in the medical literature include a blood-borne infection resulting in endocarditis (heart infection) and development of a brain abscess.

If we have any influence on our teenaged children's self-expression, we should discourage this particular outlet. Better a safety pin through the eyebrow than a stud through the tongue.

Old advice found in a new issue of JAMA

May I never see in the patient anything but a fellow creature in pain.
--Oath of Maimonides

A Complication of Forceful Nose-Blowing

I've been struggling with the remains of a cold and the never-ending drainage from the ethmoid sinus that sits right behind my left eye. So I was not happy when I was flipping through The American Journal of Medicine today and the above title caught my eye.

You're probably familiar with the medical myth that your eyes may get stuck if you cross them. In the realm of the possible, small boys could put their eyes out if playing with BB guns, and it is possible to stick a pencil through your posterior pharynx if you run through the house with the pencil in your mouth and fall flat on your face. But is it possible to blow your brains out by blowing your nose?

Apparently yes, and there's a scary MRI image in the AJM to prove it. Some old guy who had the habit of honking heartily into his hanky felt a 'pop' after one particularly forceful blow and immediately experienced pain above his left eye. The pain worsened over 4 days, he then developed a fever and lapsed into a coma.

Apparently his nose-blowing ruptured the membranes covering his brain and forced air plus bacteria into the space around his brain. After big time antibiotics, he improved, woke up, and presumably now blows gently and genteely.

And so will I!

The dirt on dirt

It's good for you. I wish I could get my son to accept this, but the fact is, when I drop food on the ground as I prepare dinner, it's better that he doesn't know that I just pick it up and put it back in the bowl.

Perhaps Dr. Yulia Iossifova of the University of Cincinnati should come to dinner to help me explain (as we pick cat hair off the fallen lettuce). Here's what she has to say:

The immune system's protective effects only appear to occur when there are high levels of microbial exposure. Cleaner environments do not have enough microbial components to trigger the immune system response.

She and her colleagues enrolled 574 families with newborn infants as part of the Cincinnati Childhood Allergy and Air Pollution Study. At least one parent in each family tested positive on a skin prick test for a panel of allergens.

The investigators then crawled around the family homes in an infantile sort of way collecting samples of dust and mold from the babies' environments. They checked the house sweepings for levels of a protein found in the cell wall of fungi; the higher the levels, the more mold at baby level. This protein is believed to cause respiratory symptoms in adults. Months laters, the tots were studied for allergic responses to skin tests and a history of wheezing episodes, and signs of allergies were correlated with levels of mold in the house.

Turns out, the moldier the floorboards, the less likely the offspring to wheeze in an allergic sort of way. Conversely, those babes in households where the parents actually found time to scrub and disinfect under chairs and in corners were far more likely to suffer from allergy-related respiratory distress.

Cracked fingernails and why they don't split

Fingernails strong by design

If you've ever wondered why cracked fingernails don't just painfully split down the middle or simply been grateful that they don't, Dr. Roland Ennos can tell you why.

Fingernails have three fibrous layers. The outer and inner layer have fibers running in all directions that give the fingernail its flexibility. The outermost layer also wraps around the sides to help prevent cracks from forming in the first place. The thick middle layer has fibers that traverse the nail, sending those cracks laterally instead of into the quick.

To test his theory of nail mechanics, Dr. Ennos attached instrumented scissors to a measuring device and found that nails were twice as difficult to cut towards the base as across it...Consequently cracks are deflected around the end of the nail, protecting the nail bed from damage.

Stoned lung cancer cells stopped in their tracks!

The beauty of this study is that we are showing that a substance of abuse, if used prudently, may offer a new road to therapy against lung cancer.
--Anju Preet, Ph.D.

Medical marijuana may not be just for nausea and pain control anymore. Dr. Preet and colleagues discovered that THC or Δ-9 tetrahydrocannabinol which is the active ingredient in the drug inhibits the growth and spread of an aggressive form of lung cancer.

Cellular cannabinoid receptors in cells can be activated by endocannabinoids--naturally produced marijuana-ish sorts of molecules--as well as by THC. Once occupied by the right sort of molecule, these receptors participate in various biological functions such as pain and anxiety control, and inflammatory processes. One THC derivative called Marinol has been approved for appetite stimulation in cancer and AIDS patients. Another drug called Acomplia blocks the cannabinoid receptors and is awaiting FDA approval for the metabolic syndrome, a pre-diabetic condition associated with notable weight gain around the waistline.

These Harvard investigators found that THC inhibited the progression of lung cancer cell growth both in petri dishes and in mice. While the mechanism of THC's anti-cancer action is unclear, the researchers speculate that THC may interfere with the formation of the cancer's blood supply.

I've recently discovered the origin of the term hightailing as in "I'm going to hightail it out of here." Ninja the cat zipped through the kitchen on some mysterious feline mission with her tail straight up, hightailing her way to whatever her grape-sized brain had in mind.

Miserable cold here. Cold outside, cold in my head. This has been the year for upper respiratory infections, and this is my second one. Makes me wonder, as my patients often ask, "Is there something wrong with my immune system?" My inner doctor says no, I'm just exposed to a lot of sick people. This cold, however, comes to me courtesy of my office manager--you know who you are and what you've done to me!

So I'm practicing what I preach--herbs, aspirin, cough syrup with codeine for night-time cough relief, steroid nasal spray to try to keep the head open and the sinuses clear, Sudafed, and Zyrtec as this all arrived on top of springtime allergies. Like all of you, I don't have time to practice the stay at home and rest thing, I'm off to Albertson's to shop for groceries.

A woman's heart attack

I just received an e-mail from a reader of my newsletter warning others about the unusual presentations of heart attacks in women. This e-mail describes one woman's attack of 'indigestion' that was, in fact, a heart attack hitting her as she curled up in her recliner reading a book.

I clearly recall a woman coming in to my office in the aftermath of a bout of 'stomach flu' several days previous. She described nausea, vomiting, fatigue, I agreed with her diagnosis, we both agreed she was on the mend. She showed up three days later in congestive heart failure from the massive heart attack she'd suffered that seemed to be stomach flu. When she initially came, it was already to late to save any of her heart, but I certainly took this lesson to heart.

A heart attack may not send you sweating to the racquetball court floor with crushing chest pain. Take unusual and persistent symptoms in your chest or upper abdomen seriously, and call for help sooner than later. No shame in finding out you're really okay instead of finding out too late that you should've sought help.

Light pollution in the US



Blindness and breast cancer

If you want 662 pages worth of reasons to take melatonin at night, do a search on the supplement at www.pubmed.gov. There's 15 pages alone on the association between melatonin and breast cancer.

Melatonin is a hormone produced by the pineal gland at the base of our brain when the lights are out. The more we stay up late working at our computers under bright lights, the less melatonin we produce.

I've written before about what a marvelous anti-oxidant melatonin is. Turns out, it has oncostatic (cancer-stopping) properties as well, particularly with respect to estrogen-receptor positive breast cancer. One reason for this protective quality of melatonin may be that it has anti-estrogenic properties that block the stimulation of estrogen to breast tissue.

An extensive review of hospital discharge records years ago by the Centers for Disease Control found that profoundly blind women (all dark all the time) have half the risk of breast cancer compared with their sighted counterparts. Other studies have found a positive association between the degree of visual impairment and the risk of breast cancer.

My neighbors have the spotlight from hell guarding their driveway; a beacon worthy of a lighthouse that brights my bedroom into the lighted equivalent of perpetual dawn. My husband toys with shooting it out, but I'll just keep downing my melatonin. Breast cancer protection AND great dreams!

New uses for old standbys?

Here's a question recently sent to me via anonymous e-mail:

Does putting listerine in your vagina kill sperm and prevent pregnancy?

NO! Unless, of course, it makes you too sore to use your vagina.

Speaking of novel cures, one of my patients used Lysol to stop vaginal odor. It didn't work and was highly irritating. Not recommended. Another used first a.m. urine to clear her acne. It worked! Try it or not, it's your call.

MRI now recommended for high-risk breast cancer screening

Breast cancer screening just got better for women at a high (20-25%) lifetime risk of developing a malignant breast tumor. The American Cancer Society released new screening guidelines this year recommending MRI scans for women with strong family histories of breast cancer.

In 2004, a study of over 1900 high-risk women in the Netherlands compared MRI technology with standard mammograms. Analysis of 45 cancers found over the course of 3 years showed that mammograms detected 18 tumors--10 of which were visible by MRI--and missed 27 tumors. Of 32 tumors found on MRI, 22 were not visible on mammogram. Four tumors arose during the intervals between screening tests, and one tumor was detected only by clinical breast examination.

Because some tumors (nearly 18% in this series) are only detectable by mammograms, the ACS guidelines recommend both MRI and mammographic screening in high risk women. While MRIs are known to be sensitive tests for identifying cancers in very dense breast tissue (which are very hard to read on mammograms), the ACS stopped short of recommending this technique for routine use in women with dense breasts, even though such a breast pattern is associated with a six-fold increased risk of cancer.

Eventually, insurance coverage will follow these guidelines. Meanwhile, I'm considering springing for the $1,000+ test for myself.

I've been on TV twice in my adult life (we're not counting the Brownie troop's trip to the Sheriff Scotty show here). Both times, I did not wear make-up--boy was that a mistake!--but I did pre-medicate with beta-blockers. As a result, I appeared pathetically pale and totally calm.

Beta- blockers tone down the effects of the sympathetic nervous system. This is the 'fight or flight' arm of the involuntary nervous system which is driven by norepinephrine or adrenalin. Originally developed for hypertension, these drugs were subsequently found to be very useful for stage fright. Several patients of mine who are attorneys take them before they appear in court, and some sales reps use them to calm the pre-presentation jitters.

Evidence suggests that they may someday be used to prevent metatstases from cancer. In particular, studies suggest that many breast, colon, and prostate cancer cells have beta-adrenoreceptors on their surfaces. Men on beta-blockers were 18% less likely to contract prostate cancer in one Canadian study, and propranolol prevented metastases in a mice tumor model.

One cancer biologist noted:

These data imply that emotional stress may contribute to the development of cancer and may also reduce the effectiveness of cancer treatments.

Night moves

Those twitchy legs may have more serious consequences than the loss of a decent night's sleep. Canadian researchers at the Hôpital du Sacre-Cœur in Montreal studied the night moves of 10 patients with restless leg syndrome. They found that periodic leg movements during sleep (PLMSs) were associated with significant spikes in blood pressure of 20-40 points.

Restless sleepers may twitch every 20-40 seconds resulting in a whole lot of blood pressure troubles throughout the night. The scientists noted that persons with sleep apnea may suffer from these same spikey nocturnal elevations. Lead author Dr. Paola Lanfranchi concluded:

If someone has heart failure, and every 20 to 40 seconds they have an increase in blood pressure, it's going to have an impact on the function of the heart.

You appear to have caught that bug that's been going around my
waiting room.
--Doctor to patient in exam room per New Yorker cartoon

Yech, even I wouldn't have wanted to be in my waiting room yesterday!

Advair and lung cancer

I'm sure you've listened to the 'fine print' on televised prescription drug commercials. At the end of the ad, a fast-paced disclaimer rips through the potential death and destruction associated with use of the drug. My nearest and dearest relative with COPD who generally is disinclined to pay attention to any commercials whatsoever chucked his Advair in the trash after hearing out the Advair ad to its end.

Now a bunch of ex-cigarette-smoking old veterans are proving that inhaled steroids (which are part of the Advair formulation) may have additional benefits to outweigh those risks. Over 10,000 of them previously diagnosed with chronic obstructive pulmonary disease were followed for nearly 4 years in order to study the association of inhaled steroid use with the onset of lung cancer. Lung cancer is common in COPD patients and a frequent cause of death in this population.

Those subjects who stuck with their inhalation therapy, sucking in at least 1200 mcg/day of steroids had a whopping 61% decreased incidence of lung cancer over the course of the study. The Seattle investigators postulated that the anti-inflammatory effect of the medication decreased the risk of malignant cell transformations.

Perhaps someday they'll mention that in the TV ads.

Don't count on mammograms

The latest issue of the New England Journal of Medicine makes it clear that breast cancer screening via mammograms is a most imperfect science. An editorialist notes that "screening mammography is also the most common basis for lawsuits in radiology, which is not surprising, since 25 to 50% of cases of breast cancer are identified retrospectively on the previous annual screening mammogram."

In other words, when cancer is discovered in a woman's breast, at least 1 in 4 of the tumors can be seen on review of the previous year's mammogram films. Dr. Ferris Hall of Beth Israel Deaconess Medical Center in Boston goes on to note:

Screening mammography, a particularly stressful task for radiologists, is associated with a relatively high rate of burnout. For all these reasons, residents have avoided this field for decades, leaving a shortfall of fellowship-trained mammographers, many of whom are older and overworked.

If you are confused about whether or not to have annual mammograms during your forties, no wonder. Doctors can't agree on this either. Consider the opposing positions:

The reduction in this age group is smaller than that in women 50 years of age or older, is subject to greater uncertainty about the exact reduction in risk, and comes with the risk for potential harms (such as false-positive and false-negative results, exposure to radiation, discomfort, and anxiety).
--Amir Qaseem, M.D., Ph.D., American College of Physicians

This was an incredibly irresponsible decision by the American College of Physicians. They clearly don't understand the screening trials of mammography and they don't understand the data. They just totally misinterpreted things.
--Radiologist Daniel B. Kopans, M.D., of Harvard

The new ACP guidelines suggesting that routine annual mammograms for 40-somethings reopens a debate that was recently 'settled' in favor of yearly exams for through the 40's. Conventional wisdom held that while 40-ish women were less likely to get breast cancer than their older colleagues, their cancers tended to be more aggressive and more frequent screenings were useful to catch faster-growing tumors earlier by looking for them more often.

Women at higher risk for breast cancer due to an inherited predisposition should have earlier screenings PLUS breast MRI scanning. MRI screening, while expensive, is now recommended for all women diagnosed with breast cancer to look for other tumor foci. This recommendation may ultimately extend to women with dense breast tissue on mammogram; breast cancers are harder to visualize in such breasts by mammograms and these women are known to be at a much higher risk for developing malignant tumors, a risk believed to be equivalent to women with BRCA mutations.

Undernutrition without malnutrition...

May be the new lifestyle approach to cancer prevention.

While there are certainly disadvantages to life in the Democratic Republic of Congo, the women do enjoy a decreased incidence of breast cancer compared to the US.

Polish researchers theorized that the lower mean daily energy intake for the Congo--7.6 MJ/day vs. 15.3 MJ/day for the United States-- lowers levels of ovarian hormones through the African womens' reproductive years. This, in turn, favorably alters the lifetime risk of developing breast cancer.

In a study done five years ago, Krakow-based scientists found a direct correlation between salivary concentrations of progesterone during the last half of the menstrual cycle and breast cancer rates in groups of women studied from both countries. Not only were the higher hormonal levels in American women proportional to their higher cancer rates, the same mathematical relationship between salivary progesterone and cancer risk held true for populations studied in Nepal, Bolivia, and Poland.

The authors of the study concluded:

The strength of the relation strongly suggests that it is an important biological phenomenon. Furthermore, since ovarian function responds to nutritional status, the risk of breast cancer may be modified if changes are made in a woman's lifestyle.

It's the great cancer cover-up. Panicked into avoiding sunlight by health experts, we are now dying in our thousands from diseases linked to deficiencies of vitamin D. But still the exaggerated warnings come.

The oral intake of vitamin D needed to maintain levels circulating in the blood in the absence of sun exposure may be as high as 4,000 IU/day.

--Oliver Gillie

Helluva virus

I once told a young man he had a helluva virus. He pulled out a pen and small notebook and asked me to spell that for him. Well, the helluva virus is back, and I am spending far too much time trapped in tiny exam rooms with miserable patients intent on sharing the little bugger with me.

Here's the litany of troubles caused by HV, and words to the wise about what to do about it. It's possible that we are dealing with HV1 and HV2 here, but they both cause a helluvan illness:

Terrible sore throat
Tiny tickle that turns into a heckuva cough
Body aches
Show-stopping fatigue
Fever
Chest pressure and congestion
A feeling of shortness of breath
Hoarseness

If you have it, you're probably not sitting at your computer reading this post. If you get it tomorrow because you share office space with one of the patients I saw today, don't go see your doctor. There's nothing we can do for you, except, perhaps, prescribe cough syrup with codeine so you can put a stop to the misery long enough to get some sleep. I'd be willing to do that over the phone in lieu of sharing air space with you.

Drink liquids. Don't take antihistamines, do take Mucinex (guafenisen). Take aspirin or Advil for the aching, fever, and sore throat. Don't go to work. If you get worse instead of better and cough or blow out horrible stuff a week or more into your HV infection, then let's talk antibiotics.

Medicinal chemists may make breast cancers glow for the camera!

Microcalcifications...

on mammograms are not a good sign. These little white dits of calcium can indicate a developing malignant tumor. Some of us are awash in breast microcalcifications, but mammograms can't always tell which are benign.

If you've undergone one of those creepy stereotactic biopsies where the radiologist goes fishing for calcium, you'll be pleased by this news from Dr. John Frangioni in Boston. He and his colleagues have discovered that microcalcifications of the cancerous variety are hydroxyapetite deposits whereas benign mineral collections are generally calcium oxalate. While mammographic imaging can't distinguish one from the other, these Harvard chemists have discovered a way to make those bad boy hydroxyapetite crystals glow infrared.

By injecting pigs and mice with a bisphosphonate drug (think Fosamax and Actonel) that's hooked up with a compound called PAM800 that emits infrared light, the scientists have successfully put purple chemical highlights on hydroxyapetite microcalcifications in the animals. They are hopeful that this line of research will lead someday to successful infrared imaging devices that can pinpoint early cancers by the quality of their calcium.

Brain busters

I'm not sure whether to thank or curse the person who sent me this link, but they did so anonymously, so I've got no choice. Anyway, bust your brain on these tests; I trust they're good for us in the long run:

Cognitivelabs.com

Drug pens

These are actually part of my problem, the scads of cheap pens I get from drug companies. On average, they're not handing out roller balls, but rather the low cost type that takes an extra push from my index finger to keep the ink flowing evenly.

Do these pens buy my loyalty to the company's product? Are you kidding? I agree with Dr. Thomas Stossel of Harvard as he speaks out against the Prescription Project, a multi-million dollar initiative funded by the Pew Charitable Trusts to squelch pharmaceutical influence on doctors:

I'm not going to fall on my sword for pizzas and pens. If doctors in practice are too dumb to figure out that when a drug rep takes him out to play golf that the rep is trying to sell him something, we're in trouble.

But PenAgain...

Not. This pen is too small! Either I'm way to grippy about it, or this device needs to come sized to your hand. I finished my charts last night with my little black PenAgain--my index finger was painless, but the knuckles of my third and fourth finger complained as though they'd been jammed together for the duration in a glove two sizes too small.

PenAgain

The very thing for those of us who write all day every day. My handwriting is not bad because I'm a doctor, it's bad because the top joint on my right index finger is twisting east from gripping a pen too hard and too long.

So this quirky little pen is quite the find; it has a silky feel, a silly silhouette, and a little groove where my crooked finger can gently guide the action while fully extended.

You want one? Go to Walgreen's and get one, or check out Amazon.com and read the glowing reviews.

Being a pasty white bank official must be the vitamin D equivalent of copping a permanent assignment on a nuclear sub. PWBO had the lowest vitamin D level I've seen yet, and this is sunny Denver from a woman who does drink D-fortified milk.

If your legs look like the first two boards of a picket-fence, and you're not taking extra D, ask your doctor to check your levels.

Chewing the fat

Researchers are still analyzing the fat in our lives--whether worn about the waist or taken in as hollandaise sauce--as a risk factor for breast cancer. They examined food frequency diaries from nearly 200,000 women in the National Institutes of Health-AARP Diet and Health Study abd correlated dieatary fat with incidence of breast cancer over 4+ years.

Study co-author Anne C. M. Thiébaut, Ph.D., of the National Cancer Institute noted that doubling fat intake from 20% to 40% increased breast cancer risk by 15%. Drs. Meir Stampfer and Stephanie Smith-Warner both felt that the elevated risk from dietary fat was way overshadowed by the influence of body fat on cancer risk. They wrote:

Thus, from a prevention perspective, interventions to control the amount of body fat (e.g., promotion of exercise and caloric restraint) are likely to have a greater impact on breast cancer incidence than a reduction in fat intake.

Keeping up with D news

Two new studies brought to my attention by Gretchen of Denver:

The data were very clear, showing that individuals in the group with the lowest blood levels had the highest rates of breast cancer, and the breast cancer rates dropped as the blood levels of vitamin D increased. The serum level associated with a 50 percent reduction in risk could be maintained by taking 2,000 international units of vitamin D3 daily plus, when the weather permits, spending 10 to 15 minutes a day in the sun.
--Cedric Garland, Dr.P.H.

Through this meta-analysis we found that raising the serum level of 25-hydroxyvitamin D to 34 ng/ml would reduce the incidence rates of colorectal cancer by half. We project a two-thirds reduction in incidence with serum levels of 46ng/ml, which corresponds to a daily intake of 2,000 IU of vitamin D3. This would be best achieved with a combination of diet, supplements and 10 to 15 minutes per day in the sun.
--Edward D. Gorham, Ph.D.

On making connections

Social isolation isn't good for the body or soul. Lori Levy writes of a brief encounter with a stranger on a busy day:

And though I do not stop to chat--
for that would be as out of character as
a bashful child jumping up to sing--
my smile widens and turns real,
melting inward like a flood of warmth,
as when a song you've always loved
comes on the radio and fills you up again,
if only for a moment.

Hip pain


Sometimes it's hard to tell what's what when hips hurt. Arthritis of the hip joint hurts in the groin or the front of the thigh. It increases over time, gets worse with activity, and limits the range of motion of the hip, particularly to internally rotate the joint (accomplished by turning the foot or knee inward towards the middle of the body).

Bursitis, or an inflammation of the lubricating lining of the hip, hurts at night, making sleeping on the affected side difficult. Bursitis also nags when you first rise from a seated position, but this pain subsides quickly.

Finally, pain from the sacro-iliac pain also is improperly identified as hip pain. Lie on your back bending the affected leg at the knee and placing the ankle on the opposite knee in a 'figure 4' configuration. If downward pressure on the knee of the affected side causes pain in the groin, it's the hip. If the pain is around back, the pain is probably from the sacro-iliac joint.

Just say 'scat' to scat

I'm not sure I'll ever get over the unexpected pleasure of seeing the neighborhood wildlife which includes a coyote, a fox or two, falcons, a pair of hawks, and at least one family of raccoons. I suppose losing the family cat to one of the predators would take some of the fun out of it, but, according to JAMA, here's what one of these critters may bring to the 'hood:

Scientists and public health experts say it's time to remove the welcome mat, because the animals often carry a roundworm parasite that is increasingly recognized as the cause of a rare but deadly form of encephalitis, especially in children.

This warning, from JAMA, points out an unexpected problem with sharing our living space with wild animals.

For more details, see the upcoming issue of Femailhealthnews. Not yet on the subscription list for this free e-mail newsletter? Send a blank e-mail to join-femailhealthnews@lyris.dundee.net.

Dressing like a doctor, Part II

I mentioned in a previous post (Dressing like a doctor, Part I) my unsuccessful attempt to break free of the stodgy middle-aged travel knit look of Chico's into the young modern insouciance of Anthropologie. This weekend I tried a less ambitious attempt to look the professional part while out on errands.

I inevitably run into patients at my local King Soopers when I'm decked out head to toe in my son's hand-me-downs. One seventy-something patient, beautifully dressed for church in heels and a silk dress, eyed me up and down in produce and said "My don't you look comfortable." So yesterday I donned a blouse over jeans that actually fit, a necklace, and a touch of make-up, and headed for Rite-Aid and Sunflower Market.

Score! Ran into patients at both stores, and no need for embarrassment!

Quit puffing, start huffing

I quit smoking 29 years ago this month. Coincidentally, my daughter and I went to a Jazzercise class this a.m. This hour of hopping to hip hop, along with many, many other such classes I've attended through the years cuts this ex-smoker's chance of getting lung cancer by 37%.*
_____
*The Association of Physical Activity with Lung Cancer Incidence in a Cohort of Older Women: The Iowa Women's Health Study, Cancer Epidemiology Biomarkers & Prevention Vol. 15, 2359-2363, December 2006
© 2006

Taste test?

Scientists have noted that otherwise healthy persons taking selective serotonin reuptake inhibitors--antidepressants such as Prozac and Lexapro--become extra sensitive at detecting sweet and bitter tastes. On the other hand, volunteers taking selective norepinephrine reuptake inhibitors like Effexor improved their detection of sour and bitter tastes.

These neurotransmitters, serotonin and norepinephrine, are known to be involved in taste signaling as well as mood control. Physiologist Lucy Donaldson of the University of Bristol felt this connection might be useful in the treatment of depression. She concluded:

It may be feasible to use a simple taste test to see what kind of medication people should be given.

From a patient's point of view

The opportunity to view medical care from the other side of the consultation desk is always an eye-opener. I recently accompanied a family member to a couple of medical appointments, and the experiences were polar opposites.

The un-named dermatologist entered the room with nary a howdy-do or even a trite 'how 'bout all this snow?' He immediately began mumbling about diagnoses and treatment options in terms not meaningful to your average layperson even though he had no notion at the time that I was a doctor. The only reason we reached a clear care plan by visit's end was at my insistence.

At the other end of the spectrum, Dr. Andrew Nemechek, a surgical oncologist specializing in head and neck cancers was as warm and easy to talk to as the previous doctor was inscrutable. He outlined care options on paper with an easy-to-follow, step-wise flow sheet. We are lucky to have such a specialist here in Denver; I highly recommend his services to you, but I hope you'll never need them.

Overresection of the nasal tip

Think Michael Jackson, as in so much plastic surgery there's no cartilage left in the nose to remold.

Plastic surgeons have now perfected a technique that grafts seagull wing cartilage to overdone noses, providing new definition to the profile and a new definition to the term 'winging it.' One author of an outcome study published in The Archives of Facial Plastic Surgery noted that 'patient satisfaction was high.' In this series, 92% of the subjects who flew through the procedure were pleased with the lift.

A primary care doc, writing in JAMA lists those things she won't miss as she makes plans to leave her practice:

No more forms to fill out for workers comp, diability, SSI, student loan forgiveness, long-term-care insurance coverage, FMLA, or temporary suspension of billing for credit card or mortgage or rental furniture payments owing to customer illness...

No more requests for a personally crafted letter swearing that 'Medically, it is in the patient's best interest...' to change apartments, own a pet, not swim in gym class, work only part-time, be excused from jury duty, change shifts, or not travel at this time...

No more writing a prescription for Winner med only to find out it is not on the patient's pharmacy plan. So I phone in SecondBest instead, but the formulary gods will only approve RunnerUp, but by golly I fight for SecondBest and win. Until the patient calls bbecause SecondBest is still a second-tier drug with a $50 co-pay. Could I please prescribe something cheaper, like that RunnerUp her beautician takes?

In case you wonder how I spend my office hours when not seeing patients.

American Heart Association on pain control*

Cardiologists have launched a save-the-heart-and-bear-the-pain campaign. Their cardiocentric viewpoint may leave those of us at risk for heart disease sidelined with aging, aching joints.

The AHA just issued new guidelines discouraging the use of COX-2 inhibitors such as Celebrex in heart patients or even those at risk for heart disease. Noting that these drugs increase sodium retention, decrease blood flow to the kidneys, and increase blood pressure, they encouraged non-drug treatments such as weight loss and physical therapy as the first-line defense against musculoskeletal pain.

If these measures are 'too little too late,' they recommended reaching for tylenol, tramodol, or narcotics before considering the so-called NSAIDs (non-steroidal anti-inflammatory drugs). Of all these various drugs (ibuprofen, piroxicam, etodolac and others), they endorsed naproxen (OTC Aleve) as cardiac neutral.

In the real world of aching joints holding up aging hearts, these guidelines create as many problems as they seek to avoid. There's obviously no losing weight without exercise, and there's no exercising while the arthritic knees are screaming. Naproxen may be cardiac neutral, but I just sent a middle-aged lady to the ER yesterday when she began passing blood clots instead of stool after five days on this drug. And another sixty-something patient in the midst of training for a triatholon is hobbling instead of running now that she's off NSAIDs and on blood thinners for intermittent atrial fibrillation.

Cardiologist Dr Scott Solomon of Brigham and Women's Hospital summed up the broader picture:

Physicians need to weigh any potential cardiovascular risks of nonselective NSAIDs together with the clear increased risk of GI bleeding against risk of abuse with narcotics.

*Information from AHA updates NSAID advice

High school students can download to their cellular phones ultra high-frequency ring tones that are inaudible to most of their teachers.

---Robert Dobie, MD, University of California, Davis

No wonder I never hear my cell phone when it rings in my purse. Not that it rings much, but that darling little trill of a tone just doesn't register on my aging ears on the rare occasions when someone calls.

Dr. Dobie notes that loss of ability to hear sounds of the highest frequencies begins in early adulthood and accelerates with age. Ultimately, lower, conversational frequencies start to drop out as well, so then the teenagers can actually answer their ringing phones in classes taught by 70-something substitute teachers.