Early a.m. calls

Ordinarily I'm up by 6:30 a.m. I recognize, however, that patient problems don't follow my schedule, even my more leisurely Saturday morning agenda. I also know that nagging problems have a way of seeming more urgent through the wee hours of the morning, so that which is not an emergency (say the discomfort of a bladder infection) can move a patient to place a call to me at oh-dark thirty.

That said, here's the gist of my conversation with a patient of one of my call partners at 6:30 yesterday morning:

Pt: I've had an irregular heart beat on and off for two weeks now.

Me: Is it worse this morning? Are you having shortness of breath or chest pain?

Pt: No. It's just been on my mind and I thought I'd run it by someone.

Turns out this fellow is quite the work-out fiend, feels fine when he works out without any sensation of skipped beats (typical of benign premature contractions), and I think he just wanted reassurance before he went off to his early morning work-out. I was tempted to berate him a bit for his timing (I know some people call off-hours because they know they'll get right through to the doctor), but I held my tongue as he was not my patient.

Would I have been justified in schooling him on after-hours etiquette?

Irritable bowel syndrome

Irritable bowel syndrome or IBS is a diagnosis of exclusion. In order to conclude that a patient suffers from IBS--a cluster of unpleasant abdominal symptoms including pain, bloating, gas, constipation, and/or diarrhea--we first must exclude other possible reasons that they may be suffering so.

There's a lot to be said about IBS and the many ways that it can seriously affect quality of life even if it does not result in serious illness. The pain can be quite debilitating and result in frequent absences from work or school. An article in last month's British Medical Journal discussed three simple strategies that significantly decrease the discomfort of IBS.

In a meta-analysis (a study of studies that combines results of multiple trials to amplify the significance of results) researchers found that fiber, anti-spasmodics, and peppermint oil all performed significantly better than placebo in relieving the pain and screwy bowel movements of IBS. They reported the number of patients needed to be treated for one to experience significant relief from the heartbreak of IBS were: 11 for fiber supplements (using psyllium compounds such as Metamucil) 5 for anti-spasmodics (hyoscyamine sold as Levsin, NuLev, Transderm Scop, and generically), and just 2 1/2 patients needed treatment with peppermint oil (187-225 mg. in water 2-4 times daily, available OTC) for 1 to feel better!

"How Doctors Think"

I love highlighters. And I adore those tiny sticky strips with which I mark interesting passages in the books I read. So imagine my delight when a well-known pharmaceutical company via their local sales rep gave me four highlighters, each with scores of matching sticky tabs bursting out the sides. Of course, all these freebie pens bore the branded name of an expensive, widely-advertised anti-depressant.

Before I get to my point here, let me assure you that these gifts in no way influenced my prescribing habits. The pens, in fact, were all dried-up and hopeless for highlighting, but that made me no less likely to dole out the drug. The tabs were all I could hope for, but I promise you I've written not one additional prescription based on my delight. My patients often do well on this med, and that makes me more likely to prescribe it. Many who love the mood boost stop taking it, however, due to intolerable side effects, and that makes me less likely to write for it.

So there's a little insight into how this doctor thinks, but what I'm really plugging here is Dr. Jerome Groopman's must-have book "How Doctors Think." I'm halfway through it, and pages read thus far bristle with my ill-gotten, dirty-drug-money sticky tabs, each one flagging a point I wish I'd made in a book I wish I'd written. Not only should doctors read this book to understand why we think the way we do or to change our cognitive strategies in useful ways, you and I as patients (or as people who love and support patients*) should pay close attention as well.

Regular readers know that I've spent more than a little time these past two years as a designated listener and an advocate for friends and family working their way through the medical maze. I've seen how my colleagues listen or don't, and how they arrive at outrageous conclusions...or good ones, and the ways in which doctor/patient interactions influence the outcomes. Dr. Groopman has lots to say on the subject; more to come in later posts.
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*Two other excellent books that will help you become your own best advocate are Sick Girl Speaks and Pursued by a Bear.

Geraniums for the common cold

Argh, it's starting already, the steady stream of the walking wounded with their steady stream of respiratory secretions. All of them sharing a small exam room with me, one after the other, and looking for relief for their common colds.

I want to shout to the waiting room, go home, rest, drink fluids, don't cough on me. I understand, however, that no one's got time to be sick, and they wouldn't be in my waiting room if they didn't feel awful. So I was interested to read in last month's Health magazine (it comes free with my morning paper subscription) that a South African geranium used early on in the course of a cold may shorten the illness by two days.

There's a host of studies supporting the efficacy of extract of Pelargonium sidiodes (EPs or essence of geranium). Doctors at the National Medical University in Kiev invited 206 cold victims down to the lab (but I'll bet they passed up the opportunity to get up close and personal in an exam room with these people). All the patients were assessed for their Cold Inventory Score (CIS)* intially and after treatment with EPs or some murky liquid placebo.

Darned if those dosed with the real botanical deal didn't blossom forth to health at double the rate of the control group by day five. And ten days into the illness, the experimental group was more than twice as likely to zero out on their CIS score compared to their phyto-free colleagues.

So who wants to try Umcka ColdCare? You can get it in Denver at Sunflower Market or Vitamin Cottage, or find a store near you online at Nature's Way and hook me up with your testimonial.
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*The CIS is a fancy way to prove the obvious, namely that the person in front of you coughing, sneezing, and wiping a Rudolph Red nose has a cold. The researchers asked "Do you have nasal drainage, sore throat, nasal congestion, sneezing, scratchy throat, hoarseness, cough, headache, muscle aches, and fever?" They then computed the sum of symptom intensity differences (SSID) of the cold intensity score (CIS) from day one to day five. Don't ever think that there's no scientific method behind phytomedicinal research!

Been there, done that? Share your cancer advice

I asked one of my patients years ago about the best advice and the worst advice she'd received during her treatment for breast cancer. I don't even remember what she said was the best so horrified was I to hear that my advice was the worst.

I had told her she should consider quitting her job in order to deal with the upcoming treatment. I meant well; why spend energy on work when you will need all your inner resources to undergo chemotherapy and radiation? Now I know that 1) if you quit work you lose your insurance, and 2) ongoing work may provide a measure of satisfaction and normalcy to a life that has been transformed by a cancer diagnosis. I currently advise newly diagnosed patients to consider filling out paperwork to activate the Family Medical Leave Act so absences for treatment or side effects won't jeopardize their job.

I am collaborating with my friend and colleague Gail Harrison (who has been there/done that cancer journey) on a book for newly diagnosed cancer patients. Please consider sharing your stories if you have been down that road as well, or pass this questionnaire on to a friend or family member who has been through this experience.

Getting a call back from the doc!

Just finished a week of testing for my nearest and dearest. Getting the results was a bit of a challenge, even when I pulled rank with the "This is Dr. Paley calling Dr. R. for test results" which presumably pushed pushy me to the head of the phone call line.

Here's an article I wrote several years ago on the subject. I'd love to hear your stories about getting through (or not) to your physician.

"Hands, touching hands...

Reaching out,
Touching me,
Touching you.
--Neil Diamond

Yech, maybe not. Consider this study out from the University of Colorado in Boulder.

Scientists in the ecology and evolutionary biology department there used gene sequencing techniques to check out the bacterial communities living on hands in the University community. Not only did your average student mitt carry around 150 different species of bacteria, left hands and right hands carried different species, coeds had a greater diversity of species than their male colleagues, and regular hand washing did not cut down on the wide spectrum of bacterial types.

Do we dare shake hands ever again, or just nod and smile with shaking hands when we meet another traveling petri dish on the road of life? Study co-author Rob Knight has this reassuring news for the shakers and movers amongst us: "The vast majority of bacteria are non-pathogenic, and some bacteria even protect against the spread of pathogens."

Huh?

Pt: I have a tickle in my throat, so I tried not breathing for a couple of hours.

(Seriously, he was perfectly serious).

"I need a breast biopsy..."

per the frantic e-mail on my desk, "but can't afford it. Can you order the new blood test instead/ how much will it cost?"

Argh, that dreaded phone call about the abnormal mammogram. I've gotten one as have many of my patients. Follow-up, at times, is simply a matter of additional mammographic views, maybe follow-up films in 3 or 6 months, perhaps an ultrasound. Radiologists are extremely cautious in their reports, often calling patients back for further imaging, and sometimes--insomnia city-- advising a biopsy.

I've read hundreds of abnormal and suspicious reports. Often, there is a 'vague rounded density' that turns out to be just the superimposed shadows of breast tissue heaped on breast tissue, all normal. Frequently, there are 'microcalcifications' that look benign but a short-term follow-up is ordered to assure the little flecks are stable and not increasing in number.

But... this lady's report said "highly suspicious" and "spiculated" and these are not hedge words but a near definite diagnosis of cancer. This is not a dink around with a brand new screening test sort of report, but a work out a payment plan and get that biopsy done report.

Tomorrow: What's up with this new screening test? I didn't know, so I looked it up.

Glycemic index

Bagels and cornflakes and jelly beans, oh my. These--plus baked potatoes--are the worst of the worst of food choices for those of us who do not want to develop diabetes. These foods not only have a high glycemic index but also a high glycemic load. So flakes in the a.m. may leave you flaky and foggy-brained long before lunch.

All carbohydrates are not created equally in that some raise your blood sugar more rapidly than others. The glycemic index (GI) is calculated by measuring the change in blood glucose level that occurs when a person who has been fasting consumes that food. The elevation is then compared to the blood glucose response associated with a standard highly refined, high-carb food such as white sugar (which has a GI of 100).

The higher the GI, the more the food acts in the body like pure sugar, stressing those balancing mechanisms charged with keeping our blood sugar in an ideal operating range. Cornflakes (GI=92) send blood sugar soaring, causing the pancreas to respond with the release of lots of insulin which then efficiently sweeps the carbs into the cells. This causes blood sugar to plummet, leaving Kelloggs consumers with a mid-morning blood sugar too low to sustain brain functioning. While a trip to the office jelly bean (GI=78) jar may restore the blood sugar briefly, this quick fix just perpetuates the vicious cycle.

But nothing is really all that simple. Milk (GI=27) on the cornflakes changes the cereal's effects in unpredictable ways. And some foods with high GIs may have low glycemic loads (GL) which measures the actual blood sugar response to typical servings of foods. So a low GL (considered to be less than 10) on a high GI food choice indicates that you'd have to eat a ridiculous quantity to raise your sugar in ways predicted by its GI. For instance, pineapple has a moderatly high GI of 66 but a low GL of 7. You would have to consume 1 ¾ pounds in a sitting to raise your blood sugar in the same way that a handful of raisins (GI 64, GL 28) would.

Is your head swimming as if you just ate a baked potato (GI 85, GL 26) without sour cream, butter, and a steak (GI 0, GL 0) on the side? Experts agree that this approach may be too complex for many of us, encouraging us instead to eat foods that are not highly processed--which generally increases GI--and a diet that includes a wide variety of fruits, vegetables, and low-fat dairy products.

LDL particle size

LDL stands for low density lipoprotein, a worthy protein that picks up cholesterol particles that have either been absorbed from your diet or manufactured by your liver and totes them out to the cells. And it's a good thing that we have LDL-C; our cellular membranes are made out of cholesterol as are our steroid hormones. But as you know, while a little LDL-cholesterol (LDL-C) is a good thing, a lot is not. In susceptible persons, excess LDL-C enters the arterial wall where it may become oxidized and set off a world of inflammation and cholesterol schmutz known as atherosclerosis.

Turns out, there's bad LDL-C and then there's really bad LDL-C, and the difference lies in the particle size. There's no improving on the metaphors of noted lipidologist Dr. Thomas Dayspring, so here's the scoop in his own words:

Large-sized LDL is a beach ball. It bounces off the artery and goes back to the liver. Small LDL is a bullet. It lacks vitamin E, is very prone to oxidation, and crashes right through the artery.

So how do you know if your cholesterol is bouncing or crashing? LDL particle size is measured in the pricey VAP test which stands for vertical auto profile, but the information is actually right there on your standardized lipid profile. If you've got triglyceride levels over 200 and HDL-cholesterol (that's high density lipoprotein or the good stuff) levels below 45 (35 for the guys) we're probably talking bullets in your bloodstream.

Any hope of changing bullets to beach balls? Well surprise surprise, it's the same old song as always--weight loss and exercise. But wait, there's drugs that help as well, including Tricor, gemfibrozil, niacin, and the diabetic medication metformin, Actos, and Avandia.

"Happiness is a Serious Problem"

Current events make the pursuit of happiness even more of a challenge than usual. One of several books I'm juggling now is Dennis Prager's 1998 bestseller "Happiness is a Serious Problem." Perhaps we are missing some opportunities to increase our satisfaction with our personal situation. Here's Prager's take on health:

Take the expectation of health. For most people, the only time good health brings them happiness is when they do not expect to be healthy and then find out that they are. Imagine that you discover a strange new lump on your body. You go to the doctor, who tells you that it looks suspicious and that you should have a biopsy. After waiting a week for the results, you learn that the lump is benign. That day will be one of the happiest days of your life.

Now this is remarkable because the day before you discovered the lump you were not one bit healthier than you were on the supremely happy day you learned that your lump was benign. Nothing in the state of your health has changed, yet you are now profoundly happy. Why? Because on this day, you did not expect to be healthy.

...[I]deally, we should awaken every day and be as happy about our good health as if we had just received the wonderful news that a lump was diagnosed as benign.

No talcing please!

I first heard this one 30+ years ago, and I always wondered if it was an urban myth of the bizarre variety. But here it is again, this time backed by research from Harvard Medical School. Epidemiologists there sorted through years of data from the Nurses Health Study regarding who used talcum powder on their nether parts, and whether those who did were more likely to contract ovarian cancer compared with those who dusted not.

Turns out that those who took a weekly powder were 36% more likely to end up with ovarian tumors, and a daily dousing raised the risk 41%. Talcum powder is made from hydrous magnesium silicate which has properties similar to asbestos. Neither talc nor asbestos has any business on your bum!

"Wild thing, I think you move me..."

"It is highly possible that estrogen modulates motion abilities..."
---Karl Grammer of the Ludwig Boltzmann Institute for Urban Ethology

Well, duh Dr. Grammer, just ask an aging postmenopausal woman as she gets out of a chair about the lack of estrogen and the consequent lack of ability to move. Anyway, that was a mini-rant and NOT what this post is about.

In the 'what WILL they study next' dept., we have the following information out of the University of New Mexico. Evolutionary psychologists there were wondering how human females attract mates at the appropriate time of the cycle to generate species-appropriate reproductive behavior. They recruited lap dancers from local clubs to collect data on tips earned as correlated with phase of the menstrual cycle.

Women, as opposed to say a lady chihuahua or chinchilla do not go into heat but rather have a 4-5 day fertile window mid-cycle called the estrous phase when they are highly fertile. The researchers compared tips generated during these ovulatory days compared with those brought in during the luteal phase (post-ovulation time when perhaps a woman might be more inclined to eat her mate rather than mate her mate) or while the dancers were menstruating.

Sixty days, 5300 lap dance incidents later, here's the scoop. Data from 11 women with normal menstrual cycles indicated estrous earnings of about $70 an hour whereas hourly income fell 33% to $50 for those in the luteal phase and plummeted to $35 an hour for those who were menstruating. The seven women on birth control pills earned less throughout the study period.

So there's apparently 'something in the way she moves' during estrous that attracts clients like no other time of the cycle. And no estrous? May as well move on to another profession because she's not moving up in this lap dancing business. All good for the future of pill-free couples, but no wonder that some of my patients lose that loving feeling whilst on birth controll pills.

Beta blockers and post-traumatic stress disorder

One of my family members watched another person die suddenly, violently, and unexpectedly this weekend. I think I'm more freaked than my near and dear one is, but here's my doctorly thought processes after I was done flipping out.

Norepinephrine (NE, aka noradrenaline) is a neurotransmitter integral to the stress response and the formation of emotional memories. The beta-sympathetic nervous system (the automatic 'fight or flight' response that occurs without conscious activation) is mediated by NE which enhances the vivid but not necessarily accurate memories associated with highly emotional experiences. Think of a moment that was a charged one for you, say where you were when President Kennedy was shot (if you're old enough) or when you first heard about the World Trade Centers, and notice the details of that memory compared with other, blander recollections.

Experts call the development of post-traumatic stress disorder (PTSD) a 'derailment of memory process.' Not everyone is prone to an exaggerated or detrimental response to strongly charged experiences, but those who are can develop stubborn and destructive behavior patterns that ripple way beyond the actual trauma over time. While bioethicists argue over the morality of supressing intense and unpleasant memories, for better or worse it is possible to attenuate these memories through the use of beta-blockers. Amazingly, not only do the benefits of such therapy accrue when the medication is used shortly after the traumatic even, but also when the event is re-enacted through scripted imagery after some time has passed.

Should I offer beta-blockers (such as propranolol or metoprolol) to my family member? Perhaps I should just take a deep breath and take some myself.

The amygdala and the social conservative

I've mentioned before that I have an overactive amygdala. Through a series of genetically determined events that I've explained before here, I get an intense second-hand fear response that renders me unable to watch scary movies. Just can't take it when the actress hears a noise and heads right down to the cellar to investigate when I know full well she should run even as I also know it's only a movie.

Now anxiety is a good thing when it sets off an appropriate 'fight or flight' response that allows us to recognize danger and either run or creep down those stairs provided we're fully certified in the martial arts (of course, karate is no use at all against the supernatural...). And it's a bad thing when it renders us unable to leave the house or apply for a job (met a patient like that just yesterday). But who'd have thought that an overactive--or indifferent--amygdala might affect our political beliefs? Well, color me conservative as I read the following from Science Magazine.(1)

Political scientists teamed up with psychologists in Texas and Nebraska to find out if our political beliefs might have a biological basis. In their own words:

In a group of 46 adult participants with strong political beliefs, individuals with measurably lower physical sensitivities to sudden noises and threatening visual images were more likely to support foreign aid, liberal immigration policies, pacifism, and gun control, whereas individuals displaying measurably higher physiological reactions to those same stimuli were more likely to favor defense spending, capital punishment, patriotism, and the Iraq War.

During session one, the scientists quizzed the group--preselected for the strength of their political convictions no matter what the content of their attitudes-- on their political beliefs, demographics, and personality traits. When the subjects next came down to the lab, they were hooked up to physiological equipment that measured change in skin conductance as well as the strength of their blink or startle response. They were then shown three threatening images (a very large spider on the face of a frightened person, a dazed individual with a bloody face, and an open wound with maggots in it) or three sweet little pictures (a bunny, a bowl of fruit, and a happy child) interspersed amongst non-charged visuals.

Arousal causes increased moisture on the skin which increases conductance and fear causes a hard flinch or blink response of the muscles around the eye. Well I don't think I'd have a problem with a maggot show, but I know my heart rate would rise and I'd shut my eyes in moment to a large spider crawling on someone's face. The investigators found that an exaggerated response to the threatening pictures did correlate with a more conservative or socially protective attitude.

While the researchers were reluctant to conclude just what cause and effect processes were at work, they conjectured that "political attitudes and varying physiological responses to threat may both derive from neural activity patterns, perhaps those surrounding the amygdala. Amygdala activity is crucial in shaping responses to socially threatening images and may be connected to political predispositions."

Please note that in no way do I imply that all social conservatives have an exaggerated fear response. Nor do I think that close vigilance on the part of our society with respect to external danger is a bad thing.
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Oxley, DR, et al. Political Attitudes Vary with Physiological Traits. Science19 September 2008: Vol. 321. no. 5896, pp. 1667 - 1670.

Viagra, women, and antidepressants

Depression is a surefire way to kill your libido. Treating depression with antidepressants is also a surefire way to kill your libido. Initially, patients may be so relieved to no longer be depressed that they are willing to give up their sexual interests for the medication benefits. After awhile, however, the increased pleasure in life and relationships makes intimacy issues unacceptable.

Doctors at the University of New Mexico wondered if phosphodiesterase type 5 inhibitors (aka Viagra, Cialis, or Levitra) might improve the sexual outlook for women whose spirits have risen on antidepressants even as their libidos have fallen. Viagra and company are known to lift certain parts in men on depression meds.

Over a period of 4 years, they randomized 98 women whose depressions AND sexual interests were completely squashed on serotonin reuptake inhibitor type medications. Taking no one's word for granted, they not only followed up the women's sexual activity event log, but also administered the Clinical Global Impression function scale, the Female Sexual Function Questionnaire, the University of New Mexico Sexual Function Inventory (female version of course), AND the Hamilton Depression Rating scale (just to make sure no depression was creeping back in the picture).

The women on the real deal Viagra sent their Clinical Global Impression sexual function scale soaring to nearly double the levels of their pre-treatment activity. They also improved their scores on their Sexual Function quizzes. The investigators do note that this study selected for a group of women motivated to improve their sexual functioning and relationships, and therefore the findings might not be generalizable to all women experiencing such troubles while on antidepressants. It's also possible that filling out forms and quizzes on sexual functioning might enhance sexual interest.

I find this study particularly interesting as Viagra-like drugs work particularly well in men through the promotion of blood flow into certain parts that must be engorged with blood for proper sexual functioning. It is encouraging to find that the medications can increase interest and activity in women whose sexual response is less dependent on the localized pooling of blood.

Herd Immunity...

or why you should get a flu shot.

Flu season is coming, and hopefully this year's outbreaks will be preceded by a robust flu shot season. Here are the 2 most commonly cited reasons why my patients decline the vaccine:

1. I always get the flu from the flu shot. While some people notice fluish sorts of symptoms such as mild fever and muscle aches after receiving the shot, the inactivated viral particles which comprise the vaccine cannot cause disease.
2. I never get the flu. Well, lucky you. Remember, however, those who await your arrival back home. Perhaps you generally don't get the flu, but if you with your hardy immune system pick up a mild case while in close proximity with the coughing public, that young child, elderly grandma, or chronically ill spouse could be vulnerable to an amplified version of same with devastating or even fatal results.

Be a good member of the herd. When you get vaccinated, the influenza virus does not get a free ride in your respiratory tract on to its next victim.

You can change your wicked ways...

but at the heart of your matter, your poor choices live on.

The Coronary Artery Risk Development in Young Adults (CARDIA) study followed twenty years of health outcomes in over 3500 young adults. The researchers studied modifiable risk factors such as cigarette use, prehypertension (BP's 120-139/80-89), LDL-cholesterol, and fasting blood sugars.

Many of the subjects with less than sterling health habits didn't smoke that much nor did they have huge elevations in the other parameters studied. Many of them turned their acts around and improved their lifestyle choices over the course of the trial. Despite improvements made, their early adult profiles were more predictive of the presence of coronary artery calcification (CAC) after age 35 than their most current situation. CAC has been shown to correlate with the presence of atherosclerotic changes in coronary arteries.

Voltaren Gel

This is a great idea, but the logistics are awkward.

Voltaren is an non-steroidal anti-inflammatory (NSAID) pain reliever, and a rather effective one at that. It is available in pill form as the generic diclofenac. The downside of any NSAID is its adverse effect on the stomach and intestinal tract, causing pain, gastritis, ulcers, and diarrhea. In addition, the drugs can increase the risk of stroke and heart attack, and, in susceptible individuals, can decrease blood flow to the kidneys thus increasing the risk over years of use of decreased kidney function. Specific to Voltaren is the risk of "severe hepatic reactions, including liver necrosis, jaundice, fulminant hepatitis with and without jaundice, and liver failure" per www.voltarengel.com. Well shoot, who wants any of that?

We do, however, want arthritis pain relief, and Voltaren does that well. So Novartis minced it up and put it in an alcohol-based gel so that we could smear it right on our throbbing joints. Once absorbed through the skin, it reduces arthritic hand pain 46% after 6 weeks of use, and pain levels plunge 51% after 3 months of slathering it on arthritic knees. Drug levels reaching your stomach, kidneys, and liver are 6% that of an oral dose so, while the risks are not nothing, they're a whole lot less than the pill delivers.

The problem is in the how much cream how often department. The web site recommends 2 gm four times daily to upper extremity sites and 4 gm four times daily for the lower extremity. A tube of toothpaste is 170 gms so that amount of Voltaren Gel would get you through just over ten days of knee treatment. The stuff is definitely gooey, lightly but pleasantly scented, and dries within 4-5 minutes leaving a light sheen but no residual sticky stuff. I cannot imagine using it during the workday if I wore pantyhose. Pulling them back up again after gelling your hip would be like getting a wet bathing suit back on a small child. But then again, who wears pantyhose anymore? What about for one throbbing , chronically hyperextended index finger swollen from years of writing chart notes and prescriptions? The very thing I think, but you can't wash the area for 1 hour after each application.

The other problem is cost. By my calculations, you would apply your way through $172 worth of gel to service one bum knee for a month. Does insurance pay? Dunno, but I kind of think not.