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.