The pit and the parabens

I just glanced at the ingredients on my deodorant's label, and it reads like the contents of a well-stocked biochemistry lab. Can this arsenal of armpit aromatizers contribute to breast cancer risk or is this just another urban myth? In case you need one more thing to worry about, read on for the evidence linking deodorant use to breast cancer.

Scientists from the UK noted that the majority of breast cancers are found in the upper, outer quadrant of the breast, nearest the armpit. They wondered if underarm hygiene habits, particularly the application of deodorant, contributed to this skewed tumor distribution. On sorting through 20 breast tumor samples, they found high concentrations of para-hydroxybenzoic acids (parabens) in 18 of the cancers.

Parabens are used as preservatives in cosmetics. Unfortunately, they are xeno-estrogens, meaning that they are molecules whose structure is similar enough to estrogen that they can occupy the estrogen receptor sites on cells. Korean scientists added butyl-parabens to mutant yeast cells (that had somehow been induced to express human estrogen receptors) and found that the parabens not only bound to the receptors, but also exhibited an additive estrogenic effect when administered along with estradiol. The yeast approved of their supple cell membranes and decreased hot flashes, but the investigators were concerned about the implications for human exposure to parabens.

Male rats, however, were not amused when their testosterone levels fell after they were exposed to parabens at levels equivalent to the "upper-limit acceptable daily intake of parabens in the European Community and Japan." Cultured breast cancer cells positive for estrogen-receptors increased their growth rate under the influence of parabens. But a population-based study in Seattle that randomly dialed for deodorant habits amongst breast cancer survivors and cancer-free controls found no association between armpit applications and breast tumors.

Molecular biologist Philippa Darbre was so appalled by her research results that she quit using cosmetic products some years ago. As I review the chemical stew in my Tom's of Maine deodorant, I can rejoice because it's parabens free. Likewise, the yummy-smelling stuff from Avalon Organics. Crocky or no, there's no reason to bother the breasts with the likes of parabens.

This is not cool. The bird flu virus (H5N1) strains in Africa and Europe are demonstrating a mutation that make them more infectious to humans.

Birds are literally hot; their body temperature is 106 degrees compared with our normal 98.6. Our airways are cooler still at an average of 91.4. This new flu change allows the little buggers to live well in cooler climes...such as our upper airways.

While the current influenza vaccine, of course, does not protect against bird flu, the fewer opportunities that H5N1 has to mix its genetic material with usual flu thriving in ordinary people, the better. Do consider getting a flu shot this year and every year.

Panic attacks: False biological alarms

Panic, which is the most dramatic form of acute anxiety, is the cry for life.
---Eric Griez, University of Maastricht, the Netherlands

If you've never had one, you cannot imagine how compelling and physical they are. The feeling is not a 'Hoo-boy am I anxious' one, but rather a 'Dear heaven I am not getting enough oxygen and I may pass out or die' sort of experience. Until I experienced one myself, I put some patients with panic attacks through pulmonary, cardiac, or GI work-ups. Now I often spot them coming based on their chief complaints of 'trouble breathing' as listed on my daily schedule.

I was instantly drawn, then, to an article in an October issue of PLoS One* regarding altered sensitivity to carbon dioxide as the basis of panic attacks. Scientists previously noted that individuals prone to panic have panic-attackish sorts of episodes if exposed to inhaled gases heavy on the carbon dioxide. The panic response to rising levels of carbon dioxide makes evolutionary sense, but an overactive, internal suffocation monitor can lead to unwarranted alarm.

Dr. Griez et al invited 64 panic-free volunteers down to the lab to suck a little air with varying concentrations of carbon dioxide. As carbon dioxide content rose, so did the volunteers' feelings of fear, depersonalization, and a loss of sense of reality. The authors are hopeful that this laboratory model of induced panic attacks may lead to better opportunities to study drug therapy for patients with panic disorder as well as for chronic pulmonary patients dealing with behavorial panic resulting from their high body levels of CO2.

My situational panic disorder developed after I was in a car accident. Although I was not injured, in the moments before the impact my best guess assessment was that I would die. I subsequently became scarcely able to breathe while driving and assumed (what internist wouldn't?) that I had a mid-chest tumor pressing on my trachea. Once I identified my difficulties as panic, the road back to carefree driving was a long strange trip through various medications and behavioral therapy.

If you suffer from panic attacks after in intense experience such as mine where you perceive your life is in danger, check out Crash Course. Dr. Heller's techniques were the most helpful to me in my recovery.
_____
*Griez EJ, Colasanti A, van Diest R, Salamon E, Schruers K (2007) Carbon Dioxide Inhalation Induces Dose-Dependent and Age-Related Negative Affectivity. PLoS ONE 2(10): e987.

Oh dear, do those of you who 'fessed up as fans of For Better or Worse, and Funky Winkerbean feel a little drained this a.m.? What a way to start the day: tragicomics!

Exercise that is good for the heart is not detrimental to the knee joint.
---Flavia M. Cicuttini, PhD and colleagues*

Well that's good news. I was just debating tonight whether to take my right knee to step aerobics tomorrow or not. One deep knee bend over the sprinkler system three weeks ago left me with screaming pain from the lateral meniscus. It's much better now--who knows why--and I wondered if it was sheer folly to step out to a little music much needed by me for the heart and the soul.

Dr. Cicuttini et al studied nearly 300 adults over 10+ years. At study's end, their knees were, on average, 58 years old. The investigators correlated their activity logs with the amount of cartilage still clinging to the top of their tibiae on the bottom of their knee joints. Those who particpated in more frequent vigorous exercise in the years prior to the study had a significantly larger chunk of residual cartilage compared with those who sat out the decade on the couch. And the best predictor of defect-free cartilage was each individual's current participation in vigorous exercise.
_____
*Racunica TL, et al "Effect of Physical Activity on Articular Knee Joint Structures in Community-Based Adults" Arthritis Rheum 2007; 57: 1261-1268.

Dr. Smak, whose blog posts invariably ring true in my experience and often crack me up, commented today that inspecting used tissues is often instructive. Reminds me of a patient's visit last cold and flu season that sent my staff scurrying for the Lysol.

She came to her appointment for 'sinusitis' carrying a large grocery sack. She didn't, however, save her contents for my eyes only but proceeded to dump them over the front office counter.

"See," she said, indicating at least a hundred used tissues spread out on the surface, "I used all of these in just one day!"

Even the earliest physicians supported inspecting your a.m. productions


Rise early...every day to see what has gone down from the anus.
If it has gone down like black lumps you shall say his belly is
in a bad state, blistered.
--Ancient Egyptian medical text, circa 2,000 BC

She's got Bette Davis eyes...

Did Bette Davis have thyroid eye disease (TED)? Her prominent eyes are characteristic of a mild case of TED or Graves ophthalmopathy. This eye condition is associated with hyperthyroidism which is also known as Graves Disease where the body directs antibodies against its own thyroid tissue causing the gland to overproduce thyroid hormone. At times, these same antibodies cross-react with the tissues behind the eyeball causing the eye to bulge outwards.

Three times in as many months I have had female patients (this condition--as are all autoimmune problems--is more common in women) look at me through Bette Davis eyes. Not only were their eyes quite prominent, they also displayed lid lag (the eyelids lag behind the eyes' movement as the patient looks downward) and a staring gaze as the retracted upper lids revealed a band of the white part of the eye above the colored iris they looked straight ahead.

One of these patients was indeed hyperthyroid on lab testing while the other two had normal thyroid function. All three women had elevations of the auto-antibody called thyroid stimulating immunoglobulin or TSI. Unfortunately, treatment for hyperthyroidism does not affect the course of the eye problem, and a few patients will ultimately need surgery to not only avoid 'Marty Feldman eyes,' but to relieve the eye irritation that results from an inability to completely close the lids over the eyes.

BRBPR

The world is divided into those who look at their productions before flushing, and those who push the lever with nary a backward glance. Even though I declared myself a non-discloser in my last post, I must admit I am one of the former. It's just good self-care I think.

What you do NOT want to see is BRB or bright red blood. This BRBPR (that's Per Rectum per MD abbreviations) is alarming, and no further prodding should be needed to visit your MD for prodding. Yesterday was BRBPR day--two women with same, but two different problems.

I've mentioned before my reluctance to examine 'samples' that patients bring me in baggies and bottles, but BRBPR Patient #1 was an exception. These (blood) out-of-body experiences tend to look worse to the bleeder than they really are, so Pt. #1's specimen in a jar was instructive. It was indeed blood--not bits of sun-dried tomatoes--and a fair amount of it at that, deep maroon and mixed in with stool.

Other than this being episode #3 in as many months for her (no alarmist she!), she felt quite well, no pain, no fever, no weight loss, no loss of appetite. Classic story for diverticular bleeding. Diverticula are little intestinal outpouchings that occur commonly in middle-age and beyond. Those of us who are under-fibered and stopped up on Western diets are at particular risk. Mostly asymptomatic, diverticula can become inflamed (diverticulitis) or occasionally hemorrhage. There's no depouching a colonic pouch, however, if they continue to bleed--and they can bleed big-time--the solution is a surgical parting with that part of the colon.

Pt. #2 was also passing BRBPR. She was thankfully sampleless, but her bleeding occurred after she began large doses of ibuprofen for back pain. She developed diarrhea (a known Intestinal complication of ibuprofen) and the blood followed. While diarrhea can cause hemorrhoids to flare-up and bleed, I suspect she will be found to have intestinal ulcerations from the use of this OTC analgesic.

8 Random Facts About Me

Tagged by Suture for a Living means I now must list 8 facts about me and tag 8 others to do the same. I am a listener, not a self-discloser, by nature, so this is a rough one. Here goes:

1. I love shopping in thrift stores.
2. I was a hippy in the early '70s.
3. I have a mild case of disposaphobia, and in particular I am a victim of unread magazines.
4. I am teaching myself Spanish just to see if I can do it by reading my son's old textbooks and watching Spanish language TV. I will never understand why they talk so fast that I can never understand them.
5. I often cry over the morning paper, including the comics Funky Winkerbean and For Better or Worse. What sort of comics make you cry over them?
6. My favorite guilty pleasure is Mexican pizza from Taco Bell.
7. I used to smoke cigarettes.
8. Drinking alcohol makes me so tired that I am always sorry when I do.

It's hard for me to spout random facts about myself on the Internet, so I'm going to pass on tagging others even if it means I break the chain and will have seven years of bad luck.

I came of age in the '60s, so I'm a little behind in the world of body beautification. How, I'd wonder, do so many women have blond hair, curls, tan breasts? Well, of course, it's dyed, it's permed, it's a tanning booth stupid. I understand the how of the latest trend in pubic hair or lack thereof (it's waxed), but I don't get the why.

I try to keep my observations to myself on various piercings, tattoos (can't really say 'so what's up with the green teddy in a pink nightcap on your chest, dude?'), and shavings, but recently I just had to ask a twenty-something whom I've known since she was in high school about her pubic hairstyle.

The pattern, she laughed, is called a landing strip. Or did she maybe say a parking stripe? Either way, I got the point.

A novel way to lose weight

I'm always delighted when patients lose weight, and I always ask them how they did it. Here's a new one:

Phil lost weight because his wife had a hysterectomy. Well, you might say, she obviously ceased cooking during her post-op recuperation, and he then lost weight. Not that simple.

Phil's wife is a lousy cook. Despite her deficiencies in meal prep, and his lack of time, interest, or skill in doing it better himself, he ballooned up to nearly 300 pounds. You see, even though he did not enjoy the meals, he felt bad that his wife was near housebound with heavy periods and pain, so he always took seconds to make her feel better.

After many years of sympathy seconds, he actually became diabetic within the last year. As his weight topped out in spring, I pleaded with him to lose weight. This summer, he carried 10# less into his follow-up appointment. She felt better, and he passed on the extra helpings.

And I always thought it took exercise and self-discipline...

My laughs for the day

I was hauling a box loaded with textbooks into the post office to mail to my daughter. A thirty-something man behind me hurried forward to open the door for me.

Me: Thanks
He: You're welcome, that looks heavy. (He leans forward confidentially) Besides my dad is watching from that car over there, and he'd be mad if I didn't help the lady.

Later, taking blood pressure on a woman during a physical exam.

Me: Hold this (I thrust the BP gauge into her other hand)
Me: Uh, could you move your thumb so I can read the dial?
She: Oh sorry, I didn't even realize what I was holding. It could've been a turd for all I knew; I'm a teacher, I'll hold anything.

The point of no return

I've noted in my practice that people go for years with slightly abnormal, gradually increasing, blood sugars, a state known as impaired fasting glucose. Then abruptly and suddenly, they plunge into diabetes. Phoenix doctors, analyzing blood sugar data over years of studying Pima Indians (an ethnic group known for high prevalence of diabetes) confirmed this pattern.

A consistent trend was apparent in those individuals who became diabetic over the course of the analysis. Blood sugar at first rose in an even, linear sort of way, then turned upward with a rapid exponential rate.

The timeframe of this latter change may be very rapid for some individuals - beyond our ability to detect with biennial exams, meaning that some individuals transition from a normal to a diabetic state in less than 2 years, and how much less we do not know.
---Dr. Clinton Mason, National Institutes of Diabetes and Digestive and Kidney Diseases

Dr. Mason theorizes that interventions could prevent this rapid final rise of blood sugars into the diabetic range, thus delaying for years that dangerous development.

We can't change them into the happy, laughing life of the party, but we can keep them out of the coffin.
---Steve Cole, genomics researcher at UCLA

The chronically lonely are known to be more likely to suffer from ill health. A recent study suggests that this state of mind actually affects gene action in a way that decreases immune response and increases inflammation.

Dr. Cole and his colleagues set out to find the biological basis for the detrimental effects of loneliness on health. They studied the DNA of a group of 153 volunteers, looking for abnormal gene expression as related to the self-expressed degree of loneliness in their subjects.

The UCLA Loneliness Scale was used to determine just how isolated these folks felt. Then DNA gleaned from white blood cells of the 8 top lonely scorers was compared with the DNA from the 6 subjects most connected to others. The researchers found 209 genes abnormally expressed in the lonely genome, many involved in activation of the immune system and production of inflammation. The genes in charge of inflammation were overexpressed, and those that regulate the production of antibodies against bacteria and viruses were underexpressed.

These results may explain why isolation and loneliness increases vulnerability to infection and cardiovascular disease. Dr. Cole theorizes that strategies that decrease inflammation may promote better health amongst the isolated.

Programmed cell death (PCD)

That's a good thing. All you have to do is look in the mirror after a certain age to realize that old cells don't function like young ones. Eliminating old cells in an orderly fashion (and this is done by voluntary cellular suicide) prevents the buildup of abnormal cells whose DNA is mutating in an unfortunate sort of way after years of attacks by roving bands of free radicals.

Population studies suggest that those in the populace who are physically active have a lower risk of colon cancer. Dr. Kristin Campbell and colleagues in Seattle set out to determine if regular exercise encouraged old colon cells to check out in a programmed sort of way.

Nearly 200 men and women were randomly assigned to slouch on in their usual low-activity sort of way or join in a fun aerobic exercise program for one hour on six days each week over the course of a year. Colon tissue samples were collected from all before and after the study period (whoops--fun's over!).

The analyzed samples indicated that exercise increased PCD in the bowels of men but not in women. Campbell was unclear why women's colonic linings were uninterested in the effects of exercise. With regards to the suicidal cells of men, she noted: "We are interested that we saw changes--now we have to figure out why."

Speculum reprieve...

for certain groups of women. The U.S. Preventive Services Task Force has reviewed the pros and cons of that annual dreaded ritual of a Pap smear and determined that some of us can pass:

The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease.

The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer.

This does NOT mean those of you in the above mentioned groups should forego the annual exam, including the health review, blood pressure check, and breast exam. Just say no to the speculum.

Glycosylated hemoglobin

If you don't know what this is, chances are good that neither you nor your near and dear have diabetes. This test, also known as hemoglobin A1c or HbA1c, is a measure of how much glucose your iron-containing hemoglobin molecules are carrying.

Over the course of the 120 day lifespan of a red blood cell, the hemoglobin within binds irreversibly with glucose, forming glycosylated hemoglobin. The higher the level of glucose in the blood, the greater the fraction of hemoglobin A all gummed up with sugar. Although a little junk food binge would be immediately reflected in subsequent blood sugar measurements, it would take 2-4 weeks of binging to affect the HbA1c levels.

For that reason, HbA1c is used to monitor long-term success in the treatment of diabetes. It is not used to diagnose diabetes; the disease is defined by elevated fasting glucose levels or an abnormal glucose tolerance test. Boston researchers* using data from the Women's Health Study, however, have found that elevated HbA1c levels even though still within the normal range are potent predictors of future diabetic risk.

Over 26,000 women age 45 and older with baseline A1c levels of 5 (ideal is <6% and goal for diabetics is <7%) were followed over 10 years for the development of diabetes. Relative to the old gals who maintained A1c values of 5, those who dinked above 5.5 but less than 6 had three times the diabetic risk; this risk rose 29-fold for those between 6 and 6.4 and the women above 7% had 81 times the risk which pretty much means they became diabetic.

Dr. Aruna Pradhan and colleagues issued the usual bland sort of 'needs further study' statement: Although these data do not support the use of HbA1c as a single measure of diabetes risk, our results do suggest that the prognostic significance of elevated HbA1c may warrant a greater emphasis in primary prevention.
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Am J Med 2007;120:720-727.

A vast sea of misery could be avoided if this condition received the same attention and resources as AIDS or cancer.
---Marjorie Wallace, chief executive of the UK mental health charity SANE on depression

Depression has a greater impact on quality of life than most medical conditions. Worst of all with respect to overall health is the combination of depression plus a co-morbid medical condition.

If my patients wonder why I increasingly run behind through the day, on average it's because I often ask "And how are you holding up with all this." Seldom a short answer to that one.

Vaccination Schedules

One dose is better than no dose.
---www.immunize.org/guide

Yesterday a young woman came in for her second dose of Gardasil. The recommended interval between dose #1 and dose #2 is 2 months, but she'd received her first shot three months ago. She asked me if that was a problem.

Increasing the interval between shots in a 2-dose or 3-dose series does not diminish the effectiveness of the vaccine, it just delays the development of immunity against the disease. Per the CDC, the vaccination series does not need to be started over again in this case.

More problematic, however, is decreasing the intervals between doses to accomodate patient preference in scheduling. This, the CDC web-site notes, can prevent a full antibody response to the vaccination. On the other hand, even if you never get back for that follow-up dose of hepatitis-A, hepatitis-B, Gardasil, or MMR, a little immunity is better than none at all.

Good IDEA-033

I am a great fan of delivering drugs through the skin. As we age and transdermal technology expands, we may tape ourselves together with patches containing hormones (for women and for men), antihypertensives, antidepressants, neurostimulants (Ritalin), and now this, slather-on pain relief:

IDEA-033 is a formulation containing ketoprofen in an ultradeformable vesicle aka Transfersome. Ketoprofen, a non-steroidal anti-inflammatory drug or NSAID (same class of drugs as Advil and Aleve) is loaded into these ultradeformable carrier particles and smeared on painful, arthritic knees.

Germany's Matthias Rother explains the idea behind IDEAs: "Once the Transfersomes are on the skin, water starts to evaporate and deprive carriers of their suspending medium. Carriers reaching their solubility limit are attracted by the higher water content in the skin, resulting in spontaneous migration of IDEA-033 through the skin barrier.

Now in the skin, the little Transfersomes migrate into the next structure down which is the unhappy knee joint. Once there, the ketoprofen goes to work on the inflammation, delivering pain relief equivalent to Celebrex.* Best of all, there's no associated stomach irritation as would be found with an oral NSAID.
_____
Ann Rheum Dis. 2007;66:1178-1183.

Gardasil

Gardasil

This vaccine against several strains of the human papilloma virus (HPV) is recommended for girls and women under the age of 26. This group, when sexually active, is particularly vulnerable to the carcinogenic effects of certain HPV sub-types, particularly 16 and 18.

I have many women past 26 ask me if the shot would be appropriate for them as well. The problem, as women get older, is that they are more likely to have already been infected by these strains of HPV. Once exposed to 16 and 18, a recent study suggests that the vaccine is not particularly efficacious in improving the possibility that women can immunologically kick these bad actor HPV types out of their cervical cells.

Researchers* studied 2000 HPV-positive women in Costa Rica over a 12 month period. One group received the bivalent HPV-16/18 vaccine and the others received a control vaccine against an unrelated virus. Both groups developed acquired immunity against the virus at similar rates, suggesting that those who did mount an immune response were doing so under their own power without a boost from the vaccine.

This study emphasizes that there is an optimal time to vaccinate against this cancer-causing virus, and that is before exposure, i.e. before the onset of sexual activity.
_____

Hildesheim et al. JAMA. 298, 743(2007).

Good news for old coots

Men prefer mates who are younger and women prefer mates older than themselves.
--Fieder, M, Huber S. Biol Lett. 2007 Aug 28.

Old(er) guys who snag young wives appear to have an evolutionary advantage over younger men. According to the anthropological team of Fieder and Huber, "maximum offspring count" occurs if HE is 6 years older than SHE.

This study was based on data from 10,000 Swedish baby boomers. They found that a pairing of younger moms with older dads produced 5% more progeny than same-age couples. Over a large population, this may represent a huge evolutionary advantage to those women who genetically find older guys attractive and vice versa.

Doc-in-a-Van

Some patients are just plain uncomfortable sitting in a doctor's office.
--Randolph Swiller, MD, Ft. Lauderdale, FLA

So if the patient won't come to Dr. Swiller, he comes to them. In fact, that's what he does, all car rounds all of the time. He believes that medicine has become "time-centric and impersonal," and that home visits are "one way physicians can reclaim the high ground in medicine."

My lowdown on his high ground is that it sounds wildly impractical and inefficient. I am sure, however, that there are any number of people right here in Denver so spooked by the very idea of medical care that they would never set foot in a doctor's office. A free-wheeling MD (and Doc Swiller offers sliding scale visits!) could certainly change their lives.

In our culture, it's a difficult thing to talk about.
--Patricia Lenton, University of Minnesota's School of Dentistry, on bad breath

And this is one of my dilemmas--do I, and how do I, talk to people about body odors?

I spend a lot of time with people in the closed quarters of a small exam room. Cigarette smokers who smoke in their cars reek of old smoke. I don't have any trouble discussing their habit with them. People who drink alcohol before their appointment smell strongly of that, and I always initiate discussions with them--especially if they're my first visit of the morning!

But people with B.O. so bad that I have to abandon the room for an hour or two lest future patients think that I smell of old sweat, well I just can't bring myself to mention that. Likewise bad breath.

I feel like it's my duty to do so, but mentioning another person's odor is so taboo, I still can't point this out to my patients.

Gee whiz moments

Spontaneous gut feelings may be the stuff of which great discoveries are made. Consider Archimedes running naked from his bath after discovering the principle of buoyancy. Here's a real-life, up-to-date, Eureka moment from the Center for Marine Science (CMS) at the University of North Carolina.

Marine biologists already knew when there's a red tide in the morning, asthmatics take warning. The microorganism responsible for red tides produces a powerful toxin that constricts airways. If an onshore breeze blows this noxious spray inland, susceptible individuals may experience an asthmatic attack. But these little red buggers, aka Karenia brevis, also make a substance dubbed brevenal that counteracts their pulmonary poisons and reverses bronchial spasm.

CMS investigator Andrea Bourdelais discovered this potentially useful substance while dosing guppies in the lab with K. brevis products. Those guppies that survived the first red blast seemed oddly immune to another dose of red tide toxins. Per Dr. Bourdelais:

I had a spontaneous gut feeling--a gee-whiz moment--that the first material was an antidote to the second one.

Not only does brevenal block red tide brevetoxins, the substance also seems to promote mucous clearance. Airway blockage and sticky mucous are two lethal characteristics of cystic fibrosis, and brevenal seems to counteract these tendencies more potently than amiloride, a drug currently used to alleviate CF symptoms.

Will brevenal effectively work in humans born with this genetic disease? While trials on asthmatic sheep suggest this may be the case, scientists plan to first test brevenal on manatees. This endangered Florida sea mammal is also rendered breathless by red tides. Veterinarians at Lowry Park Zoo in Tampa, Florida have the FDA green light to break out the brevenal for manatees affected by the next red tide.

Never-ending coughs

As the new school year approaches, I face once again the prospect of being shut up in an exam room with someone in thin control of thick secretions. There are days during the cold and flu season where I feel like shouting into the waiting room "Go home, there is nothing I can do for you. Pick up a prescription for codeine cough syrup from the receptionist and call me in two weeks if it hasn't gone away."

Now, courtesy of The American College of Chest Physicians, there's a whole new lexicon in cough diagnoses. No more 'cough due to post nasal drip' as in the gunk slipping down the back of your throat is making you cough. Upper airway cough syndrome sounds more worthy of that pricey visit co-pay anyway, and the new name recognizes that it's not just about the mucous stuck in your throat anymore but also about inflammation of the cough receptors in the upper airway.

What about the never-ending coughs from hell following chest colds? These coughs last more than 2 months here in Denver where the air is dry and filled with dust and automotive schmutz through the winter months. These coughs are now called post-infectious cough secondary to upper airway cough syndrome.

While the chest docs recommend treatment with an antihistamine-decongestant combination drug, I prefer prescription Tessalon Perles (generically available as bezonatate) which specifically quiets those unhappy cough receptors. The new guidelines also tap an inhaler called Atrovent (ipratropium) as useful for post-infectious coughs.

Zelnorm is back

On a limited basis. If you found this drug to be a moving experience for your chronic constipation, the FDA has created a loophole through which you can get back on it.

This is the IND option, or investigational new drug protocol program, which states:

In some instances, patients with a serious or life-threatening disease or condition who are not enrolled in a clinical trial may be treated with a drug not approved by the FDA. Generally, such use is allowed within guidelines called a treatment IND, when no comparable or satisfactory alternative drug or therapy is available.

So while Zelnorm was yanked from the market in March when its use was linked to increased risk of ischemic cardiovascular outcomes, youngoid women under 55 with constipation from IBS or CIC (chronic idiopathic constipation) can apply for a waiver.

Big-time constipation is a real show-stopper. If you miss your Zelnorm, ask your MD to call the manufacturer at 888-669-6682 to open up options for your bowel woes.

Death by caffeine

Despite my dispatches on the health benefits of real deal coffee, I had no less than three patients yesterday admit apologetically that they still drank coffee. No apologies needed, I'm a fan! I don't even trust people who don't drink the stuff.

Imagine then how dear to my heart is Mark Malkoff who visited every Starbucks in Manhattan within a single day. Would you like to watch him do it? Check out 171 Starbucks in 24 Hours. While you're visiting energyfiend.com, you can also determine how much is too much by clicking on "Death by Caffeine." I found that 56 1/2 cups of my morning coffee would do me in.

THE defining moment

Well I've been debating ever since my last posting about whether or not to share this DM with you. I don't want you to think me unprofessional, and, after all, I did sign this Med Blogger Code of Ethics thing. However, if I relay something that happened in the course of practicing my profession in a dispassionate sort of way, how could that be deemed unprofessional?

The schedule noted her visit as Stomach flu. She sat down by my exam room desk and began rummaging in her large bag. After extracting a baggie, she tossed it across the desk to me.

Uh-oh. Close encounters of the turd kind. Thank heavens for Snap n' Seal. This, she declared, is what's coming out of me. What almost came out of me is uncontrollable laughter. The final crowning moment of the quintessential DM? She started to leave the room without her production at the end of the visit. Would you mind, I asked gently, taking that along with you?

Defining moments

I find many of patients get associated in my mind with one 'defining moment,' whether it be some event in their lives that they've described to me or some notable medical problem that they've had. When I see them in the waiting room or even just seeing their name on the day's schedule evokes these strong associations.

One delightful sixty-something African-American woman wished to travel several years ago and went looking for a tour group to join. By some means unremembered, she hooked up with a busload of middle-aged white guys from a poker club in Colorado Springs. This odd pairing of my patient with this bunch of buddies turned out splendidly. While she has not been able to travel much since, the C. Springs men have called her on several occasions to join them on the road or just to see how she's doing.

Another one of my patients exactly my age told me on questioning that she had attended Kent State during her undergraduate years. Immediate goosebumps for me: "So you were there in the spring of '70?" (talk about a defining moment for an entire generation) "My roommate," she says, "died that day in my arms."

One of my favorite layered memories of a patient involves first finding years ago an extensive inflammatory cancer in her breast. On surgery, all lymph nodes found were positive for cancer. That, of course, is not the good part of the memory. What makes me smile is that ten years later she brought me a bottle of wine to celebrate a decade cancer-free. Even better yet, now 16 years have passed and wine or no, I love seeing her for mundane routine check-ups.

Brains join bowels and skin...

as body parts that thrive with daily caffeine.

French researchers studied 7,000 men and women with respect to their drinking habits and their ability to retain their marbles over the course of 4 years. The men, unfortunately, became tongue-tied and befuddled independent of coffee consumption. But the women, particularly the old gal octogenarians, remained nimble in word-finding and spatial orientation by tossing back three cups daily of the real caffeinated deal.

Per Karen Ritchie of the French National Institute of Medical Research:

The more coffee one drank, the better the effects seemed to be on (women's) memory functioning in particular.

Coffee also seems good for the basal ganglia, a part of the brain that regulates movement. Trouble here causes movement disorders such as Parkinson's Disease and also the abnormal muscle spasms known as dystonia. One form of dystonia is blepharospasm or eyelid twitching. Think Chief Inspector Dreyfus in "The Pink Panther." Coffee consumption inversely relates to risk of Parkinson's (the more you drink, the lower your risk of developing the disorder), and now a study from Italy suggests that daily use will also keep your eyelids still(1).
_____
Defazio G, et al. J Neurol Neurosurg Psychiatry. 2007 Aug;78(8):877-9.

Best Advice, Worst Advice

I once asked a patient who had recently completed breast cancer therapy what was the best advice she received and what was the worst. I don't actually remember what the best advice was so shocked was I to hear that I had offered her the worst advice. I counseled her to consider quitting her job to deal with the effects of chemotherapy. Well obviously you can't get chemotherapy if you've quit your job and lost your insurance. Quite an eye-opening lesson to me.

Now as I complete a heart-wrenching week considering nursing home or no for my mother, here's the best advice I got from my friend Ed:

Standing by her is the right thing to do. Whatever the burden on you--
which I know is huge--you are honoring your commitment. And of course you
can't do everything.

I found that very hard, personally...to know that I couldn't really lift
the weight off my mother. Her needs were infinite; my capacity to help was finite. But I offered what I could. You are doing the same.

My mom stays in her home. I continue on as #1 caretaker.

"...no reason to give it up"

Patients continue to tell me with pride that they have given up coffee. Gotta love coffee, however, and indeed I do. You see, what the drink does unto skin cells (see post below) it also does unto colon cells.

Japanese investigators studied the coffee-swigging habits of 96,000 people. While men showed no particular colonic benefit from coffee, women who indulged in 3 or more cups per day over the 12 year course of the study had less than half the risk of invasive colon cancer compared with their uncoffeed peers. Says Manami Inoue of the research team:

Some people cannot tolerate caffeine, so they should not force themselves to drink coffee. But for people who like it, there is no reason to give it up.

Dr. Allan Conney and his colleagues went looking for a way to provide hairless mice with a safe summer glow.

Caffeine-laced lab water increased the mice's ability to kill off precancerous cells in their icky white skin by 100% as did regular work-outs on the exercise wheel. But go-getter mice who indulged in caffeine AND exercise between sessions with the UV lamp were nearly 400% more effective at policing their sun-damaged DNA.

The researchers were hopeful that this simple formula for sun protection would work for humans as well. They issued, however, this final note of caution:

Don't go out and exercise and drink a lot of coffee and assume you're going to be protected. Keep in mind that these are studies in mice.
--Allan Conney PhD, Rutgers cancer researcher

Oscar the Cat

You've doubtless heard by now of Oscar the death-sniffing cat. He made my local morning newspaper; I'm sure he was in yours as well. Oscar lives at the Steere House Nursing and Rehabilitation Center in Providence, Rhode Island. He senses when the residents there are on their way out. Here's an excerpt from a day in his life as published in the latest New England Journal of Medicine(1):

Oscar arrives at Room 313. The door is open, and he proceeds inside. Mrs. K. is resting peacefully in her bed, her breathing steady but shallow. She is surrounded by photographs of her grandchildren and one from her wedding day. Despite these keepsakes, she is alone. Oscar jumps onto her bed and again sniffs the air. He pauses to consider the situation, and then turns around twice before curling up beside Mrs. K.

One hour passes. Oscar waits. A nurse walks into the room to check on her patient. She pauses to note Oscar's presence. Concerned, she hurriedly leaves the room and returns to her desk. She grabs Mrs. K.'s chart off the medical-records rack and begins to make phone calls.

Within a half hour the family starts to arrive. Chairs are brought into the room, where the relatives begin their vigil. The priest is called to deliver last rites. And still, Oscar has not budged, instead purring and gently nuzzling Mrs. K. A young grandson asks his mother, "What is the cat doing here?" The mother, fighting back tears, tells him, "He is here to help Grandma get to heaven." Thirty minutes later, Mrs. K. takes her last earthly breath. With this, Oscar sits up, looks around, then departs the room so quietly that the grieving family barely notices.

I was at my mom's today. She is suffering from a series of small strokes, and today was a particularly bad brain day. I think both she and I would have welcomed Oscar's ministrations this afternoon, but cat attendant or no, today was not the day.
_____
1. Dosa, DM. NEJMVolume 357:328-329 July 26, 2007 Number 4.

Exhausted arteries

My mom lives in a condominium complex with a beautifully landscaped central area, complete with pond. As you walk the grounds, a background roar suggests the wind or sea but is, in fact, the traffic noise of I-25 just behind the high wall surrounding the complex. Out of sight may be out of mind, but the arteries within may never forget that highway nearby.

German researchers studied nearly 5,000 subjects living in the industrialized Ruhr area(1). The participants underwent electron-beam computed tomography or heart CT scans to determine their degree of coronary artery calcification (CAC) which indicates the level of cholesterol build-up in arteries. The investigators found a significant correlation between CAC scores and the proximity of the nearest highway to the subjects' homes.

Immunologists at UCLA determined the underlying mechanism of this relationship between urban air pollution and risk of heart disease(2). In both human artery tissue samples and in mice, these California docs determined that diesel particles plus LDL-cholesterol leads to more severe atherosclerosis than either soot or cholesterol alone. Both arterial irritants cause the release of 'free radicals' or reactive oxygen molecules known to be highly damaging to human tissue.

My guess is that the summer air here in Denver that hangs visibly through the trees on a hot summer day is the equivalent of living next to I-25 with respect to our heart's health.
_____
1. Hoffmann B et al. Residential Exposure to Traffic Is Associated With Coronary Atherosclerosis Circulation. 2007;0: CIRCULATIONAHA.107.693622
2. Nel a et al. The cellular impacts of diesel exhaust particles: beyond inflammation and death. Eur Respir J. 2006 Apr;27(4):667-8.

...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.
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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.