Pt: I have a tickle in my throat, so I tried not breathing for a couple of hours.
(Seriously, he was perfectly serious).
Thursday, November 06, 2008
Wednesday, November 05, 2008
"I need a breast biopsy..."
per the frantic e-mail on my desk, "but can't afford it. Can you order the new blood test instead/ how much will it cost?"
Argh, that dreaded phone call about the abnormal mammogram. I've gotten one as have many of my patients. Follow-up, at times, is simply a matter of additional mammographic views, maybe follow-up films in 3 or 6 months, perhaps an ultrasound. Radiologists are extremely cautious in their reports, often calling patients back for further imaging, and sometimes--insomnia city-- advising a biopsy.
I've read hundreds of abnormal and suspicious reports. Often, there is a 'vague rounded density' that turns out to be just the superimposed shadows of breast tissue heaped on breast tissue, all normal. Frequently, there are 'microcalcifications' that look benign but a short-term follow-up is ordered to assure the little flecks are stable and not increasing in number.
But... this lady's report said "highly suspicious" and "spiculated" and these are not hedge words but a near definite diagnosis of cancer. This is not a dink around with a brand new screening test sort of report, but a work out a payment plan and get that biopsy done report.
Tomorrow: What's up with this new screening test? I didn't know, so I looked it up.
Argh, that dreaded phone call about the abnormal mammogram. I've gotten one as have many of my patients. Follow-up, at times, is simply a matter of additional mammographic views, maybe follow-up films in 3 or 6 months, perhaps an ultrasound. Radiologists are extremely cautious in their reports, often calling patients back for further imaging, and sometimes--insomnia city-- advising a biopsy.
I've read hundreds of abnormal and suspicious reports. Often, there is a 'vague rounded density' that turns out to be just the superimposed shadows of breast tissue heaped on breast tissue, all normal. Frequently, there are 'microcalcifications' that look benign but a short-term follow-up is ordered to assure the little flecks are stable and not increasing in number.
But... this lady's report said "highly suspicious" and "spiculated" and these are not hedge words but a near definite diagnosis of cancer. This is not a dink around with a brand new screening test sort of report, but a work out a payment plan and get that biopsy done report.
Tomorrow: What's up with this new screening test? I didn't know, so I looked it up.
Sunday, October 26, 2008
Glycemic index
Bagels and cornflakes and jelly beans, oh my. These--plus baked potatoes--are the worst of the worst of food choices for those of us who do not want to develop diabetes. These foods not only have a high glycemic index but also a high glycemic load. So flakes in the a.m. may leave you flaky and foggy-brained long before lunch.
All carbohydrates are not created equally in that some raise your blood sugar more rapidly than others. The glycemic index (GI) is calculated by measuring the change in blood glucose level that occurs when a person who has been fasting consumes that food. The elevation is then compared to the blood glucose response associated with a standard highly refined, high-carb food such as white sugar (which has a GI of 100).
The higher the GI, the more the food acts in the body like pure sugar, stressing those balancing mechanisms charged with keeping our blood sugar in an ideal operating range. Cornflakes (GI=92) send blood sugar soaring, causing the pancreas to respond with the release of lots of insulin which then efficiently sweeps the carbs into the cells. This causes blood sugar to plummet, leaving Kelloggs consumers with a mid-morning blood sugar too low to sustain brain functioning. While a trip to the office jelly bean (GI=78) jar may restore the blood sugar briefly, this quick fix just perpetuates the vicious cycle.
But nothing is really all that simple. Milk (GI=27) on the cornflakes changes the cereal's effects in unpredictable ways. And some foods with high GIs may have low glycemic loads (GL) which measures the actual blood sugar response to typical servings of foods. So a low GL (considered to be less than 10) on a high GI food choice indicates that you'd have to eat a ridiculous quantity to raise your sugar in ways predicted by its GI. For instance, pineapple has a moderatly high GI of 66 but a low GL of 7. You would have to consume 1 ¾ pounds in a sitting to raise your blood sugar in the same way that a handful of raisins (GI 64, GL 28) would.
Is your head swimming as if you just ate a baked potato (GI 85, GL 26) without sour cream, butter, and a steak (GI 0, GL 0) on the side? Experts agree that this approach may be too complex for many of us, encouraging us instead to eat foods that are not highly processed--which generally increases GI--and a diet that includes a wide variety of fruits, vegetables, and low-fat dairy products.
All carbohydrates are not created equally in that some raise your blood sugar more rapidly than others. The glycemic index (GI) is calculated by measuring the change in blood glucose level that occurs when a person who has been fasting consumes that food. The elevation is then compared to the blood glucose response associated with a standard highly refined, high-carb food such as white sugar (which has a GI of 100).
The higher the GI, the more the food acts in the body like pure sugar, stressing those balancing mechanisms charged with keeping our blood sugar in an ideal operating range. Cornflakes (GI=92) send blood sugar soaring, causing the pancreas to respond with the release of lots of insulin which then efficiently sweeps the carbs into the cells. This causes blood sugar to plummet, leaving Kelloggs consumers with a mid-morning blood sugar too low to sustain brain functioning. While a trip to the office jelly bean (GI=78) jar may restore the blood sugar briefly, this quick fix just perpetuates the vicious cycle.
But nothing is really all that simple. Milk (GI=27) on the cornflakes changes the cereal's effects in unpredictable ways. And some foods with high GIs may have low glycemic loads (GL) which measures the actual blood sugar response to typical servings of foods. So a low GL (considered to be less than 10) on a high GI food choice indicates that you'd have to eat a ridiculous quantity to raise your sugar in ways predicted by its GI. For instance, pineapple has a moderatly high GI of 66 but a low GL of 7. You would have to consume 1 ¾ pounds in a sitting to raise your blood sugar in the same way that a handful of raisins (GI 64, GL 28) would.
Is your head swimming as if you just ate a baked potato (GI 85, GL 26) without sour cream, butter, and a steak (GI 0, GL 0) on the side? Experts agree that this approach may be too complex for many of us, encouraging us instead to eat foods that are not highly processed--which generally increases GI--and a diet that includes a wide variety of fruits, vegetables, and low-fat dairy products.
Wednesday, October 22, 2008
LDL particle size
LDL stands for low density lipoprotein, a worthy protein that picks up cholesterol particles that have either been absorbed from your diet or manufactured by your liver and totes them out to the cells. And it's a good thing that we have LDL-C; our cellular membranes are made out of cholesterol as are our steroid hormones. But as you know, while a little LDL-cholesterol (LDL-C) is a good thing, a lot is not. In susceptible persons, excess LDL-C enters the arterial wall where it may become oxidized and set off a world of inflammation and cholesterol schmutz known as atherosclerosis.
Turns out, there's bad LDL-C and then there's really bad LDL-C, and the difference lies in the particle size. There's no improving on the metaphors of noted lipidologist Dr. Thomas Dayspring, so here's the scoop in his own words:
Large-sized LDL is a beach ball. It bounces off the artery and goes back to the liver. Small LDL is a bullet. It lacks vitamin E, is very prone to oxidation, and crashes right through the artery.
So how do you know if your cholesterol is bouncing or crashing? LDL particle size is measured in the pricey VAP test which stands for vertical auto profile, but the information is actually right there on your standardized lipid profile. If you've got triglyceride levels over 200 and HDL-cholesterol (that's high density lipoprotein or the good stuff) levels below 45 (35 for the guys) we're probably talking bullets in your bloodstream.
Any hope of changing bullets to beach balls? Well surprise surprise, it's the same old song as always--weight loss and exercise. But wait, there's drugs that help as well, including Tricor, gemfibrozil, niacin, and the diabetic medication metformin, Actos, and Avandia.
Turns out, there's bad LDL-C and then there's really bad LDL-C, and the difference lies in the particle size. There's no improving on the metaphors of noted lipidologist Dr. Thomas Dayspring, so here's the scoop in his own words:
Large-sized LDL is a beach ball. It bounces off the artery and goes back to the liver. Small LDL is a bullet. It lacks vitamin E, is very prone to oxidation, and crashes right through the artery.
So how do you know if your cholesterol is bouncing or crashing? LDL particle size is measured in the pricey VAP test which stands for vertical auto profile, but the information is actually right there on your standardized lipid profile. If you've got triglyceride levels over 200 and HDL-cholesterol (that's high density lipoprotein or the good stuff) levels below 45 (35 for the guys) we're probably talking bullets in your bloodstream.
Any hope of changing bullets to beach balls? Well surprise surprise, it's the same old song as always--weight loss and exercise. But wait, there's drugs that help as well, including Tricor, gemfibrozil, niacin, and the diabetic medication metformin, Actos, and Avandia.
Sunday, October 12, 2008
"Happiness is a Serious Problem"
Current events make the pursuit of happiness even more of a challenge than usual. One of several books I'm juggling now is Dennis Prager's 1998 bestseller "Happiness is a Serious Problem." Perhaps we are missing some opportunities to increase our satisfaction with our personal situation. Here's Prager's take on health:
Take the expectation of health. For most people, the only time good health brings them happiness is when they do not expect to be healthy and then find out that they are. Imagine that you discover a strange new lump on your body. You go to the doctor, who tells you that it looks suspicious and that you should have a biopsy. After waiting a week for the results, you learn that the lump is benign. That day will be one of the happiest days of your life.
Now this is remarkable because the day before you discovered the lump you were not one bit healthier than you were on the supremely happy day you learned that your lump was benign. Nothing in the state of your health has changed, yet you are now profoundly happy. Why? Because on this day, you did not expect to be healthy.
...[I]deally, we should awaken every day and be as happy about our good health as if we had just received the wonderful news that a lump was diagnosed as benign.
Take the expectation of health. For most people, the only time good health brings them happiness is when they do not expect to be healthy and then find out that they are. Imagine that you discover a strange new lump on your body. You go to the doctor, who tells you that it looks suspicious and that you should have a biopsy. After waiting a week for the results, you learn that the lump is benign. That day will be one of the happiest days of your life.
Now this is remarkable because the day before you discovered the lump you were not one bit healthier than you were on the supremely happy day you learned that your lump was benign. Nothing in the state of your health has changed, yet you are now profoundly happy. Why? Because on this day, you did not expect to be healthy.
...[I]deally, we should awaken every day and be as happy about our good health as if we had just received the wonderful news that a lump was diagnosed as benign.
Monday, October 06, 2008
No talcing please!
I first heard this one 30+ years ago, and I always wondered if it was an urban myth of the bizarre variety. But here it is again, this time backed by research from Harvard Medical School. Epidemiologists there sorted through years of data from the Nurses Health Study regarding who used talcum powder on their nether parts, and whether those who did were more likely to contract ovarian cancer compared with those who dusted not.
Turns out that those who took a weekly powder were 36% more likely to end up with ovarian tumors, and a daily dousing raised the risk 41%. Talcum powder is made from hydrous magnesium silicate which has properties similar to asbestos. Neither talc nor asbestos has any business on your bum!
Turns out that those who took a weekly powder were 36% more likely to end up with ovarian tumors, and a daily dousing raised the risk 41%. Talcum powder is made from hydrous magnesium silicate which has properties similar to asbestos. Neither talc nor asbestos has any business on your bum!
Saturday, October 04, 2008
"Wild thing, I think you move me..."
"It is highly possible that estrogen modulates motion abilities..."
---Karl Grammer of the Ludwig Boltzmann Institute for Urban Ethology
Well, duh Dr. Grammer, just ask an aging postmenopausal woman as she gets out of a chair about the lack of estrogen and the consequent lack of ability to move. Anyway, that was a mini-rant and NOT what this post is about.
In the 'what WILL they study next' dept., we have the following information out of the University of New Mexico. Evolutionary psychologists there were wondering how human females attract mates at the appropriate time of the cycle to generate species-appropriate reproductive behavior. They recruited lap dancers from local clubs to collect data on tips earned as correlated with phase of the menstrual cycle.
Women, as opposed to say a lady chihuahua or chinchilla do not go into heat but rather have a 4-5 day fertile window mid-cycle called the estrous phase when they are highly fertile. The researchers compared tips generated during these ovulatory days compared with those brought in during the luteal phase (post-ovulation time when perhaps a woman might be more inclined to eat her mate rather than mate her mate) or while the dancers were menstruating.
Sixty days, 5300 lap dance incidents later, here's the scoop. Data from 11 women with normal menstrual cycles indicated estrous earnings of about $70 an hour whereas hourly income fell 33% to $50 for those in the luteal phase and plummeted to $35 an hour for those who were menstruating. The seven women on birth control pills earned less throughout the study period.
So there's apparently 'something in the way she moves' during estrous that attracts clients like no other time of the cycle. And no estrous? May as well move on to another profession because she's not moving up in this lap dancing business. All good for the future of pill-free couples, but no wonder that some of my patients lose that loving feeling whilst on birth controll pills.
---Karl Grammer of the Ludwig Boltzmann Institute for Urban Ethology
Well, duh Dr. Grammer, just ask an aging postmenopausal woman as she gets out of a chair about the lack of estrogen and the consequent lack of ability to move. Anyway, that was a mini-rant and NOT what this post is about.
In the 'what WILL they study next' dept., we have the following information out of the University of New Mexico. Evolutionary psychologists there were wondering how human females attract mates at the appropriate time of the cycle to generate species-appropriate reproductive behavior. They recruited lap dancers from local clubs to collect data on tips earned as correlated with phase of the menstrual cycle.
Women, as opposed to say a lady chihuahua or chinchilla do not go into heat but rather have a 4-5 day fertile window mid-cycle called the estrous phase when they are highly fertile. The researchers compared tips generated during these ovulatory days compared with those brought in during the luteal phase (post-ovulation time when perhaps a woman might be more inclined to eat her mate rather than mate her mate) or while the dancers were menstruating.
Sixty days, 5300 lap dance incidents later, here's the scoop. Data from 11 women with normal menstrual cycles indicated estrous earnings of about $70 an hour whereas hourly income fell 33% to $50 for those in the luteal phase and plummeted to $35 an hour for those who were menstruating. The seven women on birth control pills earned less throughout the study period.
So there's apparently 'something in the way she moves' during estrous that attracts clients like no other time of the cycle. And no estrous? May as well move on to another profession because she's not moving up in this lap dancing business. All good for the future of pill-free couples, but no wonder that some of my patients lose that loving feeling whilst on birth controll pills.
Monday, September 29, 2008
Beta blockers and post-traumatic stress disorder
One of my family members watched another person die suddenly, violently, and unexpectedly this weekend. I think I'm more freaked than my near and dear one is, but here's my doctorly thought processes after I was done flipping out.
Norepinephrine (NE, aka noradrenaline) is a neurotransmitter integral to the stress response and the formation of emotional memories. The beta-sympathetic nervous system (the automatic 'fight or flight' response that occurs without conscious activation) is mediated by NE which enhances the vivid but not necessarily accurate memories associated with highly emotional experiences. Think of a moment that was a charged one for you, say where you were when President Kennedy was shot (if you're old enough) or when you first heard about the World Trade Centers, and notice the details of that memory compared with other, blander recollections.
Experts call the development of post-traumatic stress disorder (PTSD) a 'derailment of memory process.' Not everyone is prone to an exaggerated or detrimental response to strongly charged experiences, but those who are can develop stubborn and destructive behavior patterns that ripple way beyond the actual trauma over time. While bioethicists argue over the morality of supressing intense and unpleasant memories, for better or worse it is possible to attenuate these memories through the use of beta-blockers. Amazingly, not only do the benefits of such therapy accrue when the medication is used shortly after the traumatic even, but also when the event is re-enacted through scripted imagery after some time has passed.
Should I offer beta-blockers (such as propranolol or metoprolol) to my family member? Perhaps I should just take a deep breath and take some myself.
Norepinephrine (NE, aka noradrenaline) is a neurotransmitter integral to the stress response and the formation of emotional memories. The beta-sympathetic nervous system (the automatic 'fight or flight' response that occurs without conscious activation) is mediated by NE which enhances the vivid but not necessarily accurate memories associated with highly emotional experiences. Think of a moment that was a charged one for you, say where you were when President Kennedy was shot (if you're old enough) or when you first heard about the World Trade Centers, and notice the details of that memory compared with other, blander recollections.
Experts call the development of post-traumatic stress disorder (PTSD) a 'derailment of memory process.' Not everyone is prone to an exaggerated or detrimental response to strongly charged experiences, but those who are can develop stubborn and destructive behavior patterns that ripple way beyond the actual trauma over time. While bioethicists argue over the morality of supressing intense and unpleasant memories, for better or worse it is possible to attenuate these memories through the use of beta-blockers. Amazingly, not only do the benefits of such therapy accrue when the medication is used shortly after the traumatic even, but also when the event is re-enacted through scripted imagery after some time has passed.
Should I offer beta-blockers (such as propranolol or metoprolol) to my family member? Perhaps I should just take a deep breath and take some myself.
Saturday, September 20, 2008
The amygdala and the social conservative
I've mentioned before that I have an overactive amygdala. Through a series of genetically determined events that I've explained before here, I get an intense second-hand fear response that renders me unable to watch scary movies. Just can't take it when the actress hears a noise and heads right down to the cellar to investigate when I know full well she should run even as I also know it's only a movie.
Now anxiety is a good thing when it sets off an appropriate 'fight or flight' response that allows us to recognize danger and either run or creep down those stairs provided we're fully certified in the martial arts (of course, karate is no use at all against the supernatural...). And it's a bad thing when it renders us unable to leave the house or apply for a job (met a patient like that just yesterday). But who'd have thought that an overactive--or indifferent--amygdala might affect our political beliefs? Well, color me conservative as I read the following from Science Magazine.(1)
Political scientists teamed up with psychologists in Texas and Nebraska to find out if our political beliefs might have a biological basis. In their own words:
In a group of 46 adult participants with strong political beliefs, individuals with measurably lower physical sensitivities to sudden noises and threatening visual images were more likely to support foreign aid, liberal immigration policies, pacifism, and gun control, whereas individuals displaying measurably higher physiological reactions to those same stimuli were more likely to favor defense spending, capital punishment, patriotism, and the Iraq War.
During session one, the scientists quizzed the group--preselected for the strength of their political convictions no matter what the content of their attitudes-- on their political beliefs, demographics, and personality traits. When the subjects next came down to the lab, they were hooked up to physiological equipment that measured change in skin conductance as well as the strength of their blink or startle response. They were then shown three threatening images (a very large spider on the face of a frightened person, a dazed individual with a bloody face, and an open wound with maggots in it) or three sweet little pictures (a bunny, a bowl of fruit, and a happy child) interspersed amongst non-charged visuals.
Arousal causes increased moisture on the skin which increases conductance and fear causes a hard flinch or blink response of the muscles around the eye. Well I don't think I'd have a problem with a maggot show, but I know my heart rate would rise and I'd shut my eyes in moment to a large spider crawling on someone's face. The investigators found that an exaggerated response to the threatening pictures did correlate with a more conservative or socially protective attitude.
While the researchers were reluctant to conclude just what cause and effect processes were at work, they conjectured that "political attitudes and varying physiological responses to threat may both derive from neural activity patterns, perhaps those surrounding the amygdala. Amygdala activity is crucial in shaping responses to socially threatening images and may be connected to political predispositions."
Please note that in no way do I imply that all social conservatives have an exaggerated fear response. Nor do I think that close vigilance on the part of our society with respect to external danger is a bad thing.
_____
Oxley, DR, et al. Political Attitudes Vary with Physiological Traits. Science19 September 2008: Vol. 321. no. 5896, pp. 1667 - 1670.
Now anxiety is a good thing when it sets off an appropriate 'fight or flight' response that allows us to recognize danger and either run or creep down those stairs provided we're fully certified in the martial arts (of course, karate is no use at all against the supernatural...). And it's a bad thing when it renders us unable to leave the house or apply for a job (met a patient like that just yesterday). But who'd have thought that an overactive--or indifferent--amygdala might affect our political beliefs? Well, color me conservative as I read the following from Science Magazine.(1)
Political scientists teamed up with psychologists in Texas and Nebraska to find out if our political beliefs might have a biological basis. In their own words:
In a group of 46 adult participants with strong political beliefs, individuals with measurably lower physical sensitivities to sudden noises and threatening visual images were more likely to support foreign aid, liberal immigration policies, pacifism, and gun control, whereas individuals displaying measurably higher physiological reactions to those same stimuli were more likely to favor defense spending, capital punishment, patriotism, and the Iraq War.
During session one, the scientists quizzed the group--preselected for the strength of their political convictions no matter what the content of their attitudes-- on their political beliefs, demographics, and personality traits. When the subjects next came down to the lab, they were hooked up to physiological equipment that measured change in skin conductance as well as the strength of their blink or startle response. They were then shown three threatening images (a very large spider on the face of a frightened person, a dazed individual with a bloody face, and an open wound with maggots in it) or three sweet little pictures (a bunny, a bowl of fruit, and a happy child) interspersed amongst non-charged visuals.
Arousal causes increased moisture on the skin which increases conductance and fear causes a hard flinch or blink response of the muscles around the eye. Well I don't think I'd have a problem with a maggot show, but I know my heart rate would rise and I'd shut my eyes in moment to a large spider crawling on someone's face. The investigators found that an exaggerated response to the threatening pictures did correlate with a more conservative or socially protective attitude.
While the researchers were reluctant to conclude just what cause and effect processes were at work, they conjectured that "political attitudes and varying physiological responses to threat may both derive from neural activity patterns, perhaps those surrounding the amygdala. Amygdala activity is crucial in shaping responses to socially threatening images and may be connected to political predispositions."
Please note that in no way do I imply that all social conservatives have an exaggerated fear response. Nor do I think that close vigilance on the part of our society with respect to external danger is a bad thing.
_____
Oxley, DR, et al. Political Attitudes Vary with Physiological Traits. Science19 September 2008: Vol. 321. no. 5896, pp. 1667 - 1670.
Friday, September 19, 2008
Viagra, women, and antidepressants
Depression is a surefire way to kill your libido. Treating depression with antidepressants is also a surefire way to kill your libido. Initially, patients may be so relieved to no longer be depressed that they are willing to give up their sexual interests for the medication benefits. After awhile, however, the increased pleasure in life and relationships makes intimacy issues unacceptable.
Doctors at the University of New Mexico wondered if phosphodiesterase type 5 inhibitors (aka Viagra, Cialis, or Levitra) might improve the sexual outlook for women whose spirits have risen on antidepressants even as their libidos have fallen. Viagra and company are known to lift certain parts in men on depression meds.
Over a period of 4 years, they randomized 98 women whose depressions AND sexual interests were completely squashed on serotonin reuptake inhibitor type medications. Taking no one's word for granted, they not only followed up the women's sexual activity event log, but also administered the Clinical Global Impression function scale, the Female Sexual Function Questionnaire, the University of New Mexico Sexual Function Inventory (female version of course), AND the Hamilton Depression Rating scale (just to make sure no depression was creeping back in the picture).
The women on the real deal Viagra sent their Clinical Global Impression sexual function scale soaring to nearly double the levels of their pre-treatment activity. They also improved their scores on their Sexual Function quizzes. The investigators do note that this study selected for a group of women motivated to improve their sexual functioning and relationships, and therefore the findings might not be generalizable to all women experiencing such troubles while on antidepressants. It's also possible that filling out forms and quizzes on sexual functioning might enhance sexual interest.
I find this study particularly interesting as Viagra-like drugs work particularly well in men through the promotion of blood flow into certain parts that must be engorged with blood for proper sexual functioning. It is encouraging to find that the medications can increase interest and activity in women whose sexual response is less dependent on the localized pooling of blood.
Doctors at the University of New Mexico wondered if phosphodiesterase type 5 inhibitors (aka Viagra, Cialis, or Levitra) might improve the sexual outlook for women whose spirits have risen on antidepressants even as their libidos have fallen. Viagra and company are known to lift certain parts in men on depression meds.
Over a period of 4 years, they randomized 98 women whose depressions AND sexual interests were completely squashed on serotonin reuptake inhibitor type medications. Taking no one's word for granted, they not only followed up the women's sexual activity event log, but also administered the Clinical Global Impression function scale, the Female Sexual Function Questionnaire, the University of New Mexico Sexual Function Inventory (female version of course), AND the Hamilton Depression Rating scale (just to make sure no depression was creeping back in the picture).
The women on the real deal Viagra sent their Clinical Global Impression sexual function scale soaring to nearly double the levels of their pre-treatment activity. They also improved their scores on their Sexual Function quizzes. The investigators do note that this study selected for a group of women motivated to improve their sexual functioning and relationships, and therefore the findings might not be generalizable to all women experiencing such troubles while on antidepressants. It's also possible that filling out forms and quizzes on sexual functioning might enhance sexual interest.
I find this study particularly interesting as Viagra-like drugs work particularly well in men through the promotion of blood flow into certain parts that must be engorged with blood for proper sexual functioning. It is encouraging to find that the medications can increase interest and activity in women whose sexual response is less dependent on the localized pooling of blood.
Sunday, September 14, 2008
Herd Immunity...
or why you should get a flu shot.
Flu season is coming, and hopefully this year's outbreaks will be preceded by a robust flu shot season. Here are the 2 most commonly cited reasons why my patients decline the vaccine:
- I always get the flu from the flu shot. While some people notice fluish sorts of symptoms such as mild fever and muscle aches after receiving the shot, the inactivated viral particles which comprise the vaccine cannot cause disease.
- I never get the flu. Well, lucky you. Remember, however, those who await your arrival back home. Perhaps you generally don't get the flu, but if you with your hardy immune system pick up a mild case while in close proximity with the coughing public, that young child, elderly grandma, or chronically ill spouse could be vulnerable to an amplified version of same with devastating or even fatal results.
Sunday, September 07, 2008
You can change your wicked ways...
but at the heart of your matter, your poor choices live on.
The Coronary Artery Risk Development in Young Adults (CARDIA) study followed twenty years of health outcomes in over 3500 young adults. The researchers studied modifiable risk factors such as cigarette use, prehypertension (BP's 120-139/80-89), LDL-cholesterol, and fasting blood sugars.
Many of the subjects with less than sterling health habits didn't smoke that much nor did they have huge elevations in the other parameters studied. Many of them turned their acts around and improved their lifestyle choices over the course of the trial. Despite improvements made, their early adult profiles were more predictive of the presence of coronary artery calcification (CAC) after age 35 than their most current situation. CAC has been shown to correlate with the presence of atherosclerotic changes in coronary arteries.
The Coronary Artery Risk Development in Young Adults (CARDIA) study followed twenty years of health outcomes in over 3500 young adults. The researchers studied modifiable risk factors such as cigarette use, prehypertension (BP's 120-139/80-89), LDL-cholesterol, and fasting blood sugars.
Many of the subjects with less than sterling health habits didn't smoke that much nor did they have huge elevations in the other parameters studied. Many of them turned their acts around and improved their lifestyle choices over the course of the trial. Despite improvements made, their early adult profiles were more predictive of the presence of coronary artery calcification (CAC) after age 35 than their most current situation. CAC has been shown to correlate with the presence of atherosclerotic changes in coronary arteries.
Monday, September 01, 2008
Voltaren Gel
This is a great idea, but the logistics are awkward.
Voltaren is an non-steroidal anti-inflammatory (NSAID) pain reliever, and a rather effective one at that. It is available in pill form as the generic diclofenac. The downside of any NSAID is its adverse effect on the stomach and intestinal tract, causing pain, gastritis, ulcers, and diarrhea. In addition, the drugs can increase the risk of stroke and heart attack, and, in susceptible individuals, can decrease blood flow to the kidneys thus increasing the risk over years of use of decreased kidney function. Specific to Voltaren is the risk of "severe hepatic reactions, including liver necrosis, jaundice, fulminant hepatitis with and without jaundice, and liver failure" per www.voltarengel.com. Well shoot, who wants any of that?
We do, however, want arthritis pain relief, and Voltaren does that well. So Novartis minced it up and put it in an alcohol-based gel so that we could smear it right on our throbbing joints. Once absorbed through the skin, it reduces arthritic hand pain 46% after 6 weeks of use, and pain levels plunge 51% after 3 months of slathering it on arthritic knees. Drug levels reaching your stomach, kidneys, and liver are 6% that of an oral dose so, while the risks are not nothing, they're a whole lot less than the pill delivers.
The problem is in the how much cream how often department. The web site recommends 2 gm four times daily to upper extremity sites and 4 gm four times daily for the lower extremity. A tube of toothpaste is 170 gms so that amount of Voltaren Gel would get you through just over ten days of knee treatment. The stuff is definitely gooey, lightly but pleasantly scented, and dries within 4-5 minutes leaving a light sheen but no residual sticky stuff. I cannot imagine using it during the workday if I wore pantyhose. Pulling them back up again after gelling your hip would be like getting a wet bathing suit back on a small child. But then again, who wears pantyhose anymore? What about for one throbbing , chronically hyperextended index finger swollen from years of writing chart notes and prescriptions? The very thing I think, but you can't wash the area for 1 hour after each application.
The other problem is cost. By my calculations, you would apply your way through $172 worth of gel to service one bum knee for a month. Does insurance pay? Dunno, but I kind of think not.
Voltaren is an non-steroidal anti-inflammatory (NSAID) pain reliever, and a rather effective one at that. It is available in pill form as the generic diclofenac. The downside of any NSAID is its adverse effect on the stomach and intestinal tract, causing pain, gastritis, ulcers, and diarrhea. In addition, the drugs can increase the risk of stroke and heart attack, and, in susceptible individuals, can decrease blood flow to the kidneys thus increasing the risk over years of use of decreased kidney function. Specific to Voltaren is the risk of "severe hepatic reactions, including liver necrosis, jaundice, fulminant hepatitis with and without jaundice, and liver failure" per www.voltarengel.com. Well shoot, who wants any of that?
We do, however, want arthritis pain relief, and Voltaren does that well. So Novartis minced it up and put it in an alcohol-based gel so that we could smear it right on our throbbing joints. Once absorbed through the skin, it reduces arthritic hand pain 46% after 6 weeks of use, and pain levels plunge 51% after 3 months of slathering it on arthritic knees. Drug levels reaching your stomach, kidneys, and liver are 6% that of an oral dose so, while the risks are not nothing, they're a whole lot less than the pill delivers.
The problem is in the how much cream how often department. The web site recommends 2 gm four times daily to upper extremity sites and 4 gm four times daily for the lower extremity. A tube of toothpaste is 170 gms so that amount of Voltaren Gel would get you through just over ten days of knee treatment. The stuff is definitely gooey, lightly but pleasantly scented, and dries within 4-5 minutes leaving a light sheen but no residual sticky stuff. I cannot imagine using it during the workday if I wore pantyhose. Pulling them back up again after gelling your hip would be like getting a wet bathing suit back on a small child. But then again, who wears pantyhose anymore? What about for one throbbing , chronically hyperextended index finger swollen from years of writing chart notes and prescriptions? The very thing I think, but you can't wash the area for 1 hour after each application.
The other problem is cost. By my calculations, you would apply your way through $172 worth of gel to service one bum knee for a month. Does insurance pay? Dunno, but I kind of think not.
Sunday, August 24, 2008
Red Yeast Rice
I was very grateful that i didn't have to be put on Lipitor. I just took one every evening after dinner, that was it, That easy!
--A happy Red Rice Yeast consumer on Amazon.com
Interesting stuff, this red yeast rice (RYR).* Used for over 1,000 years in Chinese medicine to promote circulation, this medicinal food is made by fermenting rice with red yeast or monascus purpureus. One of its active constituents --monacolin K-- is also known as lovastatin. Monacolins inhibit hydroxymethylglutaryl-CoA reductase (HMG-CoA reductase) which is an enzyme essential to the body's production of cholesterol. In fact, lovastatin was the first statin drug marketed in the U.S. years ago under the trade name Mevacor.
So is RYR an effective, natural, and SAFE way to lower your cholesterol? Even though the Chinese have a century+ of casual, everyday, human trials, the first formal study of the substance was conducted there in 2002. The results confirmed its efficacy: total cholesterol, LDL cholesterol, and triglycerides dropped by 23, 31, and 34 percent, respectively and HDL levels increased by 20 percent. In other words, RYR did all the good things that statins do because RYR is basically a statin or rather a statin is basically RYR. Other studies, one of which was conducted by the American Heart Association, confirmed the general findings although the benefits weren't quite as robust.
The doses used in these studies were 1.2-2.4 gms/day; some Asian diets include up to 55 gms of RYR per day. Because agents such as RYR and statins decrease the production of coenzyme Q10 which is important to energy production in muscles, supplementation of CoQ10 is recommended with either the nutraceutical or the pharmaceutical approach. The standard dose of lovastatin, however, is 20-40 mg/day whereas the daily amount present in most RYR preparations varies between 5-15 mg.
ConsumerLab.com is an independent testing laboratory that evaluates the quality and contents of nutritional supplements. In a recent investigation, they looked at different RYR products both for the amount of active ingredient (lovastatin) and for the presence of citrinin, a renal toxin that may be produced by yeast grown on cereal grains such as rice. Nature's Plus® Herbal Actives Red Yeast Rice contained very high levels of lovastatin whereas Walgreen's brand contained very little of the active monacolin. Four products had citrinin contamination.
What's in it for your brain? Recent Taiwanese studies of RYR compared its protective effects on cells under ambush from beta-amyloid (the sticky protein that gums up the brain in Alzheimer's disease) with those of lovastatin. The RYR won hands down in not only protecting against cell death from beta-amyloid but also in decreasing inflammation and oxidative stress. This same research group found that rats infused with beta-amyloid learned more, had better memories, and accumulated less beta-amyloid when they signed up for RYR supplements with their kibble.
____
*Red mold rice (RMR) if you're a Taiwanese biotech sort, and red mould rice if you're British.
--A happy Red Rice Yeast consumer on Amazon.com
Interesting stuff, this red yeast rice (RYR).* Used for over 1,000 years in Chinese medicine to promote circulation, this medicinal food is made by fermenting rice with red yeast or monascus purpureus. One of its active constituents --monacolin K-- is also known as lovastatin. Monacolins inhibit hydroxymethylglutaryl-CoA reductase (HMG-CoA reductase) which is an enzyme essential to the body's production of cholesterol. In fact, lovastatin was the first statin drug marketed in the U.S. years ago under the trade name Mevacor.
So is RYR an effective, natural, and SAFE way to lower your cholesterol? Even though the Chinese have a century+ of casual, everyday, human trials, the first formal study of the substance was conducted there in 2002. The results confirmed its efficacy: total cholesterol, LDL cholesterol, and triglycerides dropped by 23, 31, and 34 percent, respectively and HDL levels increased by 20 percent. In other words, RYR did all the good things that statins do because RYR is basically a statin or rather a statin is basically RYR. Other studies, one of which was conducted by the American Heart Association, confirmed the general findings although the benefits weren't quite as robust.
The doses used in these studies were 1.2-2.4 gms/day; some Asian diets include up to 55 gms of RYR per day. Because agents such as RYR and statins decrease the production of coenzyme Q10 which is important to energy production in muscles, supplementation of CoQ10 is recommended with either the nutraceutical or the pharmaceutical approach. The standard dose of lovastatin, however, is 20-40 mg/day whereas the daily amount present in most RYR preparations varies between 5-15 mg.
ConsumerLab.com is an independent testing laboratory that evaluates the quality and contents of nutritional supplements. In a recent investigation, they looked at different RYR products both for the amount of active ingredient (lovastatin) and for the presence of citrinin, a renal toxin that may be produced by yeast grown on cereal grains such as rice. Nature's Plus® Herbal Actives Red Yeast Rice contained very high levels of lovastatin whereas Walgreen's brand contained very little of the active monacolin. Four products had citrinin contamination.
What's in it for your brain? Recent Taiwanese studies of RYR compared its protective effects on cells under ambush from beta-amyloid (the sticky protein that gums up the brain in Alzheimer's disease) with those of lovastatin. The RYR won hands down in not only protecting against cell death from beta-amyloid but also in decreasing inflammation and oxidative stress. This same research group found that rats infused with beta-amyloid learned more, had better memories, and accumulated less beta-amyloid when they signed up for RYR supplements with their kibble.
____
*Red mold rice (RMR) if you're a Taiwanese biotech sort, and red mould rice if you're British.
Sunday, August 17, 2008
Making scents of the gene pool
Is this your man?
Scientists believe there are advantages to dipping into a gene pool far different from our own when constructing the DNA of the next generation. Not only will this strategy decrease the likelihood of passing along two copies of a gene mutation for an inherited disorder, research suggests that the children produced from a thoroughly mixed-up match of chromosomes will also be resistant to a wider range of diseases. Those genes in charge of the composition of a person's immune system are called the major histocompatibility complex (MHC), and MHC heterozygosity (meaning mom's MHC contribution is quite a bit different than dad's) gives the kids a survival advantage in future battles against a wider array of disease-causing pathogens.
Interestingly, MHC is a major determinant of body odor in mice and men and women too. The olfactory neurons of mice in charge of odor recognition respond to fragments of MHC molecules even when these peptide pieces are present in extremely small quantities. Many rodent studies confirm that mice prefer nonself MHC-types as mates.
So what's this got to do with BCPs? A 1997 study found that all male subjects and those female participants not taking contraceptives preferred the smell of used T-shirts from persons with MHCs different than their own. The more the subject liked a T-shirt's odor, the less similar their MHC profile to that of the T-shirt's owner. No such correlation was found between Pill-users and their favorite unwashed T-shirt smells.
So if you want to party hearty with respect to producing hardy children with top-notch immune systems, sniff out potential mates in a Pill-free mode before you mate.
Saturday, August 16, 2008
How a Corvette smashed my nail
My patient arrived at his physical with a blackened fingernail. When I asked him how he damaged his finger, he replied "I passed a Corvette on the highway, and that's bad luck." I replied that mostly Corvettes are going too fast to pass, bad luck or not, but what did that have to do with his nail. Here's the scoop.
For reasons unknown, he'd always believed that overtaking these sports cars was an invitation to disaster. Recently, however, he decided to defy his magical thinking and left a 'vette in the dust. Within 15 seconds of completing the deed, he got a flat tire. While changing the tire, 1) his girlfriend's nose got smashed by the car trunk as it swung open, and 2) he smashed his finger with the tire iron.
Never a dull moment at these physicals!
For reasons unknown, he'd always believed that overtaking these sports cars was an invitation to disaster. Recently, however, he decided to defy his magical thinking and left a 'vette in the dust. Within 15 seconds of completing the deed, he got a flat tire. While changing the tire, 1) his girlfriend's nose got smashed by the car trunk as it swung open, and 2) he smashed his finger with the tire iron.
Never a dull moment at these physicals!
Sunday, August 10, 2008
Hepatitis A vaccine for post-exposure prevention
(In case you're wondering what all this vaccine information is about, I am preparing a workshop on immunizations, so my brain's shot full of shots.)
In a recent post, I mentioned that hepatitis A immune globulin (IG) is the preferred approach for the prevention of infection in folks who've been exposed to the disease through household contacts or 'fecal fingers'. My information, I discover, is running about 10 months behind the times.
Last October, researchers published a study in the NEJM (1) comparing the use of HAV vaccine with IG in persons ages 1-40 exposed to hepatitis A. The two groups were randomized to receive one therapy or the other within 2 weeks of viral exposure. Few subjects developed hep A no matter which shot they received, and the CDC concluded that the two strategies were equally efficacious.
As a result, they now officially recommend the HAV vaccine for postexposure (less than 2 weeks) prophylaxis in this age range as 1) it's less painful, 2) it's more widely available, and 3) the shot provides longterm immunity. Older persons or people with chronic liver disease tend to be sicker with hepatitis A, so the CDC continues to recommend IG for them. What they really recommend, however, is that all children get this shot after age 1, and most adults should consider receiving a shot as well so they can eat unwashed lettuce with impunity and immunity.
_____
(1)Victor JC et al. Hepatitis A vaccine versus immune globulin for postexposure prophylaxis. N Engl J Med 2007 Oct 25; 357:1685.
In a recent post, I mentioned that hepatitis A immune globulin (IG) is the preferred approach for the prevention of infection in folks who've been exposed to the disease through household contacts or 'fecal fingers'. My information, I discover, is running about 10 months behind the times.
Last October, researchers published a study in the NEJM (1) comparing the use of HAV vaccine with IG in persons ages 1-40 exposed to hepatitis A. The two groups were randomized to receive one therapy or the other within 2 weeks of viral exposure. Few subjects developed hep A no matter which shot they received, and the CDC concluded that the two strategies were equally efficacious.
As a result, they now officially recommend the HAV vaccine for postexposure (less than 2 weeks) prophylaxis in this age range as 1) it's less painful, 2) it's more widely available, and 3) the shot provides longterm immunity. Older persons or people with chronic liver disease tend to be sicker with hepatitis A, so the CDC continues to recommend IG for them. What they really recommend, however, is that all children get this shot after age 1, and most adults should consider receiving a shot as well so they can eat unwashed lettuce with impunity and immunity.
_____
(1)Victor JC et al. Hepatitis A vaccine versus immune globulin for postexposure prophylaxis. N Engl J Med 2007 Oct 25; 357:1685.
Saturday, August 09, 2008
Gardasil vaccine
It's important that women understand if they're sexually active, there's a chance they won't receive full benefit from the vaccine.
--Dr. Laura Koutsky, epidemiologist at the University of Washington
I get asked this question a lot by women who are already sexually active including some who have had abnormal Pap smears as a result of infections by the human papillomavirus (HPV). HPV infections cause virtually all cervical cancer, and bad actor HPV types 16 and 18 are responsible for 70% of these malignancies. The Gardasil vaccine (and the not yet approved Cervarix vaccine) is highly effective at inducing immunity against these carcinogenic viruses; in fact, this vaccine is the first one to specifically designed to prevent cancer caused by a virus.
Dr. Koutsky and company (an enormous panel of clinical investigators) published the results of their FUTURE II trial, aka Females United to Unilaterally Reduce Endo/Ectocervical Disease, in a May, 2007 edition of the NEJM(1). While the vaccine prevented 98% of cervical lesions--precancerous and malignant--in subjects who tested negative for exposure to HPV types 16 and 18 at the time of entry into the study, it was only 44% protective in women previously infected with these cancer-causing viruses.
The ideal population, therefore, that will benefit from this vaccine is those girls/women not yet exposed to the virus. The CDC's Advisory Committee on Immunization Practices has recommended without reservation that girls 11 and 12 years of age receive this shot.
_____
(1)The FUTURE II Study Group. Quadrivalent Vaccine against Human Papillomavirus to Prevent High-Grade Cervical Lesions. NEJM,Volume 356:1915-1927, May 10 2007.
--Dr. Laura Koutsky, epidemiologist at the University of Washington
I get asked this question a lot by women who are already sexually active including some who have had abnormal Pap smears as a result of infections by the human papillomavirus (HPV). HPV infections cause virtually all cervical cancer, and bad actor HPV types 16 and 18 are responsible for 70% of these malignancies. The Gardasil vaccine (and the not yet approved Cervarix vaccine) is highly effective at inducing immunity against these carcinogenic viruses; in fact, this vaccine is the first one to specifically designed to prevent cancer caused by a virus.
Dr. Koutsky and company (an enormous panel of clinical investigators) published the results of their FUTURE II trial, aka Females United to Unilaterally Reduce Endo/Ectocervical Disease, in a May, 2007 edition of the NEJM(1). While the vaccine prevented 98% of cervical lesions--precancerous and malignant--in subjects who tested negative for exposure to HPV types 16 and 18 at the time of entry into the study, it was only 44% protective in women previously infected with these cancer-causing viruses.
The ideal population, therefore, that will benefit from this vaccine is those girls/women not yet exposed to the virus. The CDC's Advisory Committee on Immunization Practices has recommended without reservation that girls 11 and 12 years of age receive this shot.
_____
(1)The FUTURE II Study Group. Quadrivalent Vaccine against Human Papillomavirus to Prevent High-Grade Cervical Lesions. NEJM,Volume 356:1915-1927, May 10 2007.
B.Y.O.P.
Looks like I'll not only be buying my own pens in 2009, but will need my own darn sticky notes and mugs as well. New guidelines for pharmaceutical companies will end this mini-fountain of free office supplies, and physicians will have to make their own judgments about the drugs they prescribe free of that subliminal influence from their writing utensils and coffee cups.
Now I do agree that this is a silly use of funds that could (but won't be) diverted to more productive ends by the companies who distribute these freebies by the gross. I am a bit miffed by the implication that a free roller-ball pen (and they are a godsend for those of us who spend our days scratching our way through handwritten charts) would change my decision-making process. I do rely on post-it notes to remember the next step in patient care ('Call Dr. M,' 'pre-authorize MRI,' 'check on last week's labs,' etc.). On the downside, I sometimes find to my horror that I've given a post-it note to a patient that incidentally advertises vaginal cream or a drug for erectile dysfunction. But I swear that I've never noted the note, then changed my therapeutic plan based on its message.
Oh well, I'll buy my own pens, apply my own message-free sticky notes, and drink my morning coffee from a mug that declares I'm "over 50 but not over the hill". But I'll hold out hope that the new conduct code won't cut off those drug money cookies.
Now I do agree that this is a silly use of funds that could (but won't be) diverted to more productive ends by the companies who distribute these freebies by the gross. I am a bit miffed by the implication that a free roller-ball pen (and they are a godsend for those of us who spend our days scratching our way through handwritten charts) would change my decision-making process. I do rely on post-it notes to remember the next step in patient care ('Call Dr. M,' 'pre-authorize MRI,' 'check on last week's labs,' etc.). On the downside, I sometimes find to my horror that I've given a post-it note to a patient that incidentally advertises vaginal cream or a drug for erectile dysfunction. But I swear that I've never noted the note, then changed my therapeutic plan based on its message.
Oh well, I'll buy my own pens, apply my own message-free sticky notes, and drink my morning coffee from a mug that declares I'm "over 50 but not over the hill". But I'll hold out hope that the new conduct code won't cut off those drug money cookies.
Tuesday, August 05, 2008
Who needs a shingles shot? Part II
I wrote some time ago about who needs a shingles shot. Here is a summary of the last 4 people I've seen in the office, all in the past 2 weeks, who wished they'd had the shingles shot before their leftover chickenpox (herpes zoster virus) staged a comeback.
The first patient was down on my schedule as 'bug bite.' I'm always suspicious, even in summer, that a 'bug bite' appointment will actually be shingles. Indeed, this 38 year old man's painful 'bite' was, in fact, a cluster of herpetic blisters on his left shoulder. He is too young to have been offered a shingles shot as they are approved for persons sixty and over. The shot would doubtless work on younger patients, but they are quite expensive, and insurance companies would be disinclined to pay for the vaccine in this low risk population.
The second patient complained of a 'bee sting.' This theoretical bee had gotten her on her left buttocks, an area not commonly at risk for a bee attack. At 62, she could've had a shingles shot instead of this stinging red circle of blisters.
The third patient, only 52, is undergoing chemotherapy for cancer. Her shingles were extensive, painfully covering most of her buttocks. She is at risk for a recurrence of herpes zoster as her treatment has compromised her immune system.
The fourth patient--age 49 and therefore too young for the shot-- came in with back pain which she described as a strip both numb and painful from her lower back around to the middle of her front at the level of her lowest rib. She had no rash...yet. I don't know for sure, but her presentation was typical of the pain that precedes a shingles outbreak.
I actually saw one other person this week who could've used a shingles shot, but he needed it 12 years ago when he was 81. Now at 93, he continues to have a painful itch over his left eye up onto his forehead from his remote encounter with his resident zoster virus. He really should re-up his immunity now against another potential attack, but he's not fond of shots.
Who is?
The first patient was down on my schedule as 'bug bite.' I'm always suspicious, even in summer, that a 'bug bite' appointment will actually be shingles. Indeed, this 38 year old man's painful 'bite' was, in fact, a cluster of herpetic blisters on his left shoulder. He is too young to have been offered a shingles shot as they are approved for persons sixty and over. The shot would doubtless work on younger patients, but they are quite expensive, and insurance companies would be disinclined to pay for the vaccine in this low risk population.
The second patient complained of a 'bee sting.' This theoretical bee had gotten her on her left buttocks, an area not commonly at risk for a bee attack. At 62, she could've had a shingles shot instead of this stinging red circle of blisters.
The third patient, only 52, is undergoing chemotherapy for cancer. Her shingles were extensive, painfully covering most of her buttocks. She is at risk for a recurrence of herpes zoster as her treatment has compromised her immune system.
The fourth patient--age 49 and therefore too young for the shot-- came in with back pain which she described as a strip both numb and painful from her lower back around to the middle of her front at the level of her lowest rib. She had no rash...yet. I don't know for sure, but her presentation was typical of the pain that precedes a shingles outbreak.
I actually saw one other person this week who could've used a shingles shot, but he needed it 12 years ago when he was 81. Now at 93, he continues to have a painful itch over his left eye up onto his forehead from his remote encounter with his resident zoster virus. He really should re-up his immunity now against another potential attack, but he's not fond of shots.
Who is?
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