Onsolis

My dear friend is dealing with enormous post-op pain following a prolonged surgery for a bowel blockage. She's still in the IV drip phase of pain control, snowed under by varying doses of ketamine, hydromorphone, and methadone. The surgical team has called in anesthesia and the pain team to help manage her case, so we are once again dealing with multiple docs who, we hope, are more than less keeping in touch with one another.

Ways to control pain that don't require swallowing pills are important to surgical pain control as well as in situations where oral meds aren't tolerated or aren't enough. I was interested, therefore, to learn today about Onsolis, newly approved by the FDA, as an entirely new approach to the problem. Onsolis uses BioErodible MucoAdhesive (BEMA®) drug delivery technology to deliver Fentanyl across the tissues of the inner cheek into the bloodstream. Up until now, Fentanyl has been available as a skin patch which sometimes causes local irritation and occasionally results in overdose if patients apply heat to the body area on which the patch is stuck.

Gotta be careful with these heavy duty narcotics though, they are not for the uninitiated or narcotic naive patient whose liver is not muscled up for processing these drugs. I once had a patient with dreadful arthritis in her neck. She was prescribed morphine for pain control, and in an effort to be painfree, took way more than she tolerated and died in respiratory arrest. For patients like my friend, however, who have been using narcotic analgesia for some time and cannot reliably use or absorb oral meds, this little patch may be a great boon to their comfort.

Of cockatiels and trumpets

Some of my patients are 'difficult' insofar as I am stumped as to what they need and how to improve their health situation. One such customer was a middle-aged lady plagued with pain, poverty, and depression. She was a large lady, and part of each appointment was spent in the slow walk from the waiting to the exam room which she negotiated one tedious step at a time with the help of two canes. She always arrived with copious pencil-written notes about her days spent doing little other than getting by.

What her notes never included, however, were tales of her cockatiels. Who knew she raised birds? I certainly didn't. I'm not sure how it even came up, but once we discussed her birds, everything seemed to change. She still came armed with those torn notebook pages full of complaints, but she was also the person who brought pictures of her birds and their tiny little-finger sized hatchlings. She was now, for me, the bird lover who struggled with pain rather than just the pain.

Yesterday's new patient was a nervous young man who at 23 had an engineering degree and spent his working days making sure that the calculations made by his firm on bridge design were correct. I remember a magazine article on school standards (and their increasing laxity) that asked the reader whether or not they would care to drive across a bridge designed by someone in the lowest quartile of their engineering class. My first impression of this fellow was that he'd be a good one to have beneath the bridge upon which we drive with nary a thought as to its safety.

At the end of the physical, I asked him if he planned to go on to a higher degree in engineering. He answered that he felt that engineering was going to be the job that supports his real loves in life, namely playing the trumpet. I'd like, I thought, to drive across bridges designed by this engineer who plays the trumpet. No need anymore for either of us to be nervous.

Abilify testimonial

I wrote recently about a patient whose 'delusional parisitosis' was ruining her life. She felt that bird mites had invaded her home, her car, and her siblings' homes, making her too anxious and distracted to work or carry on any semblance of normalcy. A psychiatrist started her on Abilify last month during a brief involuntary hospitalization orchestrated by her frantic family.

She came in today, 5 weeks into her Abilify treatment. She looked well--rested and tear-free. She declared that things were 'almost back to normal'; she was back in her home, no longer experienced abnormal skin sensations, and had returned to work. I didn't ask her if the mites were gone, nor did she volunteer anything along the lines of 'what do you suppose that crazy business was all about?' I didn't feel like she needed to acknowledge whether or not the mites were real or imagined; it was more than sufficient that they were no longer front and center in her mind and her life.

I hope her insurance pays for this medication. It's four-plus expensive, but what an amazing difference it's made for her.

Bacteria, bad breath, and oil pulling

I've been thinking about bad breath and mouth hygiene lately (and as soon as I get the big "L" off my forehead, perhaps I'll think about something fun). First of all, I wonder what to do about patients with bad breath--not the ones who complain of it who frankly never have bad breath on examination, but rather the clueless ones who have bad breath and don't know it. Should I say something to them? Perhaps I could include "Do you have bad breath?" in my review of systems during the annual physical, and if they answer "No," tell them "Not so fast on the negative buster!"

My latest foray into alternative medicine includes a month-long experiment in the Ayurvedic practice of oil-pulling. I'm not quite sure where I came across it, but it seemed like an intriguing way to use up a bottle of organic sesame oil sitting in my 'frig. First of an a.m. on an empty stomach, I sip but don't swallow a tablespoonful of sesame oil. As I bring in the paper, make coffee, empty the dishwasher, and do the little morning chores, I 'pull' the oil through my teeth or poke at the mouthful with tongue against teeth for (theoretically) 20 minutes or until my mouth is too full and I'm too grossed-out to go on which got up to 14 whole minutes today. Spit and rinse follows, then on to breakfast.

Testimonials abound on the Internet in support of the practice which, among other things, is supposed to enhance oral hygiene, and lessen tooth decay, bad breath, and dry lips. So far, one week into it, it only dampens my enthusiasm for breakfast and seems to make me less prone to eating the crap that drug reps bring in to the office (despite new Pharma regulations against the practice!).

An article in the Journal of the Indian Society of Pedodontics and Preventive Dentistry reported a study wherein 10 adolescent boys were somehow convinced to oil-pull in the a.m. for 10 minutes, and then their levels of streptococcus mutans (a bacteria associated with tooth decay) were compared with another group of 10 who swished instead of a morning with chlorhexidine mouth wash. Both groups experienced the same drop in levels of those s mutans bad boys.

But...I dare you to find a bunch of health nuts waxing poetic over the morning use of chlorhexidine mouthwash! Consider this on oil pulling from Molly of SanFrancisco: The really bad stuff that forms plague [sic], is very attracted to the acids in the oil. So it melts this bad stuff and then you spit it out. That's why your teeth get much cleaner than by conventional means, like alcohol based rinses. And so, when you melt this bad stuff, you simply spit it out..buh bye.

On now to my real story here which is breaking news from the first ever symposium on the microbiology of odors held last month in Philadelphia. Israeli microbiologists have developed a new saliva test called OkayToKiss that tests for the presence of certain enzymes produced by gram-positive bacteria (such as s mutans) that make it easier for gram-negative bacteria in the mouth to break protein into malodorous compounds.

The doc-in-charge of the research, Dr. Mel Rosenberg, is described as an "international authority on the diagnosis and treatment of bad breath." He invented a two-phase mouthwash (containing saline and oil) based on his studies of petroleum microbiology wherein he discovered that oral microorganisms from dental plaque when mixed with nontoxic oils became bound to the oil. Voila! Does that not sound like a variation on oil-pulling to you? Check out melrosenberg.com if you want a ton of technical on the process. And the 1-2 mouthwash known as Assuta bested Listerine with respect to longterm control of halitosis.

So back to this OkayToKiss test. Due out next year, this pocket-sized test I gather is a treated piece of paper that you lick and check. If it turns blue, keep your mouth to yourself. This Dr. Rosenberg is a kick--don't miss his smellwell site for more ideas on keeping fresh as a daisy.

September, 2009 update: Still oil-pulling. I can last 15 or more minutes at it, no problem. Teeth so white that my 20-something year old daughter who commented below about how gaggingly gross this sounded is now doing it herself. My first visit with the dental hygienist post oil-pulling is next month; I'll let you know how I fare.

Dying for D

A lot of you, it seems, have not yet gotten the memo. All this sun-phobia has caused an epidemic of vitamin D deficiency. The latest articles I've seen go by implicate low levels of D as a contribution to non-melanoma skin cancers (thought you were ducking that by avoiding the sun, did you?), bacterial vaginitis(!), and depression. Now this from the Archives of Internal Medicine:

Researchers sorted through the mountain of data generated by the Third National Health and Nutrition Examination Survey looking at D levels as compared to the incidence of dropping dead in some 13,000 participants followed from 1988 through 1994.

Those participants with D levels lower than 17.8 ng/ml (and at least half my patients test into this range!) had a 26% increased risk of dying compared to those more D-endowed. The likelihood of being D-ficient was higher in those who were older, female, nonwhite race (darker skin is not as efficient at producing D when exposed to sunshine), diabetic, smokers, overweight, and in those who did not take D supplements. I have found many who rely on the D added to dairy products or calcium supplements and/or the D in multivitamins are also often deficient.

Take D. Take it everyday. Get a little sunshine on your unsunblocked self.
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Melamed, ML, et al. 25-hydroxyvitamin D levels and the risk of Mortality in the general population. Arch Int Med. 2008; 168(15):1629-1637.

Brain centers in charge of voice recognition

In everday life, we automatically and effortlessly decode speech into language independently of who speaks. Similarly, we recognize a speaker's voice independently of what she or he says.(1)

My first call of this holiday weekend was a real jaw-dropper. The youngish man was most put out; he'd been assured that his prescription was called in and, on arriving at the pharmacy, found that they had no record of it. In language worthy of a drunken sailor, he anonymously expressed his deep unhappiness, and concluded that my staff and I were copulating pieces of excrement but in different words.

Now I certainly appreciate his aggravation--been there (at the pharmacy as a customer) done that (felt my blood pressure rising that the pharmacy staff had no knowledge of any script) myself. As often as not, it's an oversight or delay at the pharmacy, but I do know (as do you my patients) that we also have system failures at the office. That said, this tirade was inappropriate done anywhere but in the privacy of one's own brain or car, and I would like to know the identity of the caller so we can discuss whether or not he should continue as our patient if he even cares to do so.

So now we're on the topic du post: voice recognition. I remember a much more pleasant call nearly two decades ago when my front desk assistant announced I had a personal call on line 6. I didn't recognize the name she gave me (remember--we do admit to system failures) but I instantly knew the voice of my freshman college best buddy whom I'd lost track of for 17 years. Now scientists have identified the bit of gray matter that lights up with delight or dismay at the sound of a familiar voice.

Using functional MRI scanning, researchers from the Department of Cognitive Neuroscience at the University of Maastricht located an area of the auditory cortex that hums with activity as test subjects decipher the message and the messenger of spoken stimuli. In order to establish the identity of my anonymous caller, I need to find a staff member whose right anterior superior temporal sulcus (this STS is a brain bit located roughly behind and slightly above the right ear) along with the nearby Heschl's gyrus roars with recognition (and righteous indignation) when the message is replayed.

And Mr. No-Impulse-Control, get this, Pat at the front desk has a highly developed STS, and we will smoke you out. And know that a plainly worded message, even one expressing anger appropriately over lost time and effort, would've resulted in a prompt call by me to your pharmacy!
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Formisano et al. "Who" is saying "What"? Brain-based decoding of human voice and speech. Science. 7 November 2008, Vol 322, pps. 970-973.

Lest you think that I don't observe my own health habits, here's the latest. I've developed a juicy head cold since I got back from South Dakota, so perhaps I got in the line of fire of infected droplets from Mr. Sneeze-in-the-hand who passed not five feet away from me at the Rushmore Memorial. On the plus side, however, I logged well over 4,000 steps* at the office today, leaving the exam room every time I needed to sneeze or cough and then, of course, washing my hands. Unfortunately, I joined the chunky mom and child in the Keystone, SD restaurant by snacking through the day on Milky Way bites (dark chocolate covered!) and chips.

My bro', whom regular readers know as a strict grammarian and my sharpest critic, wrote a limerick in response to my previous post:

A very old guy in Custer
Said it's not beer that loses your luster;
Read your own blog,
Be a stick, not a log,
(And drink coffee to make certain, buster.)

Last week, I received an endoscopy report (complete with color pictures) on one of my patients who underwent the test two days prior to evaluate her upper abdominal pain. She had a mass in her duodenum that looked scary, like something you might see growing on the Great Barrier Reef. The comment section of the report said "Pt. should call the office in 7 days for the report."

Seven days waiting for a biopsy report? Sounds like the week from hell as there's nothing worse, I think, than waiting for test results on a mass found where no mass ought to be. An hour later, the path report came over the FAX--no cancer!! I called her to let her know, although I advised her to call the GI doc to find out what the next step should be. Her response reminded me of a line from Dennis Prager's "Happiness is a Serious Problem":

"...ideally, 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."
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*I wear a pedometer every day. I'll refund the co-pay of the first person who shows up in my office for their physical wearing one! People tell me all the time that they don't need exercise as they 'run around all day at the office' or 'park at the end of the lot.' I've often wondered how many steps are involved in said running and parking.

My father was a psychiatrist. When my friends came to visit, they would ask me--half-joking--if he thought they were crazy. I know for a fact that he passed no judgments on our crazy adolescent antics, but I'm here to tell you that the internist in me is always on alert to the health habits of others. Here's several observations from my just-completed trip to South Dakota:

--The young man sneezed mightily into his hand as he walked away from Mt. Rushmore. He looked with distaste at his mucous-slicked hand, then wiped it half-heartedly on his jeans. Remember, this guy (or his cousin) touched that door knob just before you did.

--This fellow (a dead ringer for TweedleDee's silhouette) jockeyed for position at the toaster during the crowded, freebie breakfast service at the Dew Drop Inn in Rapid City. He was reaching for the whole wheat bread when the little serving lady brought in a heaping stack of chocolate muffins. To heck with bread, he nabbed two fresh muffins.

--This chunky young mom walked into the restaurant with her overweight daughter in tow. They placed their orders, and shortly thereafter the waitress brought a plate of onion rings for mom and a platter of fries for the young lady. Hmm, I thought, but oh well, they're on vacation and going for a treat before dinner. Alas, their second course was ice cream parfaits for all.

--A very thin, very old guy sat at the bar in Custer, SD, reading the paper and nursing a beer before dinner. We discovered that he was a World War II veteran, a banker, a cattle rancher, and the jeep tour driver for the lodge. He regaled us with stories from all his various careers.

I'm having whatever he's ordering!

Delusional parasitosis

The ones that crawl in are lean and thin
The ones that crawl out are fat and stout
Your eyes fall in and your teeth fall out
Your brains come tumbling down your snout

No lighthearted matter, these creeping mites, for two of my patients. The first middle-aged lady came in last summer toting a small aquarium full of water. Floating within were numerous diaphanous strands that trembled and tumbled as she heaved the case onto the table.

"Bugs," she declared, "the things that are crawling into my nose and making me crazy."

She was not kidding; she was in tears. She didn't say I think I'm going crazy because I imagine bugs, she said these are bugs.

The second lady came with her brother and sister in tow. He was carrying a crystal wine glass filled with alcohol and covered with saran wrap. Within floated three 'mites' captured as they scurried up someone's arm; I can't remember which one of the sibs caught the little buggers. I carefully poured off the alcohol and managed to snag the tiny particles onto a slide.

"Two clumps of fiber and pile of skin cells," I declared on returning to the exam room. "C'mon back and have a look."

Did they say "Oh my goodness, how foolish we feel now?" Nope, they just shrugged and said "we must've missed them which is amazing as they swarm by the thousands up our arms and legs." Lady #1 didn't go so far as to pin down the species of her infestation, Lady #2 was quite clear the pests were bird mites.

This is not only a psychotic syndrome, but the ability to pass the delusion along to others is a known phenomenon dubbed Shared Psychotic Disorder (SPD) which occurs in as many as 15% of cases of Delusional Parasitosis (DP). Must be a huge delusional exaggeration of the way one starts to itch when someone near by starts to scratch.

Per Wolfgang Trabert(1), when SPD patients are separated from the 'inducer,' a significant number of them undergo a spontaneous remission. Indeed, the brother and sister of this patient pulled back from their personal mitey troubles and had Lady #2 involuntarily admitted for psychiatric evaluation. She emerged slightly less upset due to the use of anti-psychotic meds, but still convinced that her house (that she's abandoned), her car (which she still drives but coats herself before doing so in olive oil as mites don't care for the taste), and her new apartment all continue infested.

Helping Lady #2 try to regain some semblance of a normal life is the hardest thing I've ever attempted in 28 years of practice. Her major source of information is birdmites.org. Check it out; is this fact or a web-site run by a bunch of SPD patients?
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1. Trabert, W. Shared Psychotic Disorder in Delusional Parasitosis. Psychopathology 1999;32:30-34.

Heart attacks and low cholesterol

Can you have bragging rights cholesterol and still suffer a heart attack? You bet, read on:

My patient sat relaxed and smiling in the exam room. He was here, per my schedule, for 'follow-up."

"So, what's going on?" I asked.

"Well, haven't you heard?" he asked. "I just had a heart attack a week ago Sunday."

There he sat, tan, comfortable, the only visible sign of less than perfect health in his 61 year old self was a little bit more belly than ideal bulging out at his midriff.

"You're kidding, right?"

"Nope," he replied, "to make a long story short, I had a heart attack while reading the morning paper and drinking my coffee. I started having severe chest pain, told my wife that this was the real deal, and within 78 minutes I was on the table getting a stent placed in my heart"

Gad, this guy has perfect blood pressure (110/72) on a low dose of heart-healthy lisinopril, 'walks some' for exercise which is not enough but more than many people, and has an LDL cholesterol of 80 on no meds. His dad had diabetes and died of coronary artery disease at 73.

The cardiologist found a complete blockage of his left anterior descending artery--the so-called 'widow maker-- on catheterization, which means no blood whatsoever was getting to the front wall of his left ventricle prior to stent placement. An echocardiogram after the procedure showed that only a small part of the apex of his heart was damaged.

When I was in med school, this fellow would've gone straight to bypass surgery followed by a prolonged post-op stay in the CCU. Yet here he was, scarcely a week later, already starting a cardiac rehab exercise program.

Two lessons here: prompt access to modern medicine is grand, and none of us can rest assured in our low cholesterol numbers.

"Why don't we do it in our sleeves?"

I feel an enormous amount of compassion for the sick people in my exam room. But my fountain of understanding abruptly runs dry when some infectious chucklehead lets loose an unrestrained cough or sneeze as we sit together in that tiny space.

So please, one and all, as we pass through this scary, fluish time in close quarters, check out this video . Give your family, your co-workers, and your doctor a break!

Cytokine storm and the H1N1 swine flu virus

At a time when the flu season should be winding down in North America and Mexico, scary reports are emerging from our Southern neighbor of a new swine flu variant whose victims are primarily young. Not only does this influenza A strain appear to be a previously unknown combination of bird, swine, and human genetic material, but the course of fatal illness caused by this bad actor seems to be marked by a 'cytokine storm' that leads to grave lung damage in those affected.

Well shoot, who wants to be in the eye of a cytokine storm? Cytokines are worthy molecules that various body immune cells make in response to an infectious invasion. This is generally a good thing insofar as these various chemicals amplify the body's attack on unwanted intruders. As is true of so many physiological functions, however, a little is good but a lot is destructive.

At the heart of the stormy matter are macrophages ('first responder' white cells activated by damaged cells or foreign invaders such as bacteria or viruses) and CD8+T-lymphocytes (circulating white cells that leap into killer mode the moment they get a whiff of flu viral proteins nearby). These white knights in cell membrane clothing produce a whole host of cytokines--including Tumor Necrosis Factor (TNF)-alpha, Interferon (IFN)-gamma, IFN-alpha/beta, Interleukin (IL)-6, IL-1, MIP-1 (Macrophage Inflammatory Protein), MIG (Monokine Induced by IFN-gamma), IP-10 (Interferon-gamma-Inducible Protein), and MCP-1 (Monocyte Chemoattractant Protein) to name a few. H5N1 influenza (bird flu) happens to be a particularly strong inducer of this cytokine over-production due to the virulence and enthusiasm with which it enters human tissues. Whether or not swine flu and this newest swine version causes this kind of cytokine mess is still not known.

So the human lung and too many cytokines is way too much of a good thing, causing swelling, hemorrhage, and tissue death which are, ironically, more a result of the body's defense mode than a primary flu-generated injury. Scientists theorize that young people may have a more robust cytokine response and less H1N1 immunity from previous exposure compared with older populations.

As of today, 8 cases have been reported in the US from California and Mexico that have been identified as the swinish H1N1 flu but mild and self-limited illnesses in those affected. Remember, increasing evidence suggests that robust body levels of vitamin D are flu-protective, so this might be a good time to get your blood tested for vitamin D and step up your supplements under advisement with your physician.

For up-dated information on the H1N1 flu, see Triple Reassortment Swine Influenza, H1N1 flu shots, Why should I get a flu shot?, and What's a Phase 6 Pandemic?

These glasses have got to go!

I've just returned from a round trip drive to the East coast. Don't ask why, just know that the last time I did that journey, I was 19, and it's quite a different matter to sit in a car that long that far nearly 4 decades later.

We were equipped with snacks, books on tape, and my favorite pair of sunglasses. When I tried them on at the sporting goods store, I was impressed with their style and comfort. I wore them for six months before I noticed that they had skulls embossed on the ear pieces--perhaps some sort of extreme sports insignia? Actually my son brought the look to my attention.

Well I can live with the skull thing, but I discovered during hours of driving into the late afternoon Kansas sun, these shades simply don't fit. The beskulled left ear piece digs painfully into my very own skull just above and behind my ear. So what misery to pick--squinting into the sun (wrinkles! cataracts! an inability to see the road!) or incessant fiddling with the way glasses meet head?

On top of that, my left shoulder began hurting terribly. I'm picturing my aging, degenerating neck sinking into my torso, pinching a nerve on its way to the bucket seat, and I add massaging the shoulder to sunglass fussing to my general in-car fidgets. After ripping the stupid things off when the sun went behind a cloud, I discovered that my shoulder pain resolved within minutes.

I've always told my patients that muscle tension in the neck can easily cause a headache. Apparently pounding plastic into the temporalis muscle on the side of the head can reverse the pain flow down the neck to the shoulder.

Bilateral shingles

I wished recently for a consult with Dr. House (in the form of Hugh Laurie with the patience of Mother Theresa). My patient felt awful for a week or so. She was having palpitations, her chest hurt terribly with any position change--say with settling back into bed--or with deep breathing, and the skin on the back of her neck hurt terribly. Her appetite was down, she had no pain with swallowing nor acid reflux, and generally felt unwell due to her newly diagnosed rheumatoid arthritis and Crohn's disease.

Her blood pressure was low and her pulse was up, no fever, her chest wall was not painful to touch, her lungs were clear, and her abdomen wasn't tender. Any movement of her torso caused her to cry out in pain. Her blood count and lab work were normal except for an expected elevation in her sedimentation rate (a non-specific measure of inflammation or infection in the body) due to her arthritis and colitis. A chest x-ray was clear, her thoracic spine films looked good, and the EKG showed no evidence of heart troubles.

Yikes, what on earth? Perhaps yeast in her esophagus? Yet she had no trouble swallowing food. Costochondritis (inflammation where the ribs meet the sternum)? No pain on pressing those joints. Acid gastritis? Her pain was positional and not affected a bit by eating. Heart pain? Nope, the pain was totally atypical. Pre-shingles nerve pain? Maybe in the neck, but not on both sides, and what did that have to do with her chest pain.

Two days later she broke out in shingles--on both sides of her head behind and on her ears. So much for conventional wisdom that shingles only affects one side. In fact, 4% of patients break out on both sides of their bodies. Meanwhile, she researched the side effects of Asacol (a medication used to decrease the inflammation of colitis) and found chest pain on the list. She quit the medication, and, within a day, her pain was gone.

So who needs House when patients use the Internet? I regret that I didn't start her right away on one of the drugs that work against shingles (Valtrex, Famvir, or acyclovir). House would've done that.

Meat-related mortality

I just finished a liverwurst sandwich (delicious with dijon mustard and sliced purple onion); it was 'to die for' but not exactly my definition of health food. Imagine my dismay when to die for took on a more literal meaning as I opened the March 23rd issue of The Archives of Internal Medicine to this headline news: "Meat intake and mortality: a prospective study of over half a million people."(1)

So what do 500,000 meat eaters have to teach us about the guilty pleasure of a liverwurst sandwich? Namely that the consumption of red meat and processed meats (and liverwurst, while not red, is oddly pink in a processed, not-found-in-nature sort of way) is associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality.

In other words, too much meat and you're so much dead meat. My sandwich sits like a guilty lump in my stomach. An accompanying editorial goes on to indict me further: "Far too few clinicians speak out on topics such as this. What the public hears is the side of the profession that is preaching vegetarian diets and not the side of the profession that is discussing moderation as a healthy option." So I'm telling you now, the very occasional processed meat treat may be good for your soul, but mostly you should emulate my favorite dinner--which I had last night--namely a bowl of Bear Naked Granola.

And just to further fuel my discomfort with meat, I have just ordered "Dying for a Hamburger: Modern Meat Processing and the Epidemic of Alzheimer's Disease" wherein the authors make a case that Alzheimer's Disease is spreading like an infectious disease which, per them, is carried in cow meat meals contaminated by prions, the proteinaceous particles associated with mad cow disease. Lovely. I'll let you know if this sounds cutting edge or lunatic fringe.
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1) Arch Into Med. 2009 Mar 23;169(6):562-71.

Flector patch

Looking for the anti-inflammatory relief of Advil or Aleve without the stomach distress? If you're injured and hurting, check out Flector Patch for a brand new alternative in pain control

How gross is this ad?

Actual advertisement on London bus--does this stud muffin do Pap tests?
(from copyranter.blogspot.com)

Fatty liver disease

"As the nation gets heavier, our livers will get fatter."
---Chin Hee Kim, MD

Nonalcoholic fatty liver disease (NAFLD) is the most common form of liver disease AND it affects 20-30% of the US population per Drs. Kim and Younossi writing in the Cleveland Clinic Journal of Medicine(1). NAFLD can range from no big deal fat in liver through inflammation and liver cell damage (nonalcoholic steatohepatosis or NASH) to cirrhosis, liver cancer, or liver failure.

The standard, automated laboratory blood profile includes a panel of liver enzymes. These transaminases(2) which are involved in the production of amino acids are part of the biochemical equipment within liver cells. They are normally present in the bloodstream in small amounts, but disruption of liver cells causes their blood levels to rise. A case of hepatitis skyrockets transaminase levels into the 1,000s and beyond, but even very low level elevations found on lab screening are worthy of follow-up because they may indicate an ongoing, asymptomatic inflammatory liver process that can ultimately lead to cirrhosis and liver failure.

Often, elevated liver enzymes or liver function tests (LFTs) in overweight persons demonstrating signs of metabolic troubles (fat concentrated around the waistline, elevated blood pressure, elevated triglycerides, low HDL, or high blood sugar) are the first sign of NAFLD. This fatty liver business is usually asymptomatic and only noted on lab testing. In order to chase down the cause of abnormal LFTs, we next order tests to check for chronic hepatitis B or C infections, auto-immune liver disease, or metabolic diseases such as abnormally stored copper or iron in the liver. An ultrasound of the liver is fairly accurate in assessing the presence of fat in the liver.

Liver biopsy is the best way to determine if the fatty liver troubles are benign or carry a risk of progression from nonalcoholic steatohepatosis to scarring and permanent liver damage or failure. Once diagnosed, the best approach to treating fatty livers is the same strategy that improves overall health in overweight persons on the road to diabetes or heart disease. These include weight loss (including use of bariatric or gastric bypass procedures), trials of various drugs that promote insulin sensitivity such as metformin, Actos, or Avandia or drugs that lower triglycerides and raise HDL levels such as statins and gemfibrozil. Fatty livers are more sensitive to damage from regular alcohol intake.

If you tend to pack the pounds around your waistline, be sure to ask your doctor to test your liver enzymes.
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1) Kim, HK and Younossi, ZM. Nonalcoholic fatty liver disease: A manifestation of the metabolic syndrome. Cleveland Clinic Journal of Medicine. October, 2008, Vol 75, pp 721-728.
2) Aspartate transaminase (AST) and alanine transaminase (ALT) levels generally range up to 40 or so. In mild NAFLD, AST <> ALT.

Cures for the red face?

And who wants a red face? I had a new patient in yesterday who specifically complained of a red nose, and indeed, the tip of her nose was red with tiny enlarged blood vessels visible on its surface (but only seen by me with reading glasses assist!).

Thanks again to TheDermBlog.com (and I highly recommend this site to you), I am able to bring you a little more info on the subject. One of the most common causes of a red face is rosacea, an inflammatory skin condition that often causes red cheeks and nose (and occasionally eyes), that gets redder yet with alcohol consumption, and responds to topical antibiotics like Metrogel. Sun damage also permanently dilates the superficial blood vessels in our skin, particularly visible in those with Type I sun-sensitive skin (as in fair, easily burned, often in red heads and persons of Northern European ancestry). Dr. Benabio notes on his blog that laser treatment can take away those enlarged capillaries at the skin surface.

I also see persons with acne succumb, as did I, to overscrub syndrome, using washcloths and various exfoliants in a vain attempt (in both senses of the word vain) to liberate the pores from pus and oil. I have been following Dr. Benabio's advice to wash the face less often, but it still goes against my basic impulse to scrub early, scrub often and dab with astringent in between.

He recommends anti-inflammatory, anti-redness skin products for the those who carry the red badge of sun damage/acne/rosacea front and center on their face. In particular, he mentioned Aveeno calming lotions with the herb feverfew. Aveeno apparently has gone to some trouble along with a host of phytochemists to remove the pesky parthenolide component of feverfew (which sensitizes the skin i.e. makes it redder) leaving behind its beneficial anti-inflammatory components. In particular, the parthenolide-depleted feverfew inhibits 5-lipoxygenase, a pro-inflammatory molecule that is the target of a new anti-arthritis medication working its way through clinical trials. Maybe feverfew should join the A-list of herbals that we smear on and swallow (it's supposedly good for migraine prevention as well) along with vitamin C and green tea.

Well, of all my skin troubles, redness is not one. Testimonials for Aveeno (and Eucerin) anti-redness creams abound on the internet. Let me know if you try it and like it!

Vitamin A supplements and cancer risk

A little is essential, a lot, apparently, is too much of a good thing.

Enamored with the potential of anti-oxidants in fruits and vegetables in cancer prevention, scientists theorized that concentrating these worthy phytonutrients in supplement form might be even better yet. Several studies through the years designed to test this theory on vitamin A derivatives such as carotene (that substance which imparts the orange color to carrots, sweet potatoes, melons, etc.) have been abruptly halted when smokers enrolled in the trials who took the real deal beta-carotene preparations developed lung cancer at a significantly higher rate than those on placebos.

University of North Carolina researchers took another tact and arrived at the same conclusion. They examined data from 77,000 Americans over 10 years--correlating use of dietary supplements with subsequent cancer diagnoses. Note that these subjects were not assigned to a certain vitamin or placebo but rather self-reported their use of over-the-counter vitamin pills.

Not only did beta-carotene again prove problematic in a cancer-causing sort of way for the smokers in the study group, but retinol and lutein demonstrated a potent total dose-related association with lung cancer risk. The longer a person took these supplements, the greater their risk compared with those smokers who did not use them--53% for retinol and 102% for lutein!

Lutein, of course, is recommended to help prevent macular degeneration, an age-related eye condition that can result in significant vision loss. The researchers did not comment on the conflicting reasons to take or pass up lutein, but perhaps persons who smoke should pass up the lutein.