Tuesday, March 27, 2007

Chronic Stress- Surging Glucocorticoids



In some ways we are not so different from a zebra on the Serengeti. If we are threatened with bodily harm, just like the zebra being chased by a lion, our adrenal glands kick into high gear and secrete adrenalin and glucocorticoid hormones. These hormones can keep us alive in an emergency. Blood rushes to our most needed organs (heart, lungs, muscles). Digestion shuts down and we stop salivating. Our attention gets very focused. We have no need to get an erection or urinate (save that for later if we live). These fight or flight hormones can keep us alive in an emergency. But they are meant to turn off quickly when the event has passed. Where humans differ from animals is that we can suffer from chronic worry and keep those hormones surging through our system for days on end. Heart disease, depression, diabetes, obesity, immune dysfunction, learning disorders, headaches, irritable bowel syndrome,... what do these diseases of modern man have in common? They have all been linked to chronic stress. And chronic stress means we have cortisone affecting our organs and cells when it should be turned off.

Robert Sapolsky, a brilliant Stanford neurobiologist and author of "Why Zebras Don't get Ulcers" and "A Primates Memoir" has studied baboons in Africa for decades. Doing elegant controlled studies of these social animals, he has come to some amazing conclusions that may explain how humans respond to chronic stress. He found low ranking baboons with fewer opportunities in baboon culture and less control of their lives had more stress hormones and more disease. He also found that baboons with social support, even if they weren't at the top of the hierarchy, had lower levels of harmful stress hormones. The baboons that could count on other baboons to help them out in a fight, groom them and let them hold the baby, had less harmful stress hormones, even if they weren't the alpha baboon. He also identified personality traits associated with low stress, even in the low ranking baboon. Certain baboons seemed to be unable to differentiate what was a danger and what was a non-threat in the environment. The "don't sweat the small stuff" baboons thrived compared to their hyper-anxious buddies.

Like his baboon studies, many human studies have shown that a sense of loss of control in our lives is extremely stressful and children who live with constant violence and fear, suffer from post traumatic stress disorder. People who feel they can't control their lives, who worry about the mortgage, the evil boss at work, or even the state of world events, run the risk of having stress hormones that are surging and impacting their immune systems in diseases that show up much later.
It takes a great deal of focus and attention to reduce stress and quit worrying.
Just saying "quit stressing out" or "relax" might even cause more stress.

We humans probably need more sleep, more time gazing out the window or watching rainfall, less time reading the news, less time watching TV or surfing the net, more classical music, more leisurely meals with large groups of friends and family, less shopping and errands, more realistic goals for our lives and more time grooming each other. Definitely more time grooming each other.

Monday, March 26, 2007

Multitasking

Yesterday's post on DWD, Driving While Distracted, now has more to back it up. I'm always happy to think my musings could be universal. Today, the New York Times has a great article on why it is not in our best interest to multitask. I have thought for some time that we are becoming a nation of people with ADD the way we drive, read, talk on the phone, drink lattes and apply eye makeup,all without missing a beat. Can this be good for our brains? Even more, can it be good for our spirits? Check out today's NYT and "slow down, you move to fast, gotta make the moment last"
Slow Down

Saturday, March 24, 2007

DWD - Driving While Distracted


According to the National Highway Traffic Safety Commission, 500,000 drivers a day are talking on handheld cell phones while they drive. The National Mutual Insurance Company reported 73% of the people they surveyed talked on phones while driving and 19% of motorists did text messaging while driving. Driving and talking on hand held phones make us 4X more likely to have a serious crash. It is debatable whether hand free talking is much better because of the distraction factor. Other serious distractions are reaching for a falling cup, reaching for CDs or music or just about anything in the glove box or disciplining the kids or even rubber necking as we pass something of interest.

Although all drivers can be distracted by anything that goes on inside the car, clearly digging for a ringing cell phone, tucked in a purse or pocket has got to be numero uno for big time road attention lapse. I can always tell when I am behind a cell phone driver. They are speeding up or slowing down or creeping over the lane line. Sometimes they don't see the light change or they turn abruptly in front of me.

California passed a bill banning handheld cell phone use while driving that goes into effect July 2008. California will be the fourth state with such a ban after Connecticut, New Jersey and New York. D.C. also has such a ban but most of our politicos are being chauffeured when they talk on the phone so no problem.

I personally use an ear cord when I drive and talk and that makes me feel like I am not DWD. Maybe I should have one of those bumper stickers that says " Call and tell me how I'm driving".

Friday, March 23, 2007

Embryo Ethics


Advances in medicine always bring challenges that are unexpected. Embryo screening before in-vitro fertilization usually helps parents have a healthy child. We can test for hundreds of fatal birth defects, childhood diseases and even some diseases that don't occur until adulthood. These tests are done before implantation of an embryo in infertility clinics and parents can now even choose the sex of the child. As the field advances, the ethical questions become even more important with different stakeholders having different opinions. Parents, bioethicists, disability groups, anti-abortion groups are all demanding different things. Once you choose the sex, what about other genetic features? At this time we can't identify the genes for hair color or muscles, but there is a concern that preimplantation genetic diagnosis (PGD) will lead us on a slippery slope of "designer babies".

An American public opinion survey about PGD was done in 2004 and 68% of people supported testing for fatal childhood diseases. Forty percent thought nonmedical sex selection was OK. Twenty-eight percent supported intelligence/strength trait testing. 20% of Americans favored a complete ban on testing. (genetics and public policy center at Johns Hopkins University)

For now, it is up to doctors to decide how to use PGD. It is an important discussion for bioethicists to have. Dr. Laurie Zoloth, PhD, a bioethics professor at Northwestern School of Medicine said "The point of having bioethicists at all is so that we can reflect on the nature, goal and meaning of our actions and think in advance about how to create a world we think is just and morally good, so that we can raise questions to parents and doctors that create serious conversations about their actions." (American Medical News)

Tuesday, March 20, 2007

New Innovations in Colonoscopy


Colonoscopy, the screening scope test that looks for polyps and cancers in the large bowel, may be replaced with new methods for diagnosing colon cancer. We've all been waiting for a new technology that will eliminate the awful cleansing prep the day before, the IV sedation and the hassle of spending an entire day undergoing an expensive screening test for colon cancer.
Yes, screening colonoscopy is a great way to find polyps and growths before they become invasive cancer. Yes, it is relatively safe and effective but, jeeze, what a hassle. And for a screening test, it is quite expensive, therefore millions of uninsured and underinsured people just don't get screened at all.

On the horizon is virtual colonoscopy, a high-resolution CT scan with a software program that allows you to recreate or simulate the colon. This computer-aided diagnosis will shorten the time frame and allow more screenings to be done. Currently you can get a virtual test but the prep remains the same. Soon "prepless" CT scans will eliminate the need to cleanse the colon and most patients will embrace this. Another promising alternative that is being developed is the PillCam which is a capsule with cameras that are inserted or swallowed and project images as the pill passes through the bowel. We currently have endoscopy capsule technology that images the small bowel and the new pill would have double cameras that cover twice as much area as most of the small bowel capsules. We have a way to go with this technology but given its simplicity and the rate of innovation, this may be the wave of the future.

At this point, good old fashioned scope colonoscopy remains the gold standard and in a person with no risk factors (family history of colon cancer, crohns disease or unusual bleeding), screening should begin at age 50 and every 10 years thereafter. If you are 50, go ahead and get that colonoscopy. If all goes well, with the current rate of new technology being developed, it may be the last one you need to get.

Saturday, March 17, 2007

Buy Dove Soap



The new Dove Soap campaign is not only brilliant marketing, it is Madison Avenue with a mission. These commercials break down the classic stereotypes of beauty in our society and empower women to accept themselves as they are. What would really make a difference is if you men out there would call your pre-teen or teen daughter to the computer and show her this video. Young girls are facing images of sexy, tall, thin, airbrushed, surgery enhanced bodies everywhere they turn. When they look in their own mirror they see something completely different and feel inadequate. Having your dad open the conversation about real beauty and what men like about women could have an impact that would last a lifetime.

Dove is making it easier on all of us. Let's support the companies that are making this crazy life a little gentler.

Thursday, March 15, 2007

Seniors vs. Children

I was alarmed to read a new study released by the Urban Institute that reported how children are becoming a diminishing national priority in America. The report examined federal spending from 1960-2006 and found the share of domestic spending targeted to children's programs declined from 20.1% in 1960 to 15.4% in 2007. At the same time, the spending on adults is eight times greater than spending on children. As a percentage of GDP, the adult portions of Social Security, Medicare and Medicaid (The big three entitlements)are expected to grow to 9.5% by 2017, while children's programs will drop to 2.1%.

I like our seniors as much as anyone and, gee, by 2017 that money will be spent on me! But I don't want the future of America, our children, to be ignored just because they have no political power. Marian Wright Edelman, president of the Children's Defense Fund, said, "Children are a voiceless, voteless constituency. They don't lobby, and they don't make campaign contributions".

I believe there is enough money in the United States to care for our needy seniors as well as our children. We absolutely must tackle run-away health care expenditures and stop spending 30% of the Medicare budget in the last year of life. We know that 10% of Medicare beneficiaries account for 70% of spending. Can't we target that population and manage their health more efficiently? These problems can be solved. We need better leaders and better priorities that realize investing in children's health, education and welfare makes for a richer society.

If you want to read all 33 pages of the report,go for it: Kids Budget

Wednesday, March 14, 2007

Another Order of Poison Please

http://www.youtube.com/watch?v=ZfbTO0GlONU



If you are interested in EverythingHealth, this video speaks for itself. The main fat guy (sorry to be pejorative but it is deserved in this case) is probably only 40 years old. As my mother used to say "Just because it is there, doesn't mean you put it in your mouth". People, people....this is poison to your body.

Tuesday, March 13, 2007

Drug Ads-Illness of the Month

One reason President George Bush is so beholdin' to the pharmaceutical industry may be because their drug ads on TV and in magazines are keeping this economy going. If those ad revenues stopped, we might see some major broadcasting networks shutting down their lights. The next time you are watching prime time TV, just notice how many ads are for pharmaceuticals or medical devices that require a prescription. There is even a new ad (shown over and over on American Idol) that advertises a new knee replacement device made "only for women".

A new study shows that prescription drug advertising on television is rarely educational, and mostly uses emotional appeals to entice consumers. According to Internal Medicine News, Dr. Dominick Frosch, Ph.D at UCLA, analyzed ads shown during prime time on the 4 major networks and found seven of the top ten bestselling drugs. 95% of the ads showed characters who were happy and some were practically ecstatic after taking the product.

These direct to consumer marketing ads can distort and inflate consumers' expectations about what prescriptions drugs can accomplish. When physicians are surveyed about these ads, they are overwhelmingly negative and against them. But the pharmaceutical industry knows that they work and sales soar after an ad campaign. Every day a patient shows up in the office requesting a certain drug that she saw on TV. "What about that new sleeping pill that is supposed to REALLY work!" Most of these prescription drugs don't have a generic equivalent so the consumer will pay dearly for being enticed.

Prediction - A woman will definitely win American Idol

Sunday, March 11, 2007

Heel pain - Plantar Fasciitis



My right inner heel is killing me. It started a few weeks ago after playing tennis and each time I play I wake up limping the next morning. I can press on one area of my heel (calcaneous) and "ouch" that's where it is. I have the most common cause of heel pain in adults....plantar fasciitis.

Plantar fasciitis occurs more frequently in women and is often seen in runners and dancers who use repetitive, flexion of the ankle and foot bones (metatarsophalangeal joints). It can be caused by improper footwear, change in intensity of physical activity or a change in the walking surface. Other causes are reduced flexibility, tight achilles tendon, discrepancy in leg length or sudden weight gain such as pregnancy. I think I know where mine came from...new tennis shoes and increased activity.

The plantar fascia is a band of tissue that fans out across the sole of the foot from the heel to the bones of the foot. As the heel strikes, the leg bone (tibia) rotates internally and the foot turns in (pronates) which stretches the fascia as the foot flattens. Because the plantar fascia has no elastic properties, this repetitive stretching results in microtears at the heal. These microtears lead to collagen degeneration at the calcaneous (heel bone) and this causes the heel pain. This pain usually comes on insidiously. Most patients don't remember any trauma and they describe the pain as a deep ache that is worse in the morning and lessens after about 20 minutes of walking.

Here is the good news. Plantar fasciitis is usually self-limited. Here is the bad news. It can take as much as 6 to 18 months! The longer the symptoms exist, the healing takes longer so it is important to start treatment. Here is what a person with plantar fasciitis should do:

1. Correct any training errors. Change high-impact activities to low impact such as biking or swimming. Change shoes if they are a factor.

2. Increase the flexibility of the calf muscle and achilles tendon with stretching. One way to stretch the plantar fascia is to fill a plastic bottle with ice cold water and roll the foot arch back and forth over it.

3. Ice the foot at least once daily. This can be done as ice pack (crushed ice in a plastic bag) held in place for 15 minutes or an ice bath. Soak on the heel only and keep those toes out of the ice water.

4. Strengthen the foot muscles. In one study 35% of patients cited strengthening programs as the most helpful. Strengthen by placing a foot flat on the end of a towel and keep the heel on the floor. Then pull the towel toward the body by curling the toes. One can also pick up marbles with the toes and place them in a cup, keeping the heel on the ground.

5. NSAIDs. This is Advil, Motrin or Aleeve. These non-steroidal, anti-inflammatory drugs are effective in treating pain and reducing inflammation. Prolonged NSAIDs can cause GI bleeding or kidney problems in certain patients so check with your own doctor if you take them for extended periods of time.

6. Orthotics and night splints. Over the counter arch supports can help as can a heel pad or heel cup. Custom orthoses - made from an impression of the patient's foot-are expensive and designed to control biomechanical factors. Night splints keep the ankle in a flexed position and allow stretching of the calf and the plantar fascia while the patient sleeps.

I think if I follow the doctors advise and spend a little time paying attention to and rehabing my heel pain, I can be pain free soon. Gotta go get my ice pack ready.

Saturday, March 10, 2007

It's Time to Quit Smoking






No-one has been able to answer my question of why Hollywood still has so many attractive characters smoke in movies. I suspect the tobacco manufacturers use "payola" to have the most beautiful stars light up. A study was done that shows there are more smoking scenes in movies now than there were in the 1950s. Just be aware the next time you watch a movie and notice if the cigarette adds anything to that particular scene or dialog. Most of the time it adds nothing. Clearly, it is featured for the insidious purpose of glamorizing smoking. And yes, even in 2007, it still works! Since Hollywood movies are seen and loved worldwide, the effect is profound.
I hope none of the faithful readers of EverythingHealth smoke but, believe me, there are a lot of closet smokers and 3000 teens start each day. The tobacco manufacturers have increased the addictive additives in cigarettes and smokers are really trapped once they begin. The "stop smoking" industry is huge with biofeedback,acupuncture,talk therapy, nicoderm, nicotine gum, Zyban pills, and still the relapse rate is 85%. I have often told discouraged smoker patients "Don't beat up on yourself. The properties in cigarettes are as addictive as heroin or cocaine. If cigarettes were illegal you would be knocking over little old ladies for their purse to buy more".

I am thrilled to say there is a new treatment for tobacco addiction that works.
Researchers have found nicotine and dopamine receptors in the brain and have developed a pill called Chantix which blocks those receptors from the effects of smoking.
Because it is so new I have only had two patients use Chantix but both of them were hard core, lifelong smokers who had failed other methods. They are both successful non-smokers now and said it was absolutely easy with no craving. That's right, no craving. I have never heard results such as these before. The only side effect was insomnia. Will it work for everyone? I don't know but I treat people one at a time and so far we are 100%.

I have no stake in Chantix or the pharmaceutical industry. I am happy to inform, however, something that might just help millions of smokers who are killing themselves with tobacco. Smoking is the single worst chronic thing you can do to your body. If you know a smoker, please mention this new treatment and encourage them to try again. I look forward to watching a movie and hearing the actor say "Gee, I wish I could quit smoking. Look what it's doing to my skin."

Thursday, March 8, 2007

Under the Knife- Tips for Surgery


In any given week I have several patients or friends who are having surgery. "Come and go", outpatient surgery is the fastest growing type of surgery. Even though surgery has become about as common as getting a haircut, patients should not be cavalier about it. There is a growing awareness nationwide about patient safety and improving quality and surgery is one area that is getting a lot of attention. The patient safety movement brings the patient into the partnership with doctors and nurses as members of the care team to help improve surgical care overall. When we work as a team, patient care is safer. If you or a relative is contemplating surgery, this is what you need to know:

* Tell your surgeon about other problems you may have...allergies, diabetes,smoking history. How you are handled in the operating suite may be different with this knowledge.

* Ask if you will be receiving antibiotics. Patients have better outcomes when antibiotics are given within 60 minutes before surgery and are ususally stopped within 24 hours.

* If hair needs to be removed from the surgical site, it should be clipped. Shaving leaves small nicks that increases risk of infection.

* If your surgery is complicated or prolonged, the risk of blood clots increases. Ask your doctor if there is any need for medication or special devices to prevent blood clots.

* Make sure you check out this website for information about anesthesia. Here you will find great tips for you to know before surgery. Anesthesia info

* Ask if you should take your regular medication the day of surgery.

* Make a list of all of your medications, including over the counter, and take it with you.

These things sound simple, but its amazing how many people go under the knife without knowing what the surgery is, how long they will be in the hospital and what the aftercare plan is. Check out this link for more info. Be part of the team

Monday, March 5, 2007

What Are the Medical Journals Saying?

This weeks brief synopsis from the medical journals:

Antioxidant Supplements and Mortality

Many people are taking antioxidant supplements, believing it will improve their health and prevent diseases. Researchers in Copenhagen did an extensive review of all studies published worldwide and to see if antioxidant supplements improved health. They included 68 randomized trials with 232,606 participants from 385 publications. The antioxidant supplements were taken orally. Some of them were taken in combination, some alone. Here is what they found: Treatment with beta carotene, vitamin A and vitamin E given singly or combined with other supplements, did not improve health and, in fact, significantly increased mortality. Further randomized trials are needed to establish the effects of vitamin C and selenium. The authors stressed that these results examined only synthetic antioxidants and not the effects of fruits and vegetables.
Jama

Pain in Children

Researchers looked at children ages 6-17 who came to an emergency room with musculoskeletal injuries and pain. They found that Ibuprofen provided superior pain relief at one hour compared with Acetaminophen (Tylenol) or Codeine in children with fractures. The authors speculate that the anti-inflammatory effect of Ibuprofen may be responsible for its superior pain relief. There was no difference in pain relief in kids with soft tissue injuries.
Pediatrics

Malignant Melanoma in Runners

Marathon running has surged in popularity but there are some health risks. Researchers examined 210 athletes and compared them with age and sex matched controls. They found that marathon runners had an increased risk for malignant melanoma and nonmelanoma skin cancers. Regular use of sunscreen was used in only 56.2% of runners. Potential triggers for skin cancer were UV exposure and immunosuppression due to long-term intensive exercise. It is recommended that runners should reduce UV sun exposure by wearing adequate clothing, using water-resistant sunscreens and choose training schedules with low sun exposure.
Archives of Dermatology

Methadone Deaths Rise

Methadone-related poisoning deaths are increasing far faster than deaths from other types of poisonings. Methadone is often used as a treatment for opioid (heroin) addiction. There is a growing use of the drug as a prescription pain reliever. In November 2006, the US Food and Drug Administration issued a public health advisory noting that methadone can depress breathing or cause changes in heart beat.
Centers for Disease Control

(Note: The recent death of celebrity Anna Nicole Smith may be linked to Methadone.)

Friday, March 2, 2007

The Future is Here

When I was first practicing medicine, the cell phone had not yet been invented. There was no such thing as a calling card. I had to have dimes and quarters with me at all times and I knew where every phone booth was located from Marin to San Francisco. If my beeper went off, I needed to be prepared to find a pay phone quickly so I could phone the patient or hospital. Often I needed to turn my car around and head back to the city. It sounds like the dark ages, but it wasn't so long ago. My how times have changed!

The "new new thing" in patient care is robots. This new technology allows physicians to hook up their laptop anywhere and see a patient at a distant hospital. A growing number of doctors are using robotics to connect with patients and their high-tech circuitry lets a stethoscope be attached so a doctor can hear some one's heart from a remote location. These machines are dispatched to emergency departments, operating rooms and intensive care units.

About 100 robots are in use at 60 hospitals nationwide and the trend is growing. A computer screen shows the face of the physician atop a 5 foot machine while the doctor operates the rolling robot with a joystick via computer from another location. One physician has shown x-rays to patients on the screen where the face usually is and reportedly, patients are very satisfied that they are getting information from their own physician. Digital cameras capture real-time video of the patient.

"I don't think this robot can be viewed as a replacement for a human being, however, this may be one more tool we have to extend and improve health care delivery to our patients", said Li-Ming Su, MD, director of laparoscopic and robotic urologic surgery at Johns Hopkins Hospital in Baltimore. American Medical News.

This new technology could be a godsend to rural communities where specialists are scarce. Undoubtedly more uses will be found for these links, like access to instant interpreters for emergency departments and the ability to assess patients immediately if they have a change in medical condition. In November 2006, the Michigan Stroke Network introduced robots that let participating hospitals in the state call stroke specialists at St. Joseph Mercy Oakland hospital in Pontiac, Michigan. One patient experienced the robot who came to her bedside and said "You look great". She remarked "I'd rather see a robot than nobody at all."

Now your doctor can see you whenever you wish...from just about anywhere.