Harnessing Hay Fever

The itchy eyes, sneezing, nasal drip and tickle in the back of the throat are all well known to sufferers of hay fever or "Allergic Rhinitis."  What is not commonly understood is how fatiguing this condition can be as well.  People suffer from allergies because their immune system recognizes a foreign substance (antigen) that usually enters the body through the nose and mouth.  A primed immune system will bind that antigen by a histamine receptor to what is called a Mast Cell.  The interaction causes the Mast Cell to release histamine into the blood stream, resulting in an immediate release of inflammatory products which trigger swelling of the lining of the nose, throat and eyes.  This is what causes that runny nose and watery eyes.  The work required to create this inflammation is very fatiguing.  In fact, any medical condition that causes inflammation will cause fatigue.  Sufferers of Multiple Sclerosis, Rheumatoid Arthritis or Chron's Disease know this well. In fact, it is very common for a patient with pneumonia to still feel fatigued weeks after the cough has gotten better.

Most sufferers of allergies do just that; they suffer through it.  I'll admit that I am usually one of them.  Keeping them under control, though, can help you feel more energetic and less miserable.  Let me explain the different treatment options and the rationale for each so you can decide what is best for you.  The most commonly used medicines are the antihistamines.  This includes Claritin (loratadine), Allegra (fexofenadine), Zyrtec (cetirizine), and Benadryl (diphenhydramine) to name the most common ones.  They block that initial triggering event discussed above.  Logically, the sooner they are used, the better they will work.  If you wait till you are full of fluid, they will keep your allergies from getting worse but they will not help for what you have already been exposed to.  The horse is out of the barn in this case and it is too late to close the door.  During a bad season it may be best to take the medicine on a daily basis.  They can work quite well intermittently if given prior to an exposure.  I have used them effectively prior to wood working, mowing the lawn or going to a friend's house who has a cat.  The medicines are all available over the counter now and most have a generic form which makes them less expensive.  The main draw back is that they themselves can be fatiguing.  The least sedating is Claritin and Allegra, followed by Zyrtec.  Benadryl is the most sedating.  There are also antihistamine nasal sprays and eye drops.  Those are not sedating at all but have to be used more frequently.

Nasal steroids reduce the inflammatory response from the histamine release.  They can be used with or without the antihistamine.  Since they are absorbed right in the nasal passage, almost none of the medicine enters the bloodstream, making them quite safe.  The draw back to these medications is that many people do not like squirting medication in their nose and they are quite expensive.  Thankfully, one of the best ones, Flonase (fluticasone) is now available in generic form.  They do all require a prescription.  If used daily over many weeks or months, the lining in the nose can become too thin and result in nose bleeds.  Stopping the medication for 1-2 weeks will solve that problem.  They do not work quite as well as antihistamine medications on an as needed basis.  Many use them for a few weeks out of the year during a bad season.

Allergy shots are the most effective way of reducing long term symptoms.  They induce tolerance in the immune system by introducing a small dose of antigen on a regular basis.  Over time, the immune system becomes desensitized, similar to what happens with teenage boys when their mother speaks to them.  The trigger is still there but nothing registers.  There are some obvious drawbacks to injection immunotherapy (allergy shots).  First, they are given by injection.  Second, if the dose of antigen is too high, it can induce a more serious reaction in the whole body so they must be given at the doctor's office.  Third, they have to be administered weekly for the first few months and then monthly for many years.  The hassle factor can be a big impediment.  Lastly, if you move to a new area, you have to start all over.  The injections only work for the antigens in your current environment.

There are other possible ways to help your allergies as well.  The simplest, of course, is avoidance.  That may not always be the best course of action, however. There is some evidence that children born and raised in the city have more allergies than children born in the country.  There is likely a critical age in the developing immune system where exposure induces tolerance rather than activation.  The science behind this has not been completely worked out yet.  Some have suggested that ingesting unfiltered bee honey can help.  When bees return to the hive, they not only bring the nectar to form honey but also lots of pollen.  The rationale is similar to that of injections but instead of sensitizing to very specific antigens, this would in theory sensitize to a more broad range of them.  For this to work, it should be unfiltered honey from local bee keepers to make sure that the antigens are ones that exist in your own environment.  There are likely many antigens that would not be covered by the honey, such as animal dander or dust.

I hope you find this informative.  Thanks to Debbie for the requested topic.  If you have specific questions that I did not touch, on please let me know.

Occupational Challenges

Last week I wrote about what I enjoy most as a physician.  This week, I'll share some of the challenges that I face.  Let me just say upfront that the good outweigh the bad.  I hope it will forever be the case.  My daughter once asked me what the hardest part of my job was.  She had an occupational survey to do for a school assignment.  My mind went immediately to the part of the physical exam which is most distasteful to both me and my male patients.  Upon further reflection, though, I decided that delivering bad news was probably the hardest.  As I said last week, the end process can be very satisfying, but that initial conversation when I need to tell someone that they have cancer, or another serious illness, is very difficult.  It is gut wrenching.  About the only thing that comes close is when I was in a movie theater many years ago watching the "Lion King" with my daughter.  Simba's father falls to his death in the canyon stampede.  With tears in her eyes, she looks into my face and asks, "Is he going to be all right, Daddy?"  You want to respond that all is going to be fine.  It is important to give hope when there is hope and to be positive so that the patient remains positive.  However, it is also important to be truthful so that they understand what to expect and how to plan.  Some are not ready to hear the bad news and it may have to be explained several times.  Patience is the key.

Sometimes I wish I could be perfect.  There are many stresses that come with our job as physicians.  We have the stress of trying to stay on time, of writing complete notes, of being too busy, of not being busy enough.  We have phone calls and tasks and emails, faxes and letters all pulling us in a hundred different directions.  Now we have the stress of the electronic health record.  We have to make sure we have clicked every box and entered every requirement or we are told that medicare will void out the entire visit.  It is stressful to respond to a patient who is requesting a medication that we feel would do them more harm than good.  By nature we want to please.  Some patients can become very upset if they are not given an antibiotic for their cold or pain pills for their headaches.  Above all else, my greatest stress, though, is the stress of missing a diagnosis or of making the wrong treatment decision.  There have been times when I have made a subtle diagnosis that has likely saved a patient's life.  One in particular was that of picking up prostate cancer in a 38 year old man.  I did an exam and it felt abnormal so I sent him for a biopsy.  He now lives 2000 miles a way but just last year, while visiting St. Louis, he came to say hello and thank me once again.  He is doing fine.  Instead of feeling good about this, it frightens me.  When I saw him, I thought he was over forty.  I did the exam by mistake.  It was pure luck that allowed for his early diagnosis.  Another example is that of an older woman with a fatty mass in her thigh.  I have felt many of these, "lipomas" in patients and sent them on their way, telling them it was nothing to worry about. In her case, it felt just a bit different than the others.  It was a little more firm and more fixed to the leg.  I can still recall the back and forth of my thoughts considering course of action to take.  I was so close to letting it go that her words of gratitude terrify me.  I know how close it was.  She had an aggressive tumor that is usually fatal.  Another month or two may have made the difference between life and death.  It terrifies me that there will be someone else who I may decide to go the other way.  I know I cannot always be right, but I want to be.  I want to do the best for my patients.  That is my greatest stress.

This may be more truth than what you want to hear from a physician but I felt like it would be good to share.    Let me know what your concerns are as you come to the doctor's office.  What worries you the most?  What are your expectations?

Laughter is the Best Medicine :)

The following is a post from my colleague, Dr. Benjamin Voss.  Great information-enjoy!

Is Laughter really the Best Medicine?                                                                

 

This talk was originally presented on July 29, 2010 at Washington University School of Medicine Grand Rounds. This is backed by real research. Smile, it’s true.

 

I have always been told the laughter is the best medicine and when I finished residency, I was determined to investigate if this is indeed true. The story of the The Roseto Effect peaked my interest. In the 1950s, a visiting professor named Dr. Stewart Wolf noted that he rarely found anyone from Roseto, Pennsylvania under the age of 65 with heart disease. Their diet was high in fat consisting of lard, pizza, and biscotti, they smoked heavily, and the majority of them were overweight. After years of research, he concluded that their unique Community where they recreated their Italian heritage was health protective. They had three-generation family meals, talked to each other in the street, respected elders, enjoyed the calming effect of church, and had many civic organizations. The protective social structure insulated them from the pressures of the modern world.

 

Depression is obviously bad. However, its severity is traditionally underappreciated. Depression is an independent risk factor for developing heart disease and dying regardless of one’s other medial problems. Answering yes to “During the last month have you felt so sad, discouraged, hopeless, or had so many problems that you wondered if anything was worthwhile?" more than doubled one’s risk of developing heart disease. People with a Type A personality have a 2-fold increase risk of having a heart attack. Depression after a heart attack predicts the likelihood of death as much as developing heart failure after the heart attack. There are many physiological theories and explanations for this, but the key is that one’s body has “chronic sympathetic activation,” or a stressed body and mind all the time.

 

Positive affect, defined as “the experience of pleasurable emotions such as joy, happiness, excitement, enthusiasm, and contentment,” has the opposite effect on people. Comedian Bill Cosby once said “Immortality is a long shot, I admit. But somebody has to be first.” While humor is his occupation, the research actually supports his idea. Studies have shown people with a positive affect have better immune function and a greater resistance to upper respiratory infections. People who have hope and curiosity have lower blood pressure. Agreeing with one of the following four statements:“I felt that I was just as good as other people,” “I felt hopeful about the future,” “I was happy,” and “I enjoyed life,” showed a lower risk of stroke. While depression increases the risk of death in diabetics, positive affect lowers that risk. Hospitalized patients who answered yes to “I still enjoy things I used to enjoy” lived longer than patients who disagreed. Positive affect lowers the risk of death after a heart attack and in patients with AIDS. The physiological explanation here is enhanced parasympathetic activation, meaning lower heart rate, lower blood pressure, and increased glucose tolerance.

 

“Behavioral activation interventions” have been studied and these include increasing the frequency of enjoyable hobbies and activities. Exercise has been shown to reduce depression. Nutritional counseling in order to avoid overeating when stressed is important. Stress management options include yoga, vacations, and music. Social support is critical and walking groups are a great way to exercise and build community. So while it is critically important to take your medication and listen to your doctor, try adding a laugh or two to your daily routine.

 

Thank you Dr. Fuller for this opportunity to be a guest blogger. I do my best to get him to laugh everyday. 

The Statin Scare

Many of you may have heard the recent news in regards to the FDA updating the risk profile for the common cholesterol lowering medications referred to as "statins."  As portrayed by the media, if you take this medication you are sure to end up with dementia and crippling diabetes.  Let me share my perspective on this situation.

First of all, it must be reemphasized that statin medications have unequivocally resulted in lower rates of death due to heart disease.  Even in the short time that I have been in practice I have seen far fewer patients develop heart disease, suffer heart attacks or had the need for procedures and surgery.  This certainly is not due to the population eating better and getting more exercise since obesity rates have steadily climbed higher and higher over that same time period. It is due to driving down cholesterol levels, largely from statin medications.  This has been quantified to about a 25% decrease chance of death in those who take the medication.  That is very substantial.

Now to the cautions.  I'll be the first one to say that I do not want to take one of these medications.  I put a lot of time and effort into exercising regularly and eating right so that I do not have to.  I have grandparents who had heart disease and stroke.  My father was recently put on a statin medication.  I may have to take one some day but I will do all in my power to lower my risk through non pharmaceutical means first.  If my levels raise despite my best efforts I'll have no second thoughts about trying a statin medication.

The FDA highlighted two main concerns.  The first is the "reports of memory loss."  This sounds like the medicine can cause dementia.  That is as scary a thought as having cancer.  I have dementia in my family as well and have no desire to head down that path.  What has been reported is not dementia but more of a "brain fog." Patients describe this as muddled thinking, not being as sharp.  The good news is that this is totally reversible.  It goes away when the medications is stopped.  It happens quite infrequently but I have seen it in my practice on occasion.

The second concern is for elevated blood sugar readings.  As a prescribing physician I have not seen diabetic patients have problems with their blood sugars after taking the statin medications.  I wonder if this is related to the population becoming more obese.  That would be a reason both for having elevated cholesterol levels requiring medication as well as being predisposed to developing diabetes.  It is important to understand that the lower cardiovascular risk seen in studies using statin are the most robust in the subset of patients who have diabetes.  It is currently considered to be bad practice to avoid statin drugs in diabetics whose LDL cholesterol values are over 100 mg/dl.  Dr. Amy Egan, the deputy director of safety for the FDA's metabolism and endocrinology division summed it by saying, “Clearly we think that the heart benefit of statins outweighs this small increased risk, But what this means for patients taking statins and the health care professionals prescribing them is that blood-sugar levels may need to be assessed after instituting statin therapy” (link here).


If you have concerns, by all means share those with your physician but don't stop taking your medication till you do.  These are life saving medications.  They need to be treated with care, yes.  The risks of not taking them may well be higher than the risk of stopping them.  

The Wicked Whoop

One of medicine's achievements is the near eradication of  of whooping cough.  Or so we thought.  This potentially devastating illness often attacks the very young resulting in spasm after spasm of violent coughing.  It is now also making a resurgence in adults.  The force of air through the throat results in a "whooping" noise, thus the name.  The cough is not only severe it is doggedly persistent, lasting for months in many patients.  There are antibiotics which treat the infection but even if started early, the cough may linger for months.  The disease is caused by the bacteria Bordetella Purtussis.  It is the "P" in the childhood vaccine DPT.  As children have been vaccinated, the incidence of whooping cough has dropped significantly in our society.  Given the aging population of those who have received the vaccine, there is now a sizeable number of adults who have never had whooping cough.  It was felt that the vaccine provided life long immunity until a few years ago when groups of cases started popping up.  We have now learned that adults need a booster.  A new form of the tetanus vaccine is available called the Tdap, which accomplishes just that.  It is recommended to be given immediately to anyone who has close contact with infants.  The rest of us should receive it ten years after our last tetanus shot.  It is a completely killed vaccine, not a partially live one. It is quite safe.  The most common effects are a sore arm or a headache.  Many people are not familiar with how bad whooping cough can be.  Let me assure you, it is worth having the pain of the vaccine.  Don't let the wicked whoop snatch you.  Ask your doctor about getting your vaccine.

Shingles

For those who have had the disease, the term, "shingles" may evoke dread, pain and misery.  For those who have not, it may stir confusion and fear.  The name "shingles" comes from the Latin word "cingulum," which means belt or girdle.  Shingles is the reactivation of the chicken pox virus (herpes zoster) that lays dormant in our nerve roots.  We never completely get rid of it.  Later in life, the virus may escape the surveillance of our immune system, which keeps it in check, and will flare through one of the nerves.  These nerves commonly wrap around from the spine to the front of the body in a belt like fashion, thus the term "cingulum."  The rash irritates the corresponding nerve, resulting in pain which can be quite severe.  As opposed to muscle or joint pain, shingles pain does not respond well to the usual pain killers.


Sometimes the pain is the first symptom that presents itself.  At this stage it can be difficult to diagnose.  I have been fooled more than once by shingles, but if I am at all suspicious, I'll warn my patients that if a rash develops, to let me know. Recently I have been seeing a woman for back pain going down her leg.  It sounded very much like sciatic nerve pain.  We discussed using heat and she then told me that she had tried that but it gave her a rash.  I asked her to show me the rash and there it was: shingles.  It did not occur to her that it was related but her lack of response to the usual treatments for back pain made absolute sense when I realized the correct diagnosis.


Whereas chicken pox is a viral illness that goes throughout the body, shingles is confined to just the nerve root.  Chicken pox is highly contagious as it is spread through tiny droplets of moisture that is released in the atmosphere by simple breathing.  Shingles is only contagious to those who have never been exposed to the chicken pox virus or vaccine and only if there is direct contact to the rash.  If it is transmitted, the receiver will get chicken pox, not shingles.  You cannot give someone else shingles directly.


If shingles is diagnosed within three to four days of developing the rash, antiviral medications can be given which will shorten the duration of symptoms and decrease the chance of developing the painful nerve syndrome (post herpetic neuralgia).  If you think you have shingles, go see your doctor.  The rash may start as a few blisters on a red base (similar to chicken pox).  There is often a feeling of burning over the skin.  Many confuse this with a patch of insect bites.  


In addition to the antiviral medication, the pain can be treated with medicine that calms down nerve transmissions (such as gabapentin).  If the rash is in a defined area, topical lidocaine (lidoderm) can also be effective.  

It is now recommended that patients in their 60's receive the shingles vaccine (Zostavax).  It is quite safe, being the same vaccine used with children for the chicken pox virus, only it is given at a higher dose.  It decreases the chance of getting shingles by about 75%.  My patient with the back pain actually had been vaccinated, so it is not 100% foolproof.  The biggest issue with the vaccine is its cost.  Most facilities charge $250 for the shot and as of now, insurance coverage is spotty.  Check with your carrier first if you are considering getting the vaccine.

Managing Medications

I hold out hope that some day, I'll be able to send my patient to the lab for a "hypertensive DNA genotype array" which will check a person's genetic makeup and tell me why an individual has high blood pressure and which medicine will work the best for that particular patient.  We have learned much in the last 50 years in regards to why people have high blood pressure but we do not have a simple way as of yet to apply that on an individual basis.  As of right now when a patient needs medications to control their blood pressure, we as physicians use our knowledge, experience and our best guess as to what will work for a given person.  Trial and error is inevitable.  Some patients may require three, four or even five separate medications to control their pressure.  Others may be able to do it with life style changes alone.  Each medicine may have side effects that might limit its usefulness.  One may need to be stopped and another started.  As discussed previously, though, it is essential to get the blood pressure down and to keep it down.

I want to reemphasize that it is always better to be on less medication if possible.  I talk to all my patients with high blood pressure about their salt intake but very few of them really take me seriously.  I believe that it has a much greater influence than most people realize.  I came across a study some years back where researches studied a primitive island population in the Pacific.  They grew and or gathered almost all of their food.  Their diet was high in potassium given the high fruit content and it was extremely low in sodium in comparison to ours.  The astounding aspect to me was there was not a single person on the island that had high blood pressure.  Not even one.  Surely, I would suspect that someone would have a genetic defect giving them hypertension but it was overcome by a much healthier diet.  As stated in last week's post, it is essential to keep the sodium level under 2000 mg a day.

Some medications can be taken as needed.  Allergy medications, pain relievers or acid reducers can all be taken sporadically.  High blood pressure medications may not be used now and then.  They must be taken every single day.  The medicine will only work when it is taken and will have no lasting effects if doses are missed.  In fact, beta blockers if used inconsistently will trigger the blood pressure to spike to potentially dangerous levels.  I encourage all of my patients who are on daily medications to use a weekly pill box.  Many don't want to do so, saying they are not "old and senile."  We all will make mistakes if we are taking medicine from a bottle.  We can easily become distracted and then not remember if it was taken.  If we are using the pill box we will know for sure if it was taken or not.

Make sure you set up a routine.  Many patients will say that they remember their morning medications but often forget in the evening.  Put the medicine next to your tooth brush (which you should be using every night !), set an alarm if you need to.  Leave a note next to your bed stand to remind you.  Make sure you are consistent.

I want to finish with a word about side effects.  The printout given by the pharmacy is rather daunting.  It lists so many possible problems that most feel rather timid about taking any medication.  In general, medicines have 2-3 potential side effects that are more common.  If you think you are having a side effect to a medication, ask your physician.  Don't just stop the medicine and tell him three months later.  It is not always easy to tell if a symptom is related to a medication or not.  Remember that uncontrolled high blood pressure has side effects also.  The risks of both need to be weighed prior to making changes.  Your doctor is your health partner.  Don't leave him or her out of your important medical decisions.

Harnessing Hypertension

Does having hypertension automatically consign one to taking medications for the rest of one's life?  What about all of the side effects of taking medications?  Aren't they bad for you?  Knowing the risks posed by high blood pressure (see my previous post), what can be done to keep the pressure down?  answers to these questions are not always straightforward and can only be answered correctly on an individual basis.  Let me discuss some generalities first.

It is always better to control blood pressure without medications.  Always.  It may not always be possible to lower blood pressure enough with healthy living alone, but doing so will certainly decrease the number and or the dose of medications needed to keep it under control.  There are four basic precepts to keep in mind in harnessing hypertension.

First, if you smoke you must quit.  Nothing else you do will matter much if you keep smoking.  You may have a perfectly normal blood pressure, controlled with medications but your risk of heart disease and stroke will not go down significantly if you keep smoking.  Nicotine is a vasoconstrictor.  This means that it narrows the blood vessels.  Think of your garden hose.  If you want to increase the pressure in the hose to wash off your deck you apply a device at the end of the hose that narrows it.  Every time a cigarette is smoked the blood vessels narrow for about twenty minutes.  I see this all the time in my office.  A patient will come in with a higher than normal blood pressure.  One quick sniff tells me that they likely had one last cigarette before walking in the door.  At the end of the visit, I'll recheck the blood pressure and it will have come down.  In the beginning these changes are reversible.  With time, the stress on the walls of the blood vessel cause it to become thickened.  This is like taking that garden hose and turning it into a pipe.  As there is no elasticity or give in the blood vessel wall, pressure shoots up even more.  This whole cascade is caused from cigarette smoking.  I know that it is hard.  You must quit smoking.

Second, regular cardiovascular exercise is as good as taking a medication.  The side effects are much better.  It will not give you a cough, make your ankles swell or take away your sex drive.  It will give you more energy, relieve stress and help you sleep better.  The biggest side effect from exercise is injury, of course.  Start slow and gradually build up.  Consistency is the key.  To effectively lower blood pressure some sort of exercise needs to be done at least four days of the week.  During exercise, the blood pressure will actually go up.  This is normal.  The muscles need more blood flow during exercise to provide fuel and oxygen to the muscles.  The heart responds by contracting more quickly and with a greater force.  As the heart itself gets in better shape, it pumps more efficiently.  A well conditioned athlete will have a very low heart rate and excellent blood pressure readings. This is a sign that the blood vessels are relaxed and the heart is not burdened.

If you want to avoid taking medications or limit the number that you need, make sure that the fuel you give your body is of the highest quality.  In particular, limiting the salt content in your food will help your blood pressure.  The sodium in salt causes your body to retain more water in the kidneys.  This is equivalent to turning up the knob on the garden hose.  The higher the volume in the tubes, the higher the pressure.  You must first break the habit of salting your food.  This includes tomatoes and cantaloupe.  In addition, much of the food that we eat has a lot of salt in it to begin with.  Make the effort to look at everything that you eat in a day.  Look at the labels, find out how much sodium is in all that you eat.  Your total sodium intake in a day should be less than 2000 mg.  It is easy to find a website to tell you how much salt is in common foods (here's one).  If it is in a package, a wrapper or a can, it likely has salt in it.  If it says "low fat" it likely has salt in it.  Guess what has not salt in it at all?  Fruits and vegetables.  In fact, fresh fruits and vegetables are naturally high in potassium.  When potassium is delivered to the kidney it exchanges with sodium, excreting it in the urine.   By eating fruits and vegetables you are actually getting rid of salt.  The best diet to lower your blood pressure is the DASH diet (dietary advice to stop hypertension).

Lastly, limit the toxins in your system.  Admittedly this includes nicotine and salt but those two are so important they get their own category.  In addition, alcohol can be an issue.  Up to four glasses of red wine has been shown to have a beneficial effect on cholesterol levels but not more, and not any other kind of alcohol.  No amount of beer, vodka or other forms have been shown to have any beneficial effect.  The alcohol molecule itself can have adverse effects on the heart.  Alcohol also contains sodium and "empty calories" (they don't do your body any good).  Caffeine is not as bad as nicotine but it is a stimulant.  It will artificially raise the heart rate.  The only safe way of doing this is through exercise.  Just this week I saw a patient in follow up who has dramatically reduced his blood pressure by eliminating soda, coffee and adding exercise.  Many medications can make blood pressure worse.  Anti-inflammatory medications such as Aleve (naproxen) or Advil (ibuprofen) can have a deleterious effect, especially in older individuals. ADD drugs such as Aderall and Ritalin can also raise blood pressure.  The anti-depressant Effexor also must be used with care in addition to the migraine medications like Imitrex.  Decongestants are especially bad for hypertension and should not be used.  This is just a sample.  Look on the labels of anything that you take and make sure it does not give warning in regards to high blood pressure.

In summary, I have not given any advice in this post that I have not given previously.  I have tailored it specifically to high blood pressure.  The advice remains simple, putting it into practice is difficult.  Choose on thing that you can do better and work on that.  Make a positive step in your health today.

The Silent Assassin

Like an unaware target of a vigilant sniper, most people with high blood pressure live their lives with no suspicion that danger lurks at all times.  Hypertension rarely causes immediate effects on health but its constant influence causes stress on blood vessels and the walls of the heart.  This leads to thickening of the artery walls causing them to become hard and more brittle.  The most dreaded complication due to this process is in the brain in the form of a stoke.  There are usually no warning signs of a stroke.  When blood supply to the brain is cut off it happens quickly and suddenly.  Depending on which portion of the brain is affected, the effects can be devastating.

The muscular walls of the heart respond to the stress of high blood pressure the same way a weight lifters muscles respond to working out, by getting bigger and thicker.  At first thought you may ask, "What is wrong with having a "buff" heart.  Strong, thick muscles are good for quick bursts of action but it is the lean, thin muscles of the marathoner that we would rather pattern our heart muscle after, not the hulk of a weight lifter.  Ideally we want that heart muscle to pump slow, steady and efficiently, beat after beat after beat.   When the heart muscle gets too big, it gets stiff and has a hard time relaxing.  The stiff walls of the heart inhibit the flow of blood into the chamber.  If less blood enters the pumping chamber, less blood is ejected.  To compensate for this, the heart speeds up, making it even harder to fill the chamber.  As it gets harder and harder to fill the pump, the blood flow to the heart backs up like a partially clogged sink and fluid starts to fill the lungs leading to a form of congestive heart failure.  This form of heart failure is completely preventable by controlling blood pressure. 

In addition to causing heart failure and strokes, high blood pressure can trigger a heart attack.  If the lining over a cholesterol deposit breaks open, the body will respond by creating a clot on top of that plaque (see below).  This can take a non important 50% blockage and turn it into a deadly 100% blockage resulting in damage to the heart muscle.  High blood pressure makes the likelihood of that lining being broken open much higher.  The higher the sheer forces on the blockage, the greater the chance of rupture.  

Other areas of the body can also be damaged severely by high blood pressure, including the delicate tissues of the eye and the specialized filters of the kidney.  When combined with diabetes, blood vessel damage is exceedingly more likely.  The vast majority of patients on hemodialysis (artificial kidney machine) have one or both of these conditions.

Waiting to lower blood pressure until something bad happens is a recipe for disaster.  First, make sure you know what your blood pressure is.  If you haven't been in to see your doctor, do so.  Put your arm in the machine at the grocery store or pharmacy.  If you have a family member with a home machine, try it out. There are two numbers associated with your blood pressure.  The top number (systolic pressure) is the pressure in your blood vessels as the heart contracts.  The bottom number (diastolic pressure) is the pressure after it relaxes.  Both numbers are important.  If either one of them are elevated, your blood pressure is elevated.  Normal blood pressure is to have your systolic less than 130 mm Hg and the diastolic less than 80 mm Hg.  Real damage start to occur when your levels are consistently greater than 140/90.  Next week I'll discuss what to do if your levels are too high.

Know Your Risks

I can now scientifically prove what I have been telling people for years.  If you don't want to die from heart disease, take care of your risk factors.  Today, in the New England Journal of Medicine, a study was released showing that nonsmoking people in their 40-50's with normal blood pressure, blood sugar, and cholesterol levels had a five time lower risk of getting heart disease compared with those with at least two of those risk factors.  I have had patients come in to my office worried about their risk for heart disease, wanting to get some fancy test to see if they are at risk.  I tell them, of course you are at risk.  You smoke, you don't exercise.  Your cholesterol is up.  What they really want is to ignore their risk factors and have some test saying that everything is all right.  They don't want to change.  A test may be normal but that doesn't mean it will stay that way.  I have had patients present with heart attacks six weeks after a normal stress test.

All of these risk factors are modifiable.  They can be changed.  If you smoke, you can quit.  It is hard and you may have to try again and again, but you can quit.  Help is as easy as calling 1-800-QUIT-NOW.  If your blood pressure is up, it can be controlled.  Ideally through diet and exercise but medications may be necessary. More on this later.  Know what your blood pressure is.  It should be checked every year.  The same goes for levels of cholesterol and blood sugar.  If you don't know your levels, you don't know your risk.  You may be in your forties and feel fine.  However, the time to act is now to prevent problems in the future.  Get in to your physician and get checked out.  If you wait till you have symptoms of diabetes or heart disease it will be too late.

The great news is that if your risk factors are controlled you can spend your later years in good health.  You can enjoy yourself, take trips, be with the grandchildren.  No, none of us are immortal, but we all want to enjoy the time we have here in this life.  The human body is an amazing organism.  It is a precious gift from God.  Let's take good care of it.  It is the only one we have.

Measuring Bone Health

The ultimate goal of maintaining bone health is to prevent fractures.  We use a test called a bone density to help assess fracture risk.  It is a rather simple test to have done.  It requires no needles and is not painful.  It is similar to taking an x-ray but instead of taking a picture it takes a measurement.  The measurements are averaged and compared to the bones of young healthy adults.  The comparison is quantified mathematically in the form of a logarithm, called a T score.  Now before you roll your eyes and stop reading this, all you need to know is that the further you get away from zero, the worse you get.  Zero is the normal for that young healthy adult.  Osteoporosis (brittle bones) is labeled at -2.5 and osteopenia begins at -1.0.  Since it is logarithmic, -2.0 doesn't mean it is twice as bad, it means it is twenty times as bad and -3.0 is three hundred times as bad.

Ideally a bone density scan should be done on the same machine by the same technician.  There is significant variation between different types of machines.  The least accurate measurements are from the ones that look at the heel or the wrist.  Those should only be done as a quick screen and if abnormal should prompt a full evaluation with the standard scan done on the hip and spine.  The heal and wrist scans should not be used as a determinant to guide therapy.  Our bones are not uniformly thick, therefore variations in where the beam is directed can results in different values.  The technicians are trained to perform the test in the same area but if it is possible, having the same technician will lead to the most precise results.


One condition that will affect the accuracy of the test is arthritis of the spine.  In this condition, there is a build up of calcium deposits on the sides of the bone which will make the bone appear to be thicker and stronger than it really is.  In those patients who have a significant amount of arthritis, the scan should only be done on the hip.  Arthritis of the hip does not have the same problem because the measurement is not taken through the joint where the build up occurs.

It is important to understand that the number on the test is not the only determinant of your fracture risk.  A person with a nontraumatic hip fracture may have a T score of -2.2.  That would put them in the thin but not brittle group.  However, this person has already had a fracture so the future risk of additional fractures is going to be much higher.  Regardless of the T score, this person has osteoporosis.  Someone else with the same score and no history of fracture would be at a much lower risk.  Other risk factors should be considered such as whether a person is a woman who has gone through menopause, one's level of activity, whether or not a person is a smoker, one's family history is important and body size and composition.  A tool to add risk factors to one's T score to more accurately measure fracture risk is called the FRAX calculator.  This can be easily computed on line.  A score of 3% or higher is considered to be high risk and would warrant treatment.

Who should be screened for osteoporosis and how frequently does a bone density need to be repeated?  Men without risk factors are typically not screened.  Women should be screened for a baseline at menopause, repeating the test every two to five years depending on the score and their overall risk.  Those at higher risk due to medical conditions, certain medications, unprovoked fractures, etc should be screened earlier.  If in doubt, discuss this with your physician.  You should know your risk.  If you are at an above average risk for fracture, taking care of your bones now can prevent horribly painful conditions later when it will be too late to build back your bones.

Dem Bones Dem Bones

I have received a request to discuss the treatment for osteoporosis, so here are my two or three cents.  Feel free to make additional requests.  You can leave a comment on this blog or send an email to me at mpf9973@bjc.org.

During our younger years most of us take our bones for granted.  They carry us from place to place remarkably well.  They are quite resilient and only give way under a significant amount of stress.  As we get older that changes.  I have had a patient break their pelvis by nearly bending over to pick up a load of laundry.  Slips and falls can easily lead to broken hips, collar bones or arms.  The back bones can spontaneously implode on themselves like a stepped on soda can.  Not only are all these situations extremely painful, they are dangerous as well.  If an 80 year old falls and breaks a hip, there is a 50% chance that they will no longer be alive within six months.  It takes longer to heal at that age.  The immobility will predispose one to blood clots.  Pneumonia is more common.  The physical stress of the fracture may trigger a heart attack.  Muscle wasting occurs, making future falls even more likely.  This is the reason why physicians are so concerned about your bones.

Osteoblast: Bone Builder

Osteoclast: Bone Eater

The time to act is now, not after a fracture has happened.  By that time the bones are already brittle and weak.  To understand the different therapies used to improve bone strength, let me first explain bone metabolism.  One of the reasons why bone is so strong is that it is constantly being remodeled.  You can think of bones as scaffolding composed of calcium deposits.  There are two types of workers on the scaffolding, osteoblasts and osteoclasts. The osteoblast is the builder cell.  He is your brick mason, so to speak.  The osteoclast are the low paid college kids who come in and tear out the old bone that is showing signs of decay.  Think of calcium as the bricks used to build up the scaffolding.  The reason why people develop thin bones is because of an aberration in one of these three areas.  First, the youthful demolition workers may be over active.  Second, the deliberate mason builders may work too slow to match the demolition done by their younger counterparts.  Third, there may be a deficiency of material to work with (not enough calcium).  An example of the first are people given anti-inflammatory steroids such as prednisone.  This turns on the osteoclasts and bone destruction is accelerated.  Women in menopause who lack the estrogen of youth have a decrease in the activity of their osteoblasts (mason workers).  Patients with Celiac disease don't absorb calcium as well and lack the material used to make the bones.  The same is true for patients taking long term anti-acid suppressant medications or patients with vitamin D deficiency.  An overactive parathyroid gland will result in pulling calcium out of the bones and into the blood stream.  Understanding the cause of why someone's bones are thin is important so as to recommend how to counteract those effects.

The most important way to improve bone health is to be on them and be active.  There will never be a better solution than regular weight bearing exercise.  In as little as six weeks, well conditioned, young astronauts in space will begin to lose strength in their bones.  The same happens to anyone confined to bed for an illness.  Self imposed inactivity (nice way of saying "laziness") has similar effects.  When we are active and up on our feet our bones feel that pressure.  The mechanical reaction stimulates our osteoblasts to action and they get to work building more bone.  This won't do you any good if there is not adequate calcium to work with.  Calcium is mostly found in dairy products.  It is recommended that we obtain 1000-1200 mg of calcium a day.  Each serving of dairy contains approximately 300 mg of calcium.  The absorption of calcium is enhanced by the effects of vitamin D.  Vitamin D is activated by sun light.  As little as 10 minutes of sun exposure three days a week will suffice (see "Good Rays or Bad").  If you are not getting enough calcium through your diet, it is good to supplement that with a combination calcium-vit D tablet.  I recommend using 600 mg of calcium combined with 400 units of vitamin D, 1 or 2 tablets a day depending on your diet.  If you take a medication to block the acid in your stomach, using calcium citrate, which is absorbed better in an acid free environment than is calcium carbonate, which requires acid for absorption.

Regardless of what conditions affect your bones, adequate exercise, the appropriate diet and just enough sun exposure will help.  In a future post, I'll discuss how bone strength is measured and medications used to treat brittle bones.

Anguish over Antibiotics

Having suffered with a bad chest cold for the last week, I figured this would be a good time to discuss the appropriate use for antibiotics in regards to upper respiratory infections.  By this, I refer to infections of the sinus (sinusitis), throat (pharyngitis), upper airways (bronchitis) or of the lung itself (pneumonia).  The common cold is usually referred to as rhino-sinusitis or infection of the nasal passages and sinus.  Over 90% of these infections are due to viruses.  The most important fact to understand is that antibiotics do not treat viral infections.  They treat bacterial infections.  There are times when it is appropriate to use them but for the most part they are to be avoided.

Now, one may ask, "What is the big deal about taking antibiotics?"  I have often heard, "I just get this twice a year and if I get my Z-pack, I do well."  However, after talking to the patient, I often come to the conclusion that their infection is likely viral.  I can assure you, that my life would be much easier if I just sent out the prescription for an antibiotic.  I have often wished I could give someone "placebocillin."  I would tell my patient to take these sugar pills twice a day for ten days and I know that chances are they will be feeling quite well by then.  There are three reasons to be wary in taking an antibiotic.  The first is a chance that you may develop an allergy to the medication.  Rarely can this be life threatening.  The second is the risk of developing diarrhea associated diarrhea, the worst of which is called, clostridium dificile colitis which is triggered by taking antibiotics and can be very difficult to clear and very serious.  The last is the risk that bacteria can develop resistance patterns due to being overexposed to antibiotics.  This is already began to be a problem.  We may not be too far away from a time when certain infections will have no available antibiotics that can be used to treat them.

What, then, are the symptoms which would suggest that antibiotics are appropriate?  First strep throat requires the use of an antibiotic.  The symptoms are fever and a sore throat.  Strep does not cause a cough. There is not much sinus involvment either. If you have a fever and a sore throat with a bad cough, that is not strep.  Bacterial sinusitis is characterized by a fever, sinus related facial pain in the prescence of yellow or green secretions.  Usually, these infections are secondary, meaning that they begin as a virus but with time (usually 10-14 days) bacteria can get trapped in the sinuses and start a new infection.  Commonly, a patient will tell me that they started with a cold, started to improve and then got worse again.  It is also important to know that colored secretions in and of themselves do not indicate a bacterial infection.  In fact, such are expected starting about 4-5 days after the beginning of a cold.

Resistant Bacteria

Bronchitis only requires antibiotics in the setting of an asthmatic, smoker or certain other lung diseases.  Such infections are quite common and can last a very long time.  Patience is the key.  If one is making gradual improvement, even if painfully slow, it is imperative to wait it out, letting our body clear the infection on its own.  Now if one developes chills, fever, pain with breathing or shortness of breath, it is time to go see your doctor and make sure pneumonia has not developed.

Lastly, pneumonia almost always requires an antibiotic.  Even if it is precipitated by a viral infection, it is common that pneumonia develops into a secondary bacterial infection.  The prime example of this is seen with influenza.  The deadly epidemic of 1918 was fueled mostly be pneumonia from staph that came after the influenza was contracted.  If you have symptoms to suggest pneumonia as listed above, it is always appropriate to be evaluated by a physician.

Colon Cancer Concerns

Colon cancer is one of the more dangerous forms of cancer, in fact it is the second leading cause of deaths among cancers.  Fortunately, it has a precancerous phase that can be detected.  These early growths can be removed, preventing this deadly disease.  Detection occurs through a procedure called a colonoscopy.  Now, I realize that contemplating a scope being inserted into the colon is not a pleasant experience.   It is not quite as bad as the imagination would suggest.  The procedure itself is done under sedation and is tolerated well.  The worse part of the test is getting cleaned out the night before.  The good news is that if the test is normal and there is no family history of colon cancer, it need not be repeated for ten years.

Now, surely, you ask, there must be a better way.  How about those virtual colonoscopies I heard about on T.V.?  This can be done, but here are the details.  The preparation is the same.  It is done by a CT scanner after dye and air have been forced up into and through the colon.  This does not feel good and no sedation is used.  If anything abnormal is detected, a full colonoscopy will need to follow so that a biopsy can be obtained.  Personally, I would rather have the better test and be done with it.  What about using those little cards to detect blood in the colon?  The problem with those is that there is a pretty high false positive rate.  It also misses many precancerous growths.  If the polyps do not happen to cause bleeding, nothing will be protected.  Is a colonoscopy really necessary?, my patients ask.  I respond that I cannot remember having diagnosed a patient with colon cancer who has been screened.  As opposed to screening for breast or prostate cancer which hopes to detect cancer at an early stage and cure it, screening for colon cancer finds growths before they have turned cancerous and thus the disease never develops in the first place.

When does screening begin?  A person at average risk should be screened beginning at age 50.  If someone has a family history of cancer or precancerous polyps in a first degree relative (parent or sibling), they should be screened starting 10 years prior to their affected relative or by age 50, whichever comes first.

Most agree that a diet high in natural vitamins and fiber decrease your risk of colon cancer.  There are, of course, found in fruits and vegetables.  Genetics play an important role as well.  Make sure you ask your family members if they have been screened and if any polyps were found.  Make sure you get screened.  Talk to your doctor about your individual risk.  It may well save your life.

The Problematic PSA

There has recently been much debate and discussion as to whether or not the PSA blood test should be used in screening for prstate cancer.  The PSA is a blood test.  It stands for "prostate specific antigen."  Protein particles in the prostate gland are released in small quantities into the blood stream and have found to be elevated in prostate cancer, a state in which prostate cells are multiplying and dividing at an accelerated rate.  Since the development and routine use of this test, the detection of prostate cancers has increased dramatically.  What is not clear, though, is whether increased detection has led to saved lives.  Let me discuss further some of the controversies that surround the issue.

First, the test itself is not a perfect test.  Cancer is not the only cause of having an elevated blood test.  A lower urinary tract infection may also elevate the test.  Some may have a low grade inflammation of the prostate gland (chronic prostatitis) that will lead to having an elevated PSA.  Recent sexual intercourse can cause transient elevations in the PSA as well.  If an abnormal result is found, it is important to repeat the test in 6-12 weeks prior to considering a prostate biopsy, a rather invasive and not so pleasant procedure.

Proper interpretation of the PSA is very important.  The test itself is not dangerous, but an elevated result may lead to a path consisting of first a biopsy and, if cancer is found, to possibly surgery, castration chemotherapy or radiation.  Any of these three may carry adverse effects ranging from urinary incontinence, urinary frequency, impotence and bloody diarrhea.  Though prostate cancer is the leading cause of cancer, it is far from the leading cause of cancer death.  Most prostate cancer is a slow growing process that most people will die with rather than from.  However, there are cases that can be more rapidly progressive and deadly.  In this form, the cancer can spread to other organs in the abdomen and into the bones.  At this stage, the cancer is quite difficult to treat.  The demise is usually slow, painful and progressive.  When looked at as a whole, the vast majority of patients will not have this deadlier version.  Some will interpret those statistics in such a way as to conclude that early detection of prostate cancer is not worth the complications attendant to its treatment.

What is really needed is a way to determine who will progress to the deadlier form of disease and who will not.  In such an instance, treatment could be safely withheld from those who do not need it but could be aggressively applied to those who do.  We do not as yet have such markers.  Strides in this area are being made in relation to breast cancer but are lacking as of yet for prostate cancer.  In the meantime, proper interpretation of the PSA test can help guide decision making.  This should be done on an individual basis between each patient and their physician.

I personally feel that it is appropriate to screen patients with a PSA level in their forties, especially if there is a family history of prostate cancer.  If in the forties, the PSA is low (below 1.0 ng/ml) waiting an additional five years to repeat the test is reasonable.  I recommend yearly testing in someone who is in their 50's.  In the 40's and 50's, an elevated test should first be repeated to make sure that it is accurate.  I am more aggressive in this age group since detection is much more likely to result in meaningful treatment.

As a patient enters their 60's and 70's, I look less at the absolute value of the test and more at how it is changing.  The PSA will rise with age just due to the fact that the prostate never quite stops growing.  If, through the years, there has been a slow gradual increase, I am not nearly so concerned as someone who suddenly has a steep spike in their value from one year to the next.  If repeat testing at a shorter interval shows progressive worsening, that is likely a sign of progressive disease and warrants consideration for a biopsy.  In a patient in his 80's or 90's, I would only use an elevated PSA if I thought there was progressive disease as manifested by symptoms of urinary blockage or evidence of cancer in the bones.

One comment.  The above discussion applies only to patients not previously known to have prostate cancer.  In a patient with known cancer, who has been treated, the PSA is a good marker of disease activity and there is no controversy as to its use.

Lastly, a word about treatment.  Hormonal based treatments definitely have symptoms of weakness, fatigue and hot flashes that likely will occur.  Radiation treatments have evolved so as to be more precise and involve less damage to other nearby organs (such as the large bowel and bladder).  In this instance there is less diarrhea, rectal bleeding and frequent urination.  Surgical techniques have changed considerably.  Many urologist have become quite proficient in the use of robotic procedures.  Since the prostate lies deep in the pelvis, former surgical techniques did not allow the surgeon to always see what was being stitched or cut, but was done by feel alone.  The robotic techniques allow for much better visualization of the area and much more precise stitching.  In the right hands, such a surgery has a very low incidence of impotence and incontinence.  Further studies are being done to determine if these better techniques can result in prolonged life without sacrificing the quality that we want.

In conclusion, using the PSA test to screen for prostate cancer is not a black and white issue.  Ask your doctor for his opinion.  Consider your options and choose the course that you feel most comfortable taking.

Treating Neck Pain

There are five basic components to getting better when suffering from tight muscles in the neck and shoulders.  Posture prevention.  Simple Stretches.  Helpful Heat. Meaningful Massage.  Consistency is Key.

Posture Prevention:
As mentioned in last week's post, if the head is maintained in a forward position for an extended period of time the muscles will become overworked, tight and they will spasm.  When sitting in front of a computer screen, watching television, reading a book or even knitting a scarf, take care to keep you head back so that it is being supported by the bones in your spine, not the muscles of your neck.  If you are sitting in the same position for more than thirty minutes, take a few seconds and move your neck.  Do some simple stretches (see below).  In addition to your head position, make sure that your shoulders are in a neutral position during your activity.  If your keyboard is too high and you type with the shoulders hunched up, even just a fraction of an inch, the muscles will be overworked.

Simple Stretches:

Trapezius Stretch

These are examples of three simple stretches that can be done repeatedly through the day to loosen up your muscles.  They can be done in just a minute or two.  You can do them right in your chair at work.  There are many ways to stretch.  Most of them are quite acceptable.  First, listen to your body.  If the activity causes pain which is more than simple muscle stretching, don't do it.  In the neck, especially, be careful with spinal manipulation.  If you are older or have any risk factors for hardening of the arteries, consult with your physician prior to considering treatment consisting of neck manipulation.  It can result in disruption of the blood vessel in the neck.  Though quite rare, it is a potentially devastating complication.  You Tube has many videos demonstrating how to stretch the neck and shoulders.  An example of simple neck stretching is found here.  I enjoyed another one entitled, "Yoga Spine Exercises."  In fact, signing up for a Yoga class would be a great way to learn new techniques and enhance your flexibility in general.  Another form of exercise with great results for the spine is Pilates.  An example of some basic Pilates stretching is found here.

Helpful Heat:

Tight muscles in spasm tend to stay in spasm.  Heat helps to soften them up by increasing blood flow to the area.  Ice will contract the muscles and will make it worse.  Ice is best used when there has been an injury and swelling needs to be controlled.  For stiff muscles, heat is the best.  A great way to deliver heat is a "U-shaped" pack.  They may be filled with rice, barley, corn or other materials which can then be microwaved and will retain their heat for about 10-15 minutes.  This is just the right amount of time to apply it.  When is the best time to use heat? There is no bad time to do it.  Most people get lazy and don't do it enough.  Put it around your neck as you drive to work.  Put it on as you go to bed.  Using heat prior to stretching and massage is especially helpful.


Meaningful Massage:
Massage can release the painful knots or triggers that keep the muscles tight.  Certainly, going to a massage therapist is the best way to get relief.  A good physical therapist will also utilize massage in his/her treatment plan.  Lower cost alternatives may involve a close friend or family member.  Even if untrained, you can point out where the knots are.  A golf or tennis ball can be rolled over that area.  Even a rolling pin can work!  The vibrating massage balls sold in stores are not a bad idea either.

Consistency is Key:
Our bodies have a remarkable ability to heal themselves when given the chance.  We all have a tendency to ignore aches and pains knowing that eventually we will feel better, the body will take care of itself.  However, if you have reached the point where your neck and shoulder muscles are in a state of constant tightness and spasm,  those symptoms may last for a very long time.  By consistently following the simple steps listed above, the cycle can be broken and you can get back to feeling normal again.  It takes effort, but most of all it takes persistence.  Don't give up and get discouraged if you do not have immediate results.  You will feel better, but it takes time.

A Pain in the Neck

No, I'm not talking about your boss, your homework, being stuck in traffic or even all the things on your to do list.  I'm talking about the tightness between your shoulders that can cause pain up into your head, down your arms, sometimes in your chest and can even feel like a sharp pain deep in your inner ear. To explain how and why this happens, let me start with an anatomy lesson.

The main muscle group involved is called the trapezius.  It is so named due to its trapezoid shape, like a kite.  It attaches high up in the neck on the scull, extends down the spine to the mid back and flares out across to the edges to the shoulders.  The upper edge that is marked with an "X" is an area where trigger points can develop.  You know these better as "knots."  They are balled up areas of spasm that make life miserable. 

Underneath the trapezius are the scalene muscles.  They hold your head up straight and get overworked when our posture is bad.  At the bottom edge of these muscles is the brachial plexus.  This is a group of blood vessels and, more importantly, nerves that go down into the arm.  Enough spasm in the scalene muscles will cause pain, tingling and even numbness down the arm that feels similar to a bulged disc in the neck.

The sternocleidomastoid muscle group attach to the skull just behind the ear and attaches to the collar bone and breast bone.  These are the muscles that turn your head from side to side.  When they are in spasm one may feel a burning pain from the shoulder into the neck and side of the head.  This is the muscle that can make it feel like there is a sharp pick down in your ear.  This can especially be bad in those who spend a long time on the phone, holding it without hands between the ear and shoulder.

The levator scapulae muscle lifts up the shoulder blade to which it is attached.  It is responsible for shrugging your shoulders.  It is well known for knotting up on people who spend much of their time in front of a key board, especially if it is too high.  Steadily holding the shoulders in a shrugged position while typing creates constant tension in this muscle group.  It is not uncommon for me to see patients who come in complaining of a deep pain in their chest and are worried that they are having heart pains.  As I talk with them I'll hear clues that this is not their heart.  As I examine them, it becomes readily apparent that they are knotted up in the trapezius and especially the levator scapulae muscle.  I say to myself, "A ha!"  for I know that when there is a spasms in that location, it puts traction on the shoulder blade, pulling it upwards.  This then puts pressure on the other muscles which are attached to it, in this case the pectoralis minor muscle.  This is a small muscle of the chest that sits under the well known pectoralis major muscle, or "pecks."  As seen in the picture, the pectoralis minor attaches to the front of the shoulder blade and extends straight down to the rib cage.  Traction on the shoulder blade then causes a reciprocal spasm in this muscle and results in chest pains.

The number one reason for tightness and spasm in these important muscles is posture.  The head weighs about 20-25 pounds and is built to be supported by the bones in our spine.  If we are hunched forward, even just an inch or two, now those 25 pounds are being supported by the muscles of the neck instead.  I am seeing more and more patients with these problems and it is mostly due to the fact that we spend more and more time in front of a computer screen typing.  I have also seen this in patients who have bad posture while reading, sewing, quilting and even wood carving.  Tune in next week and I’ll discuss ways to help you get rid of your “pain in the neck.”

Aspirin Anguish

A report this week came to my attention that has linked a higher rate of macular degeneration with those who take aspirin on a regular basis.  Macular degeneration is a slowly progressive disease leading to blindness.  It is due to abnormal blood vessels in the back of the eye and becomes worse with age.  It is a frightening diagnosis to receive.  The news media seems to have very little interest these days in education and is rather more concerned about sensationalism.  This is the type of story that they love to scare people with.  I feel this deserves more thought and consideration.

The first issue lies in the fact that the study under consideration is retrospective.  This means that they took people who have the condition and looked back at factors that could be associated with it.  These types of studies are useful for generating questions for further study but are not in and of themselves definitive.  A prospective study is much better.  In this case, a group of people would be defined and divided into two groups.  One group would receive aspirin and the other would not. After a specified period of time, the two groups would be compared to see if one developed macular degeneration at a faster rate than the other.  This is not how the current study was performed.  Looking backwards can identify associations more so than establishing cause and effect.  One needs to ask, is aspirin the cause of the macular degeneration or could there be a different association.  As macular degeneration is a vascular (blood vessel) disease, I wonder if aspirin was just a marker for those who are at higher risk for vascular disease in general.  Aspirin has been shown conclusively in men over 45 and women over 55 to lower the risk of heart disease and stroke.  This is especially true in those who have risk factors such as high blood pressure, elevated cholesterol, smokers and diabetics.  Those at higher risk for vascular disease are likely to have a higher risk for macular degeneration as well.  Given their risk factors, such patients are more likely to have aspirin recommended to them by their doctors.  It is quite possible that if the patients who are found to have macular degeneration are taken off of their aspirin, they could have worsening of their macular degeneration.  They will certainly be at higher risk for the life ending complications of heart attack and stroke.

Aspirin use in the appropriate setting has been ranked by the U.S. Preventive Task Force as the single most effective way to save lives of any measure that we currently employ to prevent diseases.  This includes mammograms, pap smears, colonoscopies, blood pressure control, cholesterol management, etc. The single most effective!  Remember, your vision won't help you if you are dead.  Further studies are in order to determine the exact nature of the relationship between aspirin use and macular degeneration.  In the meantime, if you have risk factors for blood vessel disease, please talk to your doctor prior to considering stopping a potentially live prolonging medication, your simple aspirin a day.