Dear Readers,
You do NOT want what's going around my waiting room. I don't either. After two key personnel were felled with that which is in the air in the front office, we've implemented a 'wear a mask' policy for those of you poor souls coming in to discuss your cough and fever.
I understand what a drag it is to wear a mask. I appreciate your understanding on this. If you are uncomfortable doing so, then I will put mine on when we visit in the exam room.
For more information on the current epidemic of crud, and for other health news, read on below. And if you wish you could be kept up-to-date on the latest in medical research, please visit my blogs at Denver Doc Online, and Doc of Ages for frequent postings on the latest in medicine.
Best wishes,
Judy Paley, MD*
1575 Gilpin St.
Denver, CO 80218
303-393-0300
judy.paley@femailhealthnews.com
*Please see about femailhealthnews for more information on Dr. Paley and this newsletter.
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This information is intended to be general in nature and should not be relied upon for specific treatment. If you need medical attention, please contact your personal physician's office for an appointment.
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Table of contents
1. Bystolic and stress
2. Flow-mediated vasodilation
3. A new drug for alcohol dependency
4. What's going around?
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Bystolic and stress
All stressed out and nowhere to run, no one to punch out. I was at a meeting yesterday, one of the most stressful meetings I've ever attended. My heart was pounding, I'm sure my face was red, and I had no recourse but to listen politely to the proceedings. If ever there was a stress test for my aging heart, that hour-long ordeal was it.
My forty-something year old patient lives a perpetual stress test. Caught in a years long legal battle with a former business colleague, he lives his life in a never-ending nervous fit. His heart pounds along at a resting heart rate above 110, his blood pressure is high, but the worst symptom, the one that brought him in 2 weeks ago, is how very, very hot he feels. He can scarcely stand indoor heating; his secretary suffers the open office windows while his wife piles on the covers in their breezy bedroom.
I have seriously entertained the notion that this poor fellow has an adrenal tumor, so intense are his symptoms. While waiting for his first round of tests to come back, I wondered if we might give him, his secretary, and his wife a break with beta blockers.
Originally developed for blood pressure troubles, beta blockers have since been tapped to control abnormal heart rhythms, protect heart muscle after a heart attack, and to combat performance anxiety. They work by competitively blocking cellular receptors for beta-sympathetic adrenal hormones such as norepinephrine which set off the 'fight or flight' response. As such, they can slow down the pulse and blood pressure response to stress. The problem with earlier versions of beta-blockers is that they blocked both beta-1 receptors responsible for cardiovascular changes and beta-2 receptors which, among other things, relax smooth muscle and dilate the airways (so you can get more oxygen to run away from lions, tigers, and meetings, oh my).
As my patient also has asthma in addition to more stress than any human should have, I needed a beta-1 selective agent that would not contribute to an asthmatic constriction of his airways. Lucky for us, the sales rep from Forest Pharmaceuticals had just left a big supply of Bystolic (generic name nebivolol) in our drug closet. I gave him a bottle and hoped that there would be no unexpected beta-2 blockade.
Here's the phone message I received 2 days later:
Said the pill you gave him works wonders. His heart rate went from 160 to 78, no more body heat, has not been using his inhaler, and his BP has gone down. He also has been working all day.
Now that is a wonder drug! I wonder why I didn't take one before the meeting from hell.
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Flow-mediated vasodilation
They're not just passive pipes anymore. No longer do scientists view our blood vessels as mere conduits that carry blood from heart to bod and back again. The worthy endothelial cells that line our arteries and veins not only respond to signals from the kidneys and adrenal glands to dilate and constrict, they actively produce substances themselves that affect their functioning.
One way that researchers test the health of blood vessels is through an indirect method called flow-mediated vasodilation (FMV). This test, an indirect measure of the ability of the arterial system to respond to increased demand, is performed by pumping up a blood pressure cuff on the subject's arm to some intolerable level, then releasing it and calculating the subsequent surge of blood flow through the fingertips with a gizmo called a plethysmograph.
A small study from Italy looked at the effects of a high-fat meal on blood vessel reactivity in ten postmenopausal women. The ladies were invited down to the lab for an 'oral fat load,' doubtless a large piece of tiramisu. At two hourly intervals thereafter, their FMV was measured. At baseline, the ladies sent nearly 8% more blood coursing through their fingertips after the cuff was removed. Two hours after the high-fat treat, this number fell by two-thirds, meaning that their blood vessels' capacity to dilate in response to increased blood flow fell by over 60%.
Theoretically, then, a high fat meal, whether consumed in a fast food joint or as part of an Atkins diet, can wreak havoc in an individual with unsuspected coronary artery disease. A burst of activity after the feast, say a sprint up the block to catch a bus, calls on diseased arteries to provide extra blood flow at a time when they are clamped down from a load of Taco Bell's best. When blood supply can't keep up with demand, the oxygen-starved portion of the heart can be damaged.
Air pollution, cigarette smoke, and early morning hours all can muck up your FMV. Vitamin E, oatmeal, dark chocolate, green tea, JuicePlus*, and ACE inhibitors (a class of blood pressure meds that includes lisinopril and enalopril) all support your endothelial cells to expand on demand.
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*J Am Coll Cardiol. 2003 May 21;41(10):1744-9.
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A new drug for alcohol dependency
College campuses are filled with kids who drink for kicks. Statistics suggest that some of these early drinkers will go on to become alcoholics for the feel good, addictive thrill of it all. The majority of adult alcoholics, however, drink to relieve stress and anxiety.
Currently, two drugs are available that are supposed to alter a drinker's response to alcohol in a way that makes ongoing use less appealing. Naltrexone is an opioid receptor blocker believed to prevent the release of dopamine (a feel-good neurotransmitter) that occurs with drinking. A 2006 study reported in JAMA found that naltrexone plus behavior therapy was significantly successful in preventing relapse in abstinent alcoholics. On the other hand, this same study found no benefits from Campral, another drug used for abstinence support. Campral is believed to block the effects of glutamate on brain cells. Glutamate is an activating neurotransmitter which, in some individuals, promotes anxiety and agitation.
So what can be done for alcoholics who drink to calm themselves? Researchers at the U.S. National Institute on Alcohol Abuse and Alcoholism went looking for other substances that would modulate stress reactions in the brain. They pulled LY686017 off the back shelf of drugs tested for depression but discarded for less than perfect efficacy. Ex-alcoholics who scored high on anxiety scales were given LY686017 or placebo, then given questionnaires about just how much they craved alcohol. Those plied with LY686017 were notably less likely to long for a drink.
But these Maryland scientists did not just stop with questionnaires. They subjected the subjects to mock interviews and math tests with scowling assistants in intimidating white coats. Afterwards, the group was tested for levels of the stress hormone cortisol. All subjects also got to sniff and caress a vial of their favorite beverage and were asked just how badly they wanted to drink it. Again, LY686017 triumphed, squelching the hormonal stress reaction as well as the urge to drink.
Says neuroscientist Selena Bartlett of the Ernest Gallo Clinic and Research Center (I kid you not) at the University of California, San Francisco, "It feels like we're heading for a sea change for new therapies for alcoholism."
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What's going around?
Illness #1: Starts with a tickle or tiny cough. Patient thinks must've been exposed to perfume, smoke, cat, smog, or perhaps a minor illness. Within hours to two days, patient develops sore throat, hoarseness, and a cough that is painful, compelling, deep, possibly productive of small amount of yellow guck. Body feels toxic, aching all over and fatigue so severe that patient debates with self whether or not it's worth getting up to bathroom or perhaps better just to hold it. No one wants to be around patient, including doctor.
Illness #2: Rather abruptly develops deep cough, body aches, chilling, fever, headache. Maybe sore throat. Eyes are glassy and no one doubts patient is ill. No one wants to be around patient, including doctor.
One illness is probably croup, the other influenza. Both are nasty and highly contagious. The flu shot, as you may have heard, was not a good match for the circulating strains of influenza this season. The viral part of these illnesses lasts for a week or more, the cough lingers for weeks (or even months in Denver's cold, dry, dirty air). While we can sort of take the edge off the misery with codeine cough syrup and Advil, antibiotics won't help a bit.
Getting better involves a slow return of energy. Remember, the cough may well outlast the illness by weeks. If you succumb to one of these bad actors, look out for phase 2 of the illness. If a week or more into the illness, you feel worse instead of better, and that which you cough or blow out is colored and disgusting, you may be developing bronchitis or sinusitis. We can talk about antibiotics.
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