Monthly Archives: January 2014

Tim Russert’s sudden death from a heart attack in 2008 took America by surprise.  It seemed clear to everybody that a good man died too young.  But the condition that killed him—coronary artery disease–is actually the most common cause of death in the U.S. and around the world.

In coronary artery disease (CAD) is a waxy substance called plaque builds up inside arteries that supply blood to the heart. Fortunately, over the past few decades many less people are dying of this disease.  As this New England Journal of Medicine article demonstrates, the reduction of cholesterol is the single greatest factor explaining the decrease in deaths from coronary artery disease. 

So it was significant when on November 12, 2013, the American College of Cardiology released new guidelines for treating cholesterol.  Here are some of the key points from the guidelines.

First, the guidelines emphasized that only the cholesterol medicines called statins have been shown to reduce the risk of developing and dying from coronary artery disease.  Although other medicines such as Zetia, Niacin, and Tricor do lower cholesterol, they don’t have robust evidence for lowering your risk of getting and dying from a heart attack.

Secondly, the guidelines no longer recommend aiming for a target cholesterol level.   Formerly, physicians and patients would try to lower cholesterol below a certain number. But in the studies that show statins reduce the risk of heart disease, patients were placed on either a statin or placebo and then followed to look for a difference in the incidence of heart attacks.  Thus, faithfully translating these studies into practice means simply putting people with or at risk of coronary artery disease on a statin.

And who is at risk for coronary artery disease?  Who should doctors put on a statin?  The guidelines point to the following 4 groups of individuals who benefit from these drugs:

1)    People with a history of coronary artery disease (CAD) or cerebrovascular disease.  The latter refers to folks who have had a stroke or mini-stroke

2)    People with LDL cholesterol levels above 190.  LDL is considered the bad cholesterol since it deposits plaque in arteries.  People with very high levels of LDL have been found to experience a higher incidence of heart disease and at a younger age. 

3)    People with diabetes, age 40-75.  Statins are recommended for diabetics since they have a markedly higher risk of developing CAD.

4)    People aged 40-75 who have a 7.5% risk or higher of developing CAD in the next 10 years.  This is the most controversial of the new guidelines.  Since many people have over a 7.5% risk of developing CAD in the next ten years, if this recommendation is put into practice, a good deal more folks will be placed on statins. 

Overall, I see these guidelines as a welcome advance.  They better reflect what the studies on cholesterol and CAD actually tell us.  They also simplify treating cholesterol.  Rather than aiming for a certain cholesterol number, patients and doctors can now focus on deciding whether starting a statin will be beneficial in their individual situations. 

Unlike some of my classmates in medical school, diseases themselves are not something I often feel a passion to study.  I find philosophy, theology, politics, literature, history, psychology, and so many other subjects much more interesting.  But when I see a person suffering and looking for answers and relief, I am motivated to learn all that I can to help.

So while the topic of allergies is not something that really revs my jets, I think it’s worth writing about since it’s affecting so many Austinites right now.  Indeed, I don’t recall ever seeing so many congested, itchy-eyed, hoarse, coughing, rhinorrheic people all at once. 

So what exactly is occurring when people suffer from allergies?  In response to airborne particles such as cedar, inflammation occurs, causing sneezing, itching, and fluid buildup.  There are 4 major categories of allergens, or substances that causes allergies: Pollens, Insects, Animal Allergens, and Molds. 

The ideal response to allergies is identifying the offending allergen and avoiding it. So in the cedar fever season, affected individuals should close the windows of their car and home, stay indoors when possible, and shower every night before bed to removes cedar from their skin and hair.  But, of course, remaining inside all day is pretty impractical and lame. 

The next step, then, is to take steps to reduce the inflammation that the allergens cause.  Here are some steps for doing so.

Rinse Your Nose

This is particularly useful for treating drainage down the back of your throat, sneezing, nasal dryness, and congestion.  It helps by rinsing out allergens and irritants from the nose.  Do it once or twice daily.  Saline nasal sprays and irrigation kits can be purchased over-the-counter.

Steroid Nasal Sprays

These are the first-line treatment for allergies.  I most commonly prescribe Flonase (Fluticasone) since it’s generic and cheap.  These drugs have few side effects and significantly relieve symptoms in most people.  You may need to use a nasal decongestant like Sudafed for a few days before starting the nasal spray to reduce nasal swelling.  Be patient as it can take days to weeks for these sprays to have their full effect.

Antihistamines

Think Allegra, Zyrtec, Claritin.  These relieve itching, sneezing, and runny nose, but doesn’t help with nasal congestion.  Antihistamine nasal sprays such as Astelin, Astepro, and Patanase are also available and work quickly.

Singulair

I add this medication when people are not receiving sufficient relief from the other treatments. Some people find it to be quite effective.

Steroid Pills or Shots

If you’re really struggling, a short course of Prednisone or a corticosteroid shot can provide quick, dramatic relief.  However, your symptoms are likely to quickly return unless you get on a maintenance treatment.  Because of their side-effects, steroid pills are not a viable long-term strategy for managing allergies.

Allergy Shots or Drops

If all else fails, I send people to an allergist for allergy shots or drops. They contain solutions of the allergens to which a person is allergic.  By receiving them, your immune response to the allergen lessens over time.  The downside of this approach is that it can be time-consuming and somewhat expensive.

Good luck with your allergies!

It is one thing to describe a health condition and another thing to experience and live with it.  So I appreciated Scott Stossel’s article in The Atlantic about his lifelong struggle with severe anxiety.   In My Anxious, Twitchy, Phobic (Somehow Successful) Life, Stossel eloquently captures what it is like to daily do battle with panic attacks, phobias, and generalized worry.  The piece is also very funny in a David Sedaris kind of way. 

I do, however, wish Stossel had displayed a bit less of a nihilistic attitude toward his mental nemesis.  Readers likewise afflicted with severe anxiety might come away from the article concluding that there is little hope for effectively addressing their condition.

The reality I see in my medical practice is quite different. In my experience, most people who seek help for their anxiety disorders are able to achieve a good quality of life and level of functioning. 

Many good books have been written on managing anxiety in its various manifestations.   (I recommend Dr. Ed Hallowell’s Worry) One blog post cannot do justice to this huge topic.  Nonetheless, here are 3 scientifically validated ways to effectively address anxiety.   I have seen them enable people crippled with anxiety disorders to live full lives again.

Exercise

When we feel anxious, the body’s sympathetic nervous system kicks into high gear.  Our adrenal glands release epinephrine and norepinephrine, raising blood pressure by constricting our arteries and making our hearts beat faster and harder. Peristalsis, the natural movement of our gut, is slowed down.  Cortisol is secreted, releasing more glucose into our bloodstream.  All of this contributes to the disturbing symptoms experienced during panic attacks and the feelings of fear that afflict people with anxiety disorders.   Exercise decreases the activity of these stress systems in our body. This is evident in research showing that people who engage in regular exercise experience fewer symptoms of anxiety.

The best form of exercise is an activity that you find to be enjoyable.  It is also important that it is feasible to fit into your schedule.  For this reason, I often encourage people to start off with a vigorous 30 minute daily walk around their neighborhood.  Yoga is a type of exercise that can be especially useful for decreasing anxiety since it may activate the body’s relaxation response, a state of deep rest that changes physical and emotional responses to stress.  Yoga and other forms of exercise that require intense concentration also allow people to take a break from anxious thoughts.

Cognitive Behavior Therapy (CBT)

People suffering from anxiety disorders often adopt counterproductive ways of responding to the problems life throws their way.   For instance, when something bad happens, they might overestimate how serious and damaging it is.  They may also engage in destructive behaviors like procrastinating that ultimately result in experiencing more anxiety.  In cognitive behavioral therapy (CBT), individuals develop more healthy and functional ways of thinking and behaving.  Multiple studies show that CBT is highly effective for treating anxiety disorders.  In my work as an internist, it is inspiring to see people once severely burdened by anxiety be empowered by working with a skilled, compassionate therapist. 

Medication

Again and again I have seen patients afflicted with severe anxiety disorders have their lives transformed by getting on the right medication.  The first-line meds for anxiety disorders are selective serotonin reuptake inhibitors (SSRIs), such Zoloft (Sertraline), Lexapro (Escitalopram), Celexa (Citalopram), and Paxil (Paroxetine).  SSRIs usually take a few weeks to become effective.  So patients are often prescribed medications called benzodiazepines while waiting for SSRIs to kick in.  Benzodiazepines such as Ativan (Lorazepam), Xanax (Alprazolam), and Klonopin (Clonazepam) are effective for this purpose, but in most cases should be not be used chronically on a regular basis.  This is because over time, a higher and higher dose of benzodiazepines are sometimes required to be effective.  In addition, benzodiazepines, like alcohol, can be used inappropriately as a kind of escape from the world.  The goal in treating severe anxiety is enabling people to successfully reengage with reality.

In Summary

Scott Stossel correctly points out in his piece that anxiety is a necessary part of being human.  We must think ahead about what could go wrong in our lives, so we can plan and prepare appropriately.  But as Ed Hallowell writes, anxiety becomes toxic when it is “unnecessary, repetitive, unproductive, paralyzing and life-defeating.”  When this happens, it is important to seek help because there are solutions that work.

(Repost)

I turned 36 recently and for some reason, this birthday prompted me to reflect on the scarcity of time.  When we are young, it seems like the days will go on forever.  The reality of an ending, of death, hardly enters our mind.  I adore this care-free innocence I witness in the life of my 5 year old son.

But as we enter adulthood, there is value in clearly seeing that our days are numbered.  It can motivate us to contemplate what really matters and how we want to spend the rest of their lives.

The psychology professor Mihaly Csikszentmihalyi has carefully studied how people spend their time.  He points out that what we do during an average day can be divided into three major kinds of activities.

The first way we spend our time is producing, or generating the resources such as money that ensure our survival and comfort.  The amount of time we spend working in this way differs across time and places.  Csikszentmihalyi writes that “according to some anthropologists, among certain societies, such as the tribesman of Brazilian jungles or the African deserts, grown men rarely spend more than four hours a day providing for their livelihood–the rest of the time they spend resting, chatting, singing, and dancing.  On the other hand, during the hundred years or so of industrialization in the West, before unions were to regulate working time, it was not unusual for workers to spend twelve or more hours a day in the factory.  So the eight-hour workday, which is currently the norm, is about halfway between the two extremes.”

The second way we spend our time is preserving the body and its possessions.  Csikszentmihalyi calls eating, resting, grooming, cooking, shopping, housework, and driving maintenance activities.  Traditionally women have taken on a greater portion of the maintenance work, while men spent more time on productive roles.  But, of course, this division of labor has changed over time and will continue to evolve.  

The time left over from production and maintenance is free time or leisure.  Csikszentmihalyi notes that our free time is divided into three major sorts of activities.  The first is media consumption, consisting mostly of watching television and surfing the internet.  The second is conversation.  The third is hobbies such as making music or art, engaging in sports and exercise, and reading.  Interestingly, Csikszentmihalyi does not specify how he would categorize service and volunteer work or being involved in a spiritual community.  Is this work or leisure? 

I think Csikszentmihalyi’s poetic summary of how we spend our days is worth sharing.

These three main functions–production, maintenance, and leisure–absorb our psychic energy.  They provide the information that goes through the mind day after day, from birth to the end of life.  Thus, in essence, what our life is consists in experiences related to work, to keeping things we already have from falling apart, and to whatever else we do in our free time.  It is within these parameters that life unfolds, and it is how we choose what we do, and how we approach it, that will determine whether the sum of our days adds up to a formless blur, or to something resembling a work of art.

 

I love that last thought: Will the sum of our days add up to a formless blur, or to something resembling a work of art?

A new study by the Rush Institute for Healthy Aging in Chicago estimates that the number of people living with Alzheimer’s Disease will triple by the year 2050.  Like other forms of dementia, Alzheimer’s is characterized by deterioration in cognitive function that ultimately results in difficulty performing life’s every day activities.

Once Alzheimer’s Disease occurs, there is currently no treatment to reverse it or even stop it from getting worse.  There are two types of prescription medications that have been shown to influence the course of Alzheimer’s disease progression.  One type of medication, called acetylcholinesterase inhibitors, raises the level of a neurotransmitter called acetylcholine in the space (synapse) between neurons.  Examples of these drugs are Aricept (Donepezil), Razadyne (Galantamine), and the Exelon patch (Rivastigmine).  Studies show that the average person treated with an acetylcholinesterase inhibitor has a small improvement in cognition and in performing daily life activities.

The second type of prescription medication used to affect the course of Alzheimer’s Disease is Namenda (Memantine).  It works by blocking a receptor called NMDA.

The current standard of care in treating a person with Alzheimer’s Disease is to start an acetylcholinesterase inhibitor such as Aricept.  It is unclear whether adding Namenda offers additional benefit once a person is already taking an acetylcholinesterase inhibitor.  While one study seemed to show that adding Namenda slowed the progression of Alzheimer’s, two others did not find this to be the case.  Now a study published in the January 1, 2014 issue of the Journal of the American Medical Association shows that while combining Namenda with an acetylcholinesterase inhibitor was not helpful, adding Vitamin E resulted in a slower functional decline.

Researchers selected 613 patients with mild to moderate Alzheimer’s Disease who were already taking an acetylcholinesterase inhibitor.  While continuing to take their acetylcholinesterase inhibitors, these patients were randomized to take either 1) Vitamin E, 2) Namenda, 3) Vitamin E plus Namenda, or 4) a placebo.  The dose of Namenda was 10 mg twice daily and the dose of Vitamin E was 2,000 IU daily.

After roughly 5 years, researchers found that compared to placebo, patients taking Vitamin E had less deterioration in their ability to perform activities of daily living.  This effect was not seen in the groups taking a) Namenda plus Vitamin E or b) Namenda alone.

These results call into question the common practice of adding Namenda to an acetylcholinesterase inhibitor in patients with Alzheimer’s Disease.  I wonder if some of us have been prescribing both medications more out of a desire to offer “everything available” than on the grounds of sound evidence.  Based on this recent study, it looks like we might better serve patients with Alzheimer’s by adding Vitamin E instead.

Click here for a link to the JAMA study.  

Henry Markram is one of the world’s leading neuroscientists.  After a brilliant career of influential research, he has been charged with leading Europe’s Human Brain Project, a $1.3 billion project that aims to build a supercomputer model of the brain.  But Markram is also the father of a boy with autism.  And that has changed everything.

Maia Szalavitz’s poignant article The Boy Whose Brain Could Unlock Autism chronicles Markram’s personal and scientific journey.  From a very early age, his son Kai displayed a variety of unusual behaviors.  “When his parents tried to set limits, there were tantrums—not just the usual kicking and screaming, but biting and spitting, with a disproportionate and uncontrollable ferocity; and not just at age two, but at three, four, five and beyond. . . Preventing Kai from harming himself by running into the street or following other capricious impulses was a constant challenge. Even just trying to go to the movies became an ordeal: Kai would refuse to enter the cinema or hold his hands tightly over his ears.”

When his son received the diagnosis of autism, Markram read “every study and book he could get his hands on.”  As a visiting professor at the University of California San Francisco, he encountered Michael Merzenich, a neuroscientist who “proposed that autism is caused by an imbalance between inhibitory and excitatory neurons.”  Propelled by this theory, Markram’s lab began studying rats that had been induced to display autism-like behaviors.  To the researchers’ surprise, the excitatory networks of these rats’ brains were hyperactive.  Their brain cells “responded nearly twice as strongly as normal—and they were hyper-connected. If a normal cell had connections to ten other cells, the cell of (autistic rats) connected with twenty.”   They also noted that these rats displayed “high levels of anxiety as compared to normal rats. . .They were quicker to get frightened, and faster at learning what to fear, but slower to discover that a once-threatening situation was now safe.”  The problem with these rats was not that they couldn’t learn.  It was that “they learn too quickly, with too much fear, and irreversibly.”

Based on these findings, Markram developed what he calls the “intense world” model of autism.  He and his fellow researchers hypothesize that autistic behaviors are caused by being overwhelmed by information from the world.  To grasp this idea,

Imagine being born into a world of bewildering, inescapable sensory overload, like a visitor from a much darker, calmer, quieter planet. Your mother’s eyes: a strobe light. Your father’s voice: a growling jackhammer. That cute little onesie everyone thinks is so soft? Sandpaper with diamond grit. And what about all that cooing and affection? A barrage of chaotic, indecipherable input, a cacophony of raw, unfilterable data.

Just to survive, you’d need to be excellent at detecting any pattern you could find in the frightful and oppressive noise. To stay sane, you’d have to control as much as possible, developing a rigid focus on detail, routine and repetition. Systems in which specific inputs produce predictable outputs would be far more attractive than human beings, with their mystifying and inconsistent demands and their haphazard behavior.

This is what Markram believes it is like to be autistic.  “Unlike adults, however, babies can’t flee. All they can do is cry and rock, and, later, try to avoid touch, eye contact, and other powerful experiences. Autistic children might revel in patterns and predictability just to make sense of the chaos.”

According to the article, this “intense world” paradigm for understanding autism has been met with some caution and criticism by experts in the field.  Nonetheless, it helps makes sense of what I see in my son with autism.  Indeed, it speaks to my own compulsion to sometimes want to escape from the world in order to process what I’ve experienced.  I wonder if more introverted people have hyperactive brain networks.  Does an onslaught of information from outside compel them to be alone with their thoughts more often?