Making Sense of Medicine

According to the Guttmacher Institute (http://web.archive.org/web/20080313054435/http://www.guttmacher.org/in-the-know/incidence.html ) 46 million abortions occur yearly, worldwide. I can’t wrap my mind around 46 million, so I’ll focus on the U.S., in which 3400 occur every day.

And who are those 3400 women? 41 percent are white, 32 percent are black, and 20 percent are Hispanic. Woman for woman, though, more blacks and Hispanics have abortions, compared with white women. For every 1000 white American women, 13 have an abortion each year, whereas black women have 49 per 1000, and Hispanics have 33 per 1000. The Guttmacher Institute (http://web.archive.org/web/20080311171704/http://www.guttmacher.org/in-the-know/characteristics.html) concludes, “Over time, women having abortions have become increasingly likely to be poor, nonwhite and unmarried, and to already have one or more children.”

If you take a group of 45-year-old American women, who have reached the age when the likelihood of pregnancy is small, one out of three will have had an abortion. A lot of those women regret that abortion, and I ache for them. 

To put it another way, the first day of grief increased the risk of MI by more than twenty times what would be expected on a day without such sorrow.

Over the years I’ve heard of multiple loving couples who have died within a week of each other. I’ve heard people say: “He (or she) died of a broken heart.” The above study, published in the medical journal Circulation, supports those comments.

What I take away from this research is a renewed resolve to do what I can to support people who are grieving. Grief is a painful time. The way “life was supposed to be” has been altered, perhaps abruptly. I was walking purposefully down one path, thinking I could see my goal in the future, and now, suddenly, I am forced to walk down this other path, with no goal visible. The process of adjusting to this new reality is what we call grief. And it’s no fun.

Maybe all a grieving person needs is a wordless hug. I suspect that’s all that person needs. 

Some other time I’ll discuss the “drying” of skin, or the use of steroids (which are not, by the way, the kind of steroids taken illegally by athletes!) Today I’ll cover how to keep the skin “wet” – and some principles of moisturizing.

Skin is our first line of defense against disease. Bacteria, viruses, parasites – dangers lurk everywhere. But our epidermis (the outer layer of our skin) blocks them almost always. When people have inflamed skin, the epidermis becomes disrupted and infectious particles can enter their body. 

The key to keeping the epidermis intact is keeping it moist. Now, I’m talking about moisture just below the surface of the skin (within the epidermis), so the outside surface doesn’t feel wet. There are molecules within the epidermis that hold onto water, and which draw water to the area – from both directions. That is, from deeper inside the body and from the outer surface of the skin. 

Dry skin is itchy skin. There are skin diseases which lead to excessive water loss from the epidermis, the most common being eczema, or “atopic dermatitis”. Even those of us without eczema, however, can benefit by keeping our epidermis as moist as possible.

There are three basic types of moisturizers: lotions, creams, and ointments. A lotion is water based, which means that after you rub it in, the water in the lotion will evaporate. This makes lotions not the best option for dry skin, for you may end up having less moisture in the epidermis than you did before.

A cream has a small amount of water and more oils than a lotion, in addition to various chemicals which help to keep it from feeling greasy. An ointment has no water at all, which makes it a barrier keeping water from evaporating.

The most effective way to keep water in the epidermis is to apply either a cream or an ointment right after a bath or shower. During the shower, it’s best not to scrub the skin, but just gently wash with soap or another cleanser. Then, immediately after toweling off, apply a cream or ointment. The water from the shower is trapped on the skin, and is slowly absorbed into the epidermis.

Oily skin benefits from moisturizers, also, but it’s best to use one that doesn’t fill the pores, which might lead to an acne flare. Look for “non-comedogenic” on the label.

Three creams which many dermatologists recommend are Eucerin, Cetaphil and Nutraderm. For ointments, the cheapest way to go is plain old petroleum jelly (brand name Vaseline). Dermatologists also often recommend the ointment Aquaphor.

As people get older, their skin tends to be less oily because the glands that produce oil become less active. That means that more water evaporates from the surface of the skin, and less is trapped within the epidermis. So often older people find themselves needing a moisturizer, generally an ointment, for the first time. 

Crossing the ocean on a ship gives the body time to the slightly earlier sunrise every day (traveling east) or the slightly later sunrise (traveling west). Airplane travel across several time zones is too speedy for most of us to adjust.

Our bodies can “expand” the day more easily than it can “compress” it. Thus traveling westward, and ending up with more hours of daylight, is easier to adjust to than traveling eastward, and ending up with a shorter day.

Most people who cross more than four time zones will experience jet lag. The pineal body, a gland in the skull but just outside the brain proper, produces the hormone melatonin, which helps to regulate our “sleep/wake cycle”. When the sun sets, the gland pours out melatonin. But the gland has some sort of an internal mechanism as well as just sensing when it is dark. If we compress our day (by traveling east), it takes several days for it to “catch up” and produce the right amount of melatonin by bedtime in the new place.

For every time zone crossed traveling east, it takes one approximately one day to fully adjust. Traveling west takes less time, by about a third.

There are ways to speed up the process of adjusting, and lessening jet lag. Going west, a traveler should try to stay awake until the regular bedtime at the new destination. Going east, a traveler should be outdoors in the afternoon and early evening, so the body clock senses the dimming light.

For both east and west travel, it’s best to eat meals at your normal mealtime, according to the clock at your current destination. Also, it’s best to get plenty of exercise – take a long walk and take in the new sights.

Taking melatonin can be helpful. A Cochrane review article in 2002 looked at ten placebo-controlled papers, studying almost a thousand people who took melatonin for jet lag. The bottom line is that taking it significantly helped many of the people. The dose ranged from 0.5mg (which is not commercially available unless you buy the liquid to take that low of a dose) to 5mg. In the U.S. most drugstores carry 3mg melatonin pills without a prescription. Interestingly, the 0.5mg was almost as effective as the 5mg, although the higher dose led to slightly less time before the onset of sleep, and the quality of sleep was also slightly better.

The authors of that review suggested taking melatonin at bedtime for the first four nights at the new destination. For eastward travel (from the U.S. to Europe, say) they also recommend taking a dose on the day of travel, as you are traveling. For that dose, figure out what your regular bedtime will be at the new location and take a dose at that time.

I know it’s hard to remember east versus west, so here’s a memory aid:

If you are in California and your mother is in Rhode Island, she is eating supper while you eat lunch. If you instantly transport yourself to her side, less of your day will be left than if you were still in California. You are asking your body to compress its time clock into a shorter day. That is hard for your body to do. Stretching your day out, going west, is easier on your body.

So here’s what I’ve discovered: Melatonin is a hormone. I’ve known that since medical school, of course, but that fact has struck me as peculiar these past few weeks. Why? Because it’s sold over the counter, and many people take massive amounts of it. No other hormone is available like this. The use of other hormones, such as insulin and thyroid hormone, need careful monitoring. Is melatonin so universally safe that it can be taken at any dose, for however long? The more we learn about melatonin, the less that seems to be the case.

Hormones are substances produced in one place that then go into the bloodstream and have their effect somewhere else. Melatonin is produced in the pineal body, which is just outside the brain proper. Ten times as much of it is made during the night as during the day. Our bodies sense when it is dark and tell the pineal body to make melatonin. If we cross six time zones, however, it takes a few days for the pineal to catch up and produce melatonin at the proper time. Hence comes Jet Lag.

So do people with insomnia benefit from melatonin? Many of them swear by it, but I’m wondering whether they are taking too much. The pills in pharmacies are generally 3mg or 5mg. But the amount that reproduces what our bodies produce at night is equivalent to somewhere between 0.1mg and 0.5mg. Higher doses flood the brain with melatonin, and make it actually less sensitive to its effects. So here is where it is not good to follow the “If a little is good, then more is better” principle. Since a little is all that is needed, stick with a little.

Studies are showing that the ideal amount of melatonin for sleep problems seems to be 0.3mg. But how can you take “0.3mg” when the pill is 3mg? Do you crumble it up and take a tenth, somehow? Not practical. There are liquid preparations available, with one dropperful giving 1.0mg. So you could take a third of a dropperful. If you can’t find it at your pharmacy, check online at www.drugstore.com.

As we age, we gradually produce less melatonin. I wonder if this is why so many older people have trouble sleeping. In the last few weeks, since I’ve been reading about melatonin, I’ve started recommending it to my older patients with insomnia. But I urge them to use the liquid so they only take 0.3mg a night. They may end up needing a little more, but, as with all medications, I much prefer starting at a low dose and creeping up slowly. I’ll follow up in a few months with how people have responded. 

Sleep is an important part of health. No one knows exactly why it is so important, but everyone knows they need it, and how miserable they are when they don’t get enough of it. So here are a few tips on how to make sure you’re optimizing your chance for restful sleep.

One, go to bed at the same time, and get out of bed at the same time – even on weekends. Most adults need between seven and eight hours of sleep.

Two, try to not go to bed when you are all keyed up. That means not smoking (nicotine is a stimulant) and not drinking anything with caffeine for several hours before bed. (While you’re at it, just stop smoking forever.)

Three, exercise – but not within four hours of bedtime. Regular aerobic exercise definitely helps people sleep better, but not if done right before bed.

Four, keep the bed as dark and quiet as possible. Even if we may doze off with the television going, or the light on, our brains still perceive these things as stimulation. Even a low level of light (think of the digital clock face staring at you, or the little light on your plugged-in electronic device) may be keeping you from sleeping at the deeper, more restful, levels.

Five, don’t solve the world’s problems in bed. Or yours, either. For one thing, problems loom bigger at night. If I awake and find myself worrying and my mind racing, I try to separate myself from the anxiety by talking to myself. “Yes, this is a tangled situation, Amy, but this is not the time to tackle it.” I also talk to God (also known as prayer), which is basically putting the problem into the hands of someone bigger than me.

Another little tip I use is to reflect upon whether I am comfortable when I first get into bed. I may be able to ignore the fact that my feet are cold when I have been walking around, but once I’m in bed, and my brain and body slow down, a small annoyance becomes a big one. Also, it becomes a huge effort to get up out of bed and put on socks when I am drowsy. Better to do it when I haven’t been in bed for very long.

But in case you’re tempted to pick up a bottle of tryptophan pills as a sleep aid, I want to interject a few words of caution.

First – what exactly is tryptophan? It is an amino acid, one of the building blocks of proteins. It is an “essential” amino acid, which means that our bodies don’t make it and we have to obtain it from food. Our bodies use tryptophan to make the hormone serotonin, low levels of which are associated with depression. Serotonin, in turn, is used by our bodies to make the hormone melatonin, which is associated with sleep.

In the 1980s thousands of people became ill with a previously-rare illness called Eosinophilia-Myalgia Syndrome (EMS), which caused muscle and nerve pain and skin thickening. The culprit was suspected to be (never proved) L-tryptophan supplements, which were very popular at the time. One of the two main Japanese manufacturers had apparently recently changed their synthesis process, and it had an impurity that was blamed. All tryptophan was taken off the market, and it’s never since been as popular.

Tryptophan has been back on the market for 15 years, and the current main Japanese supplier attests that it is pure. However, there have been scattered cases through the years, including a woman taking 1500mg of it nightly, as reported in Arthritis and Rheumatism (http://www.ncbi.nlm.nih.gov/pubmed/21702023).

The researchers didn’t find any impurity in the brand of L-tryptophan she was taking. Her genetic makeup, however, made her susceptible to developing EMS.

Now let’s get back to talking turkey. For a 3 ½ ounce serving of turkey (100 grams), you consume 330mg of tryptophan. If you ate the same amount of caribou, you would get 460mg (I just had to add that for my Canadian readers). Fish, pork, chicken, soybeans (think tofu), cheese, nuts, and sesame and sunflower seeds give you a lot, also.

So is the turkey the reason we all needed to take a nap on Thanksgiving? Probably not. Tryptophan needs to be taken on an empty stomach (without other amino acids to compete with it) to have a significant effect. Much more likely our snoozing was caused by the quantity of food we ate. It takes energy to digest a huge meal, so our bodies divert the blood supply to our stomachs, and our brain tries to discourage us from much other activity, making us sleepy.

So go ahead and prepare yourself a leftover turkey sandwich. Just make it – for your stomach’s sake – a small one. 

What’s going on here? Aren’t taking supplements supposed to make us live longer? Why are we spending our hard-earned money on something that is not only not helping, but looks like it’s hurting?

This study looked at information from the Iowa Women’s Health Study, a big database of information on 40,000 women who have been enrolled since 1986, when they were at least 55. They have asked these older women what supplements they have taken over the years, in addition to many other questions. All other things being equal, women who took vitamin B6, folic acid, iron, magnesium, zinc, a multivitamin, or copper were slightly more likely to die, over the years, than women who didn’t.

Now the increased risk of dying was small, ranging from 3 to 6 percent, except for copper supplements, which, over the 18 year follow-up, was associated with a whopping 18 percent increased risk of dying.

On the bright side, the women taking calcium over the years had a 4 percent lower risk of dying.

Still, I think the chances that news like this will discourage few people from taking supplements. After all, at the beginning of the study, in 1986, 63 percent of the women were taking at least one supplement. By the end of the study, in 2004, 85 percent of the women were. Supplement use is firmly embedded in our culture.

I have to add that I urge many of my patients to take supplements. If I think they are under-nourished, I ask them to take a multivitamin. Women, especially, need a large amount of calcium, which it is very hard to get in the diet, unless they take supplements. People who are anemic may need to take iron.

I’m not a big fan of government regulation, but I respect the emphasis on safety the Food and Drug Administration (FDA) puts on medicines. The trouble is, supplements are considered, in the eyes of the FDA, to be “foods” and not medicine. So, basically, medicines have to show themselves to be helpful in order to come on the market. Supplements, however, can come on the market at any time, by anybody, and to take them off the market they have to be shown to be harmful.

My point is -- the supplements that many Americans are taking could  possibly have less of the substance than the label states, or other things could be in there that may be harmful. There is a company that tests supplements independently, and their results can be found at www.ConsumerLab.com. For around $30 a year, anyone can have access to their extensive tests on specific brand name supplements. If you take supplements (which can be expensive!), joining ConsumerLab might be a good investment, because you can make sure you’re getting the promised ingredients – and nothing else.

But just as I was gathering my thoughts, a newsletter from Louisiana’s Office of Public Health arrived. It told the story of a man from southern Louisiana who died from a brain infection of an amoeba (a rare cause of brain infection). When a bizarre death like this happens, the public health detectives get to work. Only three or four people die in America from this each year, but they generally are people who swim in freshwater, where the amoeba lives. But this guy didn’t. He did, however, use a nasal rinse container, and evidence of the amoeba was found in the family’s water heater, which wasn’t set at a high enough temperature. Infectious disease specialists recommend 160°F (71°C). 

But wait! I’m not telling this story to convince you that nasal rinsing is perilous (nor to gross you out). I think nasal rinsing can be done safely. It’s all a matter of keeping everything clean.

So first, why do nasal rinsing at all? More and more Ear, Nose and Throat (ENT) doctors are recommending it. Three main benefits are:

·      Saltwater washes mucus from the nose, as well as pollen and other things you might be allergic to.

·      Irrigation keeps the nose tissues moist.

·      The tiny hairs that move mucus, called “cilia”, are better able to do their work if they are washed in this way.

I know several people who are sure that regularly irrigating their nose has meant fewer sinus infections.

So how do you do it – and safely? First, if you choose to use a Neti pot, which can bought at most pharmacies, be sure that it can survive in dishwasher, or similarly hot and soapy water. Neti pots are also available in ceramic in various shapes – looking something like a cross between Aladdin’s lamp and a cute little teapot. The key is keeping it clean, and the dishwasher is the best way to do that.

I found a range of “recipes” for the saltwater solution, but here is one that seems reasonable:

·      Use tap water that has been boiled and then cooled.

·      Fill a quart-sized glass jar that is freshly out of the dishwasher.

·      Add a heaping teaspoon of pickling/canning salt. (Apparently this form of salt doesn’t have all the additives that table salt has.)

·      Add a teaspoon of baking soda (pure bicarbonate). Saltwater alone might irritate the tissues, so baking soda helps with that.

·      Swirl to mix.

·      Keep covered, and throw away after a week.

To use the Neti pot, you fill it with the solution and then tilt your head over the sink (or do it in the shower!) so that one nostril is higher than the other. You pour the solution slowly into the top nostril and it runs out the bottom one. Then you repeat on the other side. One Neti pot should be enough for both sides.

Let me know if you have “tips” (or cautions) to add. Remember – be sure everything is clean, clean, clean!

My last post stirred a lively discussion on my Facebook page about the value of  vaccines, and whether we are asking too much of our children’s immune systems. In 1980, children under two only received vaccines to prevent seven diseases, but today they are protected from ten diseases, and six of those involve shots on more than one occasion.

Ouch.

First – how vaccines usually work: Tiny bits of protein or polysaccharide antigens are given which aren’t the entire virus or bacteria so they can’t cause infection. People then produce an immune response that they then tuck away in their “immune memory” so if they’re exposed in the future they can fight the disease right away.

I also want you to know that I was way, way, way more obnoxious about the need for vaccines until the day I sat waiting for the nurse to enter the exam room to give my cooing, two-month-old firstborn her first shot. I looked at her creamy, perfect skin, which would soon be pierced, and I felt my heart ripping. Never again would I flippantly insist on the need for immunizations. I argue for them, sure, but I understand any lack of enthusiasm I encounter. 

So have we gone overboard and do we give too many? It turns out we are giving far less, yes less, than we used to. Remember those vaccines for seven diseases in 1980? Those vaccines contained, collectively, more than 3000 little “antigens” that the babies then responded to. The vaccines kids currently receive contain less than 200 antigens – in total.

Also, studies have been done which show that infants can produce immune responses to multiple vaccines given simultaneously, and are just as protected as if they had received them one at a time. Moreover, babies who are fighting a mild illness (and so their immune system has been activated) still produce an excellent response to immunization.

It seems we are underestimating a baby’s immune system. It’s more vigorous than we give it credit for. 

Now, any discussion of “vaccination reluctance” has to include when bad things happen because of the vaccine. Some response is expected – skin soreness and low-grade fever for a day or two. Those things happen because the person’s immune system is responding to the antigens. Then there are the “Medium Bad” responses, which include the child having a seizure. These are rare, and usually a one-time event with no long-term consequences. But what about the serious “adverse events”? On the one hand, they are very rare. On the other hand, they can be devastating.

But let’s compare risks. Measles vaccine can cause a brain swelling called “encephalitis”. It happens once in a million vaccinations. But so can natural measles. The risk is much higher with natural measles – one in a thousand infections. Two weeks I heard a woman doctor speak who had led a medical group to Africa. She showed a video of a child, probably six years old, who had contracted measles a year earlier, developed encephalitis, and who now couldn’t feed herself, speak, or walk. It is a tragedy.

Staying informed is helpful. The American Academy of Pediatrics (www.aap.org/immunization) and the Centers for Disease Control and Prevention (www.cdc.gov/vaccines) are good sites to explore. Let’s keep the discussion going.