I Prefer Being the Doctor

Good morning!

On Tuesday May 4, I started my day with visits to two patients and then an early meeting at Presbyterian Hospital Plano. After the meeting, I went to the preop area. Later that morning, I had a relatively minor scheduled surgery. The surgeon is among the world's best in my estimation. Initially after surgery, everything seemed fine but within a couple of days, I knew there was something amiss.

That's when the month of May became unusual...and a planned one night stay in the hospital became three weeks.

Fortunately, the surgeon acted on what I told him I felt, and not based on the multiple normal scans. He kept me in the hospital and when I "crashed" that weekend, I was in the right place.

I don't remember much of the move to the ICU or the emergent surgery that followed. When I awoke, I found that the original five small holes in my abdomen from the original laparoscopic surgery had been joined by a foot-long incision and I remember trying unsuccessfully to write a note to ask my nurse questions while sedated and on the ventilator.

I've gradually improved and recently come home from the hospital. I cannot eat yet and have a nearly constant companion in the intravenous pump and feedings I carry in a backpack when out of bed. IV antibiotics and other medication have made our bedroom look like a pharmacy or chemistry lab.

We talk about the importance of great medical care. The importance of seeing kids grow up, running a business, hugging family. The past few weeks have been traumatic but these thoughts have never been far away.

Dr. Keith Schrader (my personal physician), Dr. Harry Meyers (surgeon), Dr. Mike Blackmon (critical care), Dr. Kunjan Thakor (infectious disease) and Dr. Trent Pettijohn (cardiology). Along with their partners, these incredible physicians saved my life.

Ingrid has been incredible. She's watched and absorbed everything, and added "nurse" to her already long list of jobs.

I cannot count the emails, cards and prayers from patients, family and friends. Quite a humbling experience.

I'm not sure when I will be back in the office but I hope it will be soon.  I miss being the doctor - I've had more than my share of time being a patient.

Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP

We're All In This Together

"Do not take comfort from the hole in my side of the boat."

-- African Proverb

Can a Caffeine-Packed Plant Give a Boost?

A highly caffeinated South American plant is increasingly being used to provide the pep in energy drinks, dietary supplements, food products and candy. Marketers say guarana-containing products boost energy, mood and cognitive function-and may even help with weight loss. Scientists say some science does back up those claims, but they warn guarana can overstimulate the heart in rare cases.

Guarana (pronounced gwa-rah-na) is a rain-forest vine with fruit that contains high levels of caffeine. Since 2008, nearly 500 products with guarana, including different sizes and flavors of the same product, have been introduced to U.S. stores, according to London market-research firm Datamonitor PLC. Products include energy drinks, beef jerky, chewing gum, mints and even lollipops.

Guarana products often claim to simply boost energy, and some say they enhance mental performance. Some are marketed as weight-loss aids. Several studies do link guarana to weight loss, but they tend to be small, short term and often involve products with other ingredients-overall, not yet conclusive, scientists say.

The claim that guarana improves energy and boosts mental function makes sense given that caffeine is known to do so, says Kevin A. Clauson, associate professor at Nova Southeastern University in Fort Lauderdale, Fla. A British study of 26 college students, published in the Journal of Psychopharmacology in 2007, found guarana tablets boosted scores on a battery of tests for memory, alertness and mood compared with the same students' performance on a different day after taking a placebo.

While many experts attribute guarana's effects solely to its caffeine content, the British study found the effects on cognition were larger than would be expected with caffeine alone, says senior author Andrew B. Scholey, now co-director of the National Institute of Complementary Medicine's collaborative center for neurocognition in Melbourne, Australia. The reason for this is unknown, but Dr. Scholey suspects that saponins, a class of nutrients found in guarana, may be adding to its positive effect by enhancing blood flow to the brain.

Many products don't list either the amount of guarana or the total caffeine content, so you could consume a product with too little guarana to have a meaningful effect-or so much that it gives you an unwanted buzz, scientists say.  Consumers can often find the information by going to company Web sites. Performance Enhancing Meat Snacks Inc., of Englewood, Colo., which sells Perky Jerky, a beef snack marinated in guarana extract, discloses on its Web site that a two-ounce packet of the jerky contains 120 milligrams of caffeine. In an interview, the company said the level varies from 45 to 58 milligrams an ounce. VE2 Energy Gum LLC, which includes guarana and added caffeine, discloses on its Web site that each tiny piece of VE2 gum has 35 milligrams of caffeine. (By comparison, a 12-ounce can of soda typically has 30 to 50 mg.; a 12-ounce cup of Starbucks's Pike Place Roast contains 260 milligrams.)

Dr. Clauson cautions that pregnant women should keep guarana consumption to a minimum, as high levels of caffeine may harm the fetus. Also, alcoholic drinks with guarana may fool people into thinking they are alert enough to drive, or engage in other dangerous activities, he says.

People with heart trouble should be cautious. Scientific literature links guarana to rare but severe heart-related side effects. According to a 2001 report in the Medical Journal of Australia, a woman with a heart condition called mitral valve prolapse died after ingesting most of a 55 milliliter guarana and ginseng energy drink. The caffeine levels of her blood were comparable to having had 15 to 20 cups of coffee, the report said. Whether or not they have an existing heart condition, people need to take into account their other sources of caffeine when taking guarana products, says Mahtab Jafari, an assistant professor of pharmacy at the University of California in Irvine. In the Journal of Herbal Pharmacology, Dr. Jafari reported the case of a California woman who suffered tachycardia, an abnormally fast heartbeat, after taking energy pills containing guarana in addition to a cup of coffee and two glasses of Pepsi a day for more than a month. The woman had no previous known heart condition, but the combination of ordinary caffeinated drinks and guarana tablets "really exposed the heart to a lot of stimulation," says Dr. Jafari. The women's tachycardia resolved after about a week after stopping the supplement, she adds.

The Food and Drug Administration is investigating the safety of caffeine, including caffeine from guarana, in alcoholic beverages. The Department of Agriculture says it allows a small amount of guarana in meat as a flavoring, not enough to create a stimulant effect. The agency says it is reviewing whether beef-jerky products with labels marketing a stimulant effect may violate this standard. The agency didn't specify which products are under review. Performance Enhancing Meat Snacks says it believes Perky Jerky complies with the law.

From: Laura Johannes, The Wall Street Journal
Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP

Landing Gear

"You know that your landing gear is up and locked when it takes full power to taxi to the terminal."

-- Unknown

Vitamin D May Influence Cognitive Dysfunction and Dementia

Vitamin D has been receiving a lot of attention recently, and now researchers report that inadequate vitamin D levels may be involved in cognitive dysfunction and dementia.

Two papers show in separate populations that low levels of vitamin D are associated with cognitive impairment and cerebrovascular disease, including stroke. A third study of only men finds no such association. The papers will appear in the January issue of Neurology.

"What should we make of these studies?" Joshua Miller, PhD, from the University of California in Sacramento, asked in an accompanying editorial. "First, it is evident that the prevalence of vitamin D deficiency is very high among older adults."

This in and of itself, he says, could warrant expanded screening for vitamin D deficiency and adding supplements. "Whether vitamin D supplements will maintain cognitive function in older adults remains an open question," he notes.

Dr. Miller does not rule out the possibility of reverse causation. "Cognitively impaired older adults may eat poorly or they may have reduced exposure to sunlight, which could lead to reduced vitamin D status."

Investigators led by Cédric Annweiler, MD, from Angers University Hospital in France, conducted a cross-sectional study exploring these questions. Their paper was released early online September 30. The researchers looked at more than 750 community-dwelling older women. Participants were from the French study known as Epidémiologie de l'Ostéoporose. The women were 75 years or older.

The researchers report that 17% of participants had vitamin D deficiency. This was defined as a serum 25-hydroxyvitamin D level of less than 10 ng/mL. Women with vitamin D deficiency had lower mean Short Portable Mental State Questionnaire scores (P < 0.001). They also had an odds ratio for cognitive impairment of about 2 after controlling for relevant confounders.

The authors conclude that inadequate vitamin D is associated with cognitive impairment in elderly women and that vitamin D supplements may improve or maintain cognitive function.

Two Studies, Similar Conclusion

The second report, by investigators led by Jennifer Buell, PhD, from Tufts University in Boston, Massachusetts, and released November 25, came to a similar conclusion. The researchers also conducted a cross-sectional study — this one of more than 300 men and women.

Participants were 65 years or older and were involved in the Nutrition and Memory in Elders study. They were evaluated for dementia and cerebrovascular disease and underwent magnetic resonance imaging to assess overall and regional brain volumes, white matter hyperintensity, and infarcts.

Investigators show that 14% of the study sample had inadequate vitamin D. Another 44% were classified as vitamin D insufficient (10 to 20 ng/mL).

Patients with low vitamin D levels had higher white matter hyperintensity volume and a higher prevalence of large vessel infarcts. Low vitamin D level was also linked with an odds ratio of about 2 for all-cause dementia, Alzheimer's disease, and stroke after controlling for relevant confounders.

The authors conclude that vitamin D deficiency is associated with an increased risk for dementia and cerebrovascular disease and that vitamin D may have vasculoprotective properties.

However, a third report, also released November 25, came to a different conclusion.

Third Study Questions Evidence

Investigators led by Yelena Slinin, MD, from the VA Medical Center and the University of Minnesota at Minneapolis, found little evidence linking vitamin D and cognitive impairment.

The researchers conducted a longitudinal assessment of more than 1600 community-dwelling men. Participants were 65 years or older and were involved in the Osteoporotic Fractures in Men Study.

Investigators assessed cognitive function using the modified Mini-Mental State Examination and the Trails B test.

At baseline, the odds ratios for cognitive impairment were between 1.6 and 1.8 in the lowest vitamin D quartile compared with the highest. However, these odds ratios did not reach statistical significance and were lower after controlling for race, ethnicity, and education.

Low vitamin D level was defined differently in this study at less than 20 ng/mL. In the other 2 studies, vitamin D deficiency was considered less than 10 ng/mL.

For incident cognitive impairment, the odds ratio for a significant decline in Mini-Mental State Examination score was 1.5 in the lowest quartile of vitamin D concentration compared with the highest quartile. The trend across the quartiles was significant. Yet again, control for confounding by race, ethnicity, and education slightly lowered the trend — enough to lose statistical significance.

The authors suggest that additional studies should be performed that include women and tests of other cognitive domains.

Editorialist Dr. Miller argues that this study is limited by a lack of women included in the work. He says it was also limited because the lowest quartile of vitamin D status consisted of all subjects with levels under 20 ng/mL. "Perhaps a reevaluation of the data comparing deficient subjects (<10 ng/mL) to nondeficient subjects would reveal significant associations," he notes.

Next Steps

"What are needed now are placebo-controlled intervention studies to determine if vitamin D supplements will protect against age-related cognitive decline." In the meantime, Dr. Miller says, neurologists, general practitioners, and geriatricians should be aware of the high prevalence of vitamin D deficiency in their patient populations and the possibility that supplementation could be beneficial.

Adequate vitamin D for patients aged 51 to 70 years are defined as 10 µg/day (400 IU). For people older than 70 years, 15 µg/day (600 IU) is suggested or enough to maintain a vitamin D level of about 30 ng/mL or more. These recommendations, he notes, are primarily for maintaining bone health and are evolving.

Dr. Miller suggests, "The appropriate intake amounts to support brain function in older adults remain to be determined."

Dr. Joshua Miller receives research support from the National Institutes of Health, the US Department of Defense, and the American Cancer Society. Dr. Slinin is a full-time employee of the US Department of Veterans Affairs. The other investigators have disclosed no relevant financial relationships.

From: Allison Gandey, Medscape Medical News

Reviewed / Posted by: Scott W Yates, MD, MBA, MS, FACP

Mistakes

"A person who never made a mistake never tried anything new."

-- Albert Einstein