LiveLongAgeWell

A woman said to me last week—I think she was joking a bit though—that her life was marked by “before botox” and “after botox” because this substance, or really the botox procedure, had made such a positive change in her appearance and life. While such a reaction seems a bit extreme, millions of women and men every year faithfully march to doctor’s offices, typically a couple times per year, making botox injection the #1 most popular cosmetic procedure performed by physicians in the United States.

(this is not me)

One of my best friends is a cosmetic dermatologist, and two weeks ago I got a call from his nurse: could I come in right now? My friend had an unexpected opening, and he knew I “needed” a botox treatment. Since it had been about six months since my last treatment and the worry lines in my forehead had returned, I jumped at the chance and the appointment time.

(photos from http://www.botoxcosmetic.com)

I like botox for myself because over the years I developed (a family characteristic) “worry lines” in my forehead and particularly between my eyes, and when I looked in the mirror, I didn’t appreciate the stressed-worried look, even when I wasn’t. With a few botox shots, the lines literally melted away, making me feel at least more relaxed, and friends would occasionally comment (after botox) that I looked like I had a good vacation.

Botox is actually one of the strongest toxic substances known to man—a small quantity can kill you by arresting your respiratory muscles, but in very small, super-diluted doses and when applied with a fine needle into muscles, only those muscles will stop contracting, for up to six months, leaving the overlying skin free of the characteristic furrows from muscular contraction. Botox is FDA approved only for the lines on the lower forehead between your eyes (the glabellar region), but most doctors use it elsewhere around the forehead and eyes with good results. Botox can work to cut the “crows feet” lines at the corners of your eyes, but it has no place around your mouth (injection there could disturb your eating and speech functions, besides making you look bizarre), and it won’t help for the fine wrinkles caused by sun damage and inelastic, saggy skin (which sunscreens help prevent and other measures like laser could improve.)

My experience a couple weeks ago was uneventful, as my doctor friend is a true artist with the needle, ever careful not to overdue things…the best results just take the tenseness out of the forehead area without impeding facial expressions. You certainly don’t want an overdone “frozen” look, commonly seen for example in United States senators.

The procedure starts by the nurse applying a local anesthetic cream and then I lay back for about 45 minutes so the cream works to maximum effect. (A couple times I had the procedure done without anesthesia, and it’s tolerable, but much more comfortable with the cream first.) Then I sit up and make expressions as my friend carefully marks out the points for the needle sticks. Then—my eyes are closed so I don’t see the needles—about eight shots, mild pain only, a bit more in the center at the root of the nose. As for most medical procedures, the best approach while having something done is just try to be still and concentrate on slow breathing.

Then a couple superficial shots near the corners of my eyes (to kill the crows feet lines). For the actual needle part, less than 10 minutes total. Done. Then, no pain or problems at all, just slight mosquito-bite sized swellings at the site of each shot, which disappear in an hour, and for four hours, I’m conscious to keep my head higher than my heart level. In a day or so, the lines start flattening but the full result takes about two weeks. Then I’m good for a number of months. About four months from now I’ll notice the worry lines starting to return, and at about six months I’ll bother my friend again to fit me in for another session.

If you’re interested in botox, talk to any friends who may have had the procedure, and find an experienced, licensed M.D. and make an appointment. Not everyone is a good candidate, and there are risks.  While you can find family practice doctors, nurses and even skin spa personnel who do this procedure, I would only have it done by a board-certified plastic surgeon, dermatologist, or otolaryngologist (ear, nose, throat surgeon).

So for me, I’m hooked. It’s a quite simple, relatively painless procedure and I like the results. It’s a lot cheaper, easier, less risky, and more effective than many of the alternatives in the world of medical aesthetics.

Today where I am in Brazil, nearing the end of Carnival, it’s like a ghost town. It doesn’t seem like its normal self. It’s cloudy, a little chilly…those were rain drops?

Few people are outside. Most all stores are shut. Good luck if your refrigerator is empty; maybe you’ll find a pastry shop open somewhere. Many people today seem more depressed than happy. Last night they were out late and relationships were tested. As in many cities and countries, walking around late at night here—depending on where you are—can be a little dicey. Elite police units were out in force and the streets swirled and danced with frenetic people; I saw no violence…

It was great that so many readers commented on the “Carnival begins” post. Comments tell me about you the audience, and help me write a better blog with the subjects you want. I encourage you to read the comments for views different from mine.

I am beta-testing a new widget application for LLAW, called QWIDGET, and it’s a way for people to leave comments more easily (I hope). Plus you can interact with others leaving feedback if you wish. Try it out by answering the question further along in this post. See what you think, and tell me if you’d like this QWIDGET to be part of the blog.

Last post I introduced the idea of cosmetic procedures and how Brazilians—seemingly more than U.S. Americans—seem more attuned to looking good (I enjoyed the one comment that Brazilians are more appearance-oriented because they go to the beach more, need to show skin, and want to avoid “visual pollution”…haha.) But beyond that, from the phone calls and emails I received, I know that cosmetic surgery is probably a more explosive topic than even cultural comparisons. Everyone seems to have a pretty strong opinion one way or the other, and here are some comments I have heard over the years:

1.    It’s great, I want it as soon as I need it, or before.
2.    No way, never. I’m happy the way I am.
3.    Do you know any good surgeons?
4.    It’s just wrong. We have so many bigger problems, plus the economy. There are many more important things to worry about.
5.    People who resort to plastic surgery are sad people. Just accept yourself the way you are.
6.    If someone wants plastic surgery, it’s fine, but it’s not for me.
7.    You can spend money on a trip or a piece of art or an expensive watch so why not this if you want?
8.    Too many people everywhere lack access to basic healthcare so why are we even considering this?
9.    Maybe if things get really bad, I’ll do something.

[qwidget question="173"]

My opinion, and this philosophy is incorporated into my book, is that you have the right to cosmetic surgery if you want, but consider other simpler measures first. Many people get good results from treatments like facial peeling or lasers or botox and sometimes even a different hairstyle or better posture will do more good than surgery, and with those you don’t run the risk, downtime, and expense of plastic surgery. Sometimes you just need more exercise and a better diet and six months.

The Brazilian attitudes about plastic surgery are more casual than in the United States. Friends and acquaintances here freely admit if they had some procedure. There is no shame here really, and there shouldn’t be. If you want it, maybe do it, and if you don’t like the idea, that’s great too. Just don’t be too quick to judge other people about plastic surgery, whatever their choice or belief….ok, some thoughts about cosmetic surgery:
1.    Don’t try to do too much (many complications occur because some patients push for multiple or excessive procedures all at the same time).
2.    Know the risks and that not everyone is happy afterwards, but most people get good results if they do the procedure they “need” and find a good surgeon.
3.    Find the best plastic surgeon you can.
4.    Research the various procedures and options.
5.    Be in good physical and mental shape before any surgery to decrease risks and maximize good healing. If you are depressed, surgery won’t cure your depression—better to see a psychologist or a doctor you trust first. If you smoke, don’t get plastic surgery.
6.    Ask lots of questions.

Next: follow-up “botox emergency”.

Today where I am, in Brazil, Carnival begins, and there is nothing that compares in the United States. Even New Orleans is more like a small-town street fair in comparison. In Brazil, the whole country stops most its business, and people turn to having a good time, trying to forget for five days all that’s bad. That seems especially true for the poorest people here, of which there are many.

So from today and for the next five days when Carnival ends, the banks will all close and even if you have a bill due during this period, you don’t have to pay until after Carnival. Brazilians really know how to enjoy themselves (and not only during these five days). My opinion is that U.S. Americans, generally, seem to spend much more time in a competitive pursuit of money, and…where has that gotten our country now?

The life expectancy in the U.S. is about 78 years and in the south of Brazil where I am now, it’s 75 years. My observation is that down here, their 75 years are much less stressful and happier due to the easier-going attitude. I think it’s something North Americans can learn somewhat. If you do, I think you’ll live longer and age better.

I’m interested to hear my readers’ reactions to my cross-cultural observations.  Am I off-base? And what about this: despite being a more laid-back country, Brazilians seem much more appearance-conscious than North Americans. They spend a lot of time, and money, on making sure their skin and hair and bodies look good, and the cosmetic surgery rate is likely the highest in the world. What do you think about that? Is it “wrong”? More about cosmetic surgery here next week (in honor of Carnival, I’m combining the usual Monday and Wednesday posts into Tuesday).

Have a good weekend. And I hope you consider if—despite the tough economic times everywhere—you want to “loosen up” your life a bit, and if so, how you might do it.

If you have high cholesterol, and are taking or considering taking (prescription) “statin” medication to lower cholesterol and decrease heart attack risk, you might be interested in this large Israeli study. The results suggested that those who faithfully took their statin medication over a four- to five-year period had a significantly lower death rate (45 percent) than those who took their medication only occasionally. It’s interesting research—worth talking to your doctor about if you are in a high risk group—but it’s not a perfect study. It may be that those who took their medication faithfully also took better care of themselves in other ways, and those other ways were more responsible for their better survival than the statin drug.

(This dedicated to my brother for his birthday today…he’s a faithful and accomplished marathon runner. I hope he avoids cataracts based on his running, because he doesn’t use sunglasses, and that increases his risk.) Particularly if you have a family history of AMD (age-related macular degeneration, the biggest cause for blindness in adults) or cataracts, you will be interested to know that people who run faithfully may have a much decreased risk of developing those eye diseases. For example, one report showed that those who run over 4 kilometers per day (2.5 miles) cut their risk of AMD by up to 54 percent. Much more detail here.

Do you know people who still smoke, and are crazy about their pets? More about this later, but it seems that pets really suffer the effects of secondhand smoke too, and that many smokers might be motivated to quit once they realize they are harming their pets!

To Live Long and Age Well, it’s a good idea to avoid unnecessary radiation, and for most people, that means unnecessary CT scans. A typical CT scan results in much greater radiation exposure than a regular X-ray.

One new test, the cardiac 64-slice CT scan is used to look for blockages in the arteries of the heart, which indicate heart attack or high risk of heart attack. These scans give fantastic 3-D images, like the one below. You might see this or a CT brochure and think: I want one! But don’t be mesmerized by color and hype, because medicine is also a business, subject to market forces.

Cardiac CT scanning is often used in cases when someone comes to the emergency room with chest pain, and the doctor wants to know if the pain is due to a blocked coronary artery or some other cause. The use of this scan has tripled in the past two years, and the cardiac CT commonly exposes the patient to the equivalent radiation as 600 regular chest X-rays. Still, this scan can give much useful information, but due to the radiation exposure, you only want it when it’s really needed and when other less risky tests aren’t adequate.

Doctors are trained to always balance the risk of any procedure or test with the benefits received (the risk: benefit ratio), but the companies that sell the equipment do their best to convince doctors that the benefits are high, and the risks low. And doctors—used to being pushed around and mistreated by insurance companies—can be seduced by the fawning attention of the medical device sales force.

Last week in the Journal of the American Medical Association (JAMA), a report was issued by a group of American and German researchers, who evaluated how much radiation patients were exposed to while undergoing the 64-slice cardiac CT scans, and they found the radiation exposure varied from center to center by a factor of six, meaning a patient at some X-ray facilities received six times the radiation dose as someone having the same test at another center.

One reason for this center-to-center difference is that several new radiation-lowering techniques are available, but some centers don’t use them. It’s still not clear yet which are the best methods to lower the dosage, but it would be good to know your facility was employing at least one of those methods.

Below are some basic questions you might ask if a CT is recommended for you or a loved one. (Of course in an emergency situation, you might not want—or be in a position—to question the necessity of the test.)

1. Could another test, one without radiation exposure such as MRI or ultrasound, be done instead of the CT? If the answer is: “The CT is better.” then you might ask: How much better? Does the difference between CT and the other test justify the radiation exposure?

2. If you have already had a CT scan of the same type and your doctor orders a repeat scan, question him/her carefully if another scan is truly necessary.

3. Explain you have read about the radiation dose from CT and you want to go to a facility that takes measures (or has a “protocol”) to diminish unnecessary radiation.

For more detailed questions, check this link.

Today’s post was preempted by an “emergency” botox session. More about that in a week.

Monday—Part II on cutting your CT scan radiation risk.

Especially in this economy, there are lots of stories (even one today) about people skipping or cutting back on their prescription medications to save money. There was a  recent article in the New York Times detailing the ways you as a patient can save on your medications. It covered issues such as: buying generic when possible, asking your doctor if each of your medications are truly necessary, and for your long-term pills, getting a better price on a three-month supply than a one-month supply.

I want to highlight one secret that was mentioned only briefly in the Times article. It’s something very underutilized—a study in 2002 estimated that people were only obtaining 2% of the potential cost-savings. Used carefully and with your doctor’s consent, it’s something that can often save you close to 50% on a prescription.

The secret is simple: pill-splitting. You probably know that many prescription pills come in various doses, but do you know that the double-strength form of the pill might cost only a small amount more than the single-strength? So if you can safely spit the pill into two, you will save a small fortune over time for many expensive medications.

First ask your doctor if any of your medications can be safely split. (Some pills cannot be safely split, like very small ones, or when you need an exact daily dose, or capsules and extended- and time-release pills, and of course when the mathematics of pill-splitting doesn’t work for the dose you need.)

If you can safely split, invest in a good splitter. I particularly like the one made by Apex Carex Healthcare Products, which I couldn’t find in any drugstore, but only at my vet’s office. (The ones I typically found in drugstores didn’t seem to have a good enough blade/mechanism, and pills would often shatter rather than split cleanly.)  So buy the best splitter you can—you will recoup the cost of the splitter in a couple days. You can even find custom-made splitters for unusually shaped pills, like the costly Viagra.

Today and Friday’s post are about radiation, the type your doctor orders for you. In medicine, it’s often good to be suspicious of the latest. If you’re quick to buy the very newest TV technology, the worst that can happen as an early adopter is that your format becomes obsolete. But as a medical early adopter, choosing wrongly, you could really suffer.

Last week there was a report about patients receiving too much radiation (excessive risk for the benefit received) from a new and already popular X-ray. That study is the subject of the next post. Today as background let’s just look at one article that appeared in late 2007 in a top medical journal, The New England Journal of Medicine titled “Computed Tomography — An Increasing Source of Radiation Exposure”.

In the future, if and when a doctor suggests to me some sort of CT (computed tomography) X-ray, I will say: Studies show that some CTs expose people to lots of radiation, so how does this CT rate, and how good is the CT facility you’re sending me to? If my doctor doesn’t know, I will question the radiologist at the X-ray facility before I schedule the test. I will want to know how their equipment rates with other institutions on radiation exposure, and what steps they take to protect patients from unnecessary exposure.

This might be shocking, but it’s true: from a single typical CT study you will receive about the same dose of radiation as an atomic bomb survivor who was one to two miles from ground zero at Hiroshima.

Those Japanese survivors received approximately a 3000 millirem radiation dose, and for a typical CT study—depending on where it is done, the type of scan, the age of the patient, and other factors—a person will receive from 1000 to 10,000 millirems of radiation. And here we are not talking about exotic scans, just normal CT studies ordered every day in emergency rooms and doctors’ offices by the thousands for complaints ranging from headache to chest pain to bellyache.

Excess radiation exposure—studied long-term in Hiroshima/Nagasaki survivors and radiation workers in the nuclear industry—has shown an increased risk for most types of cancer. Shockingly, a recent survey revealed that 53% of radiologists and 91% of emergency room doctors did not believe that CT scans increased the lifetime risk of cancer. But these scans can and they do. 75% of these doctors seriously underestimated the radiation dose from CT scanning. When I have spoken privately to radiologist friends about the issue of radiation from CT scans, they say yes, they are concerned, but seem to be hoping for the best; they really don’t want to think that their tests might increase anyone’s chance of cancer.

Despite that hope, it’s estimated up to 2% of cancers in the U.S. today are secondary to irradiation damage from CT scans, leading to 3 million excess cancer cases in the next 20 to 30 years in the U.S. alone. And while perhaps the increased risk from only one scan might be relatively small, many people undergo multiple scans over their lifetime, and the risk is cumulative. Disturbingly, children are much—up to 10 times—more sensitive to the cancer-inducing effects of radiation.

Next…ideas how to avoid unnecessary medical irradiation.

Those of you living in the northern latitudes of the Northern Hemisphere may know the winter “blahs” these days, but there is a group of people who have much more severe symptoms during winter, and they have their own diagnosis—SAD, “seasonal affective disorder”. The more north you are, the higher the risk. It’s estimated about 9% of Alaskans suffer from SAD each winter. It’s believed to result from an increase in melatonin and/or a decrease in serotonin (a neurotransmitter commonly adjusted UP by antidepressants).

Triggered by a lack of sunshine and shortened days, SAD people suffer a depression often marked by a combination of fatigue, weight change (typically weight gain), social withdrawal, increased sleep time, loss of concentration and libido, and feelings of hopelessness. It can be so severe that some consider suicide. It’s a serious disorder that demands care, and if you or someone you know might be affected, therapy is usually highly effective.

To help prevent SAD and to treat mild cases, push yourself to get outside each day (in the midday sun if possible), and increase aerobic exercise in the winter months…it may be enough just to take a brisk 30 minute walk outside each day. Avoid areas of your house that are dark. Try to sit and work by the window, keep the blinds up, and the lights on more than usual (bright white fluorescent light bulbs are best). Socializing more each day seems to help.

If your case is more severe or not helped by simple measures, talk to your physician. First line therapy includes (no shock) “light therapy”, but there is a special light that’s recommended, used in a particular way each day for at least 30 minutes, usually in the morning. Tanning bed lights are a bad idea, and you can’t depend on regular fluorescent lights if you have significant SAD; you need the right light. A SAD therapy light may emit from 2500 to 10,000 lux, whereas a typical home light fixture might give off only 100 to 200 lux. Adequate ones costs over $100, but it’s a good investment, and cheaper than other treatments such as antidepressants (ask your doctor about ones that won’t have a sedative side-effect) and psychotherapy. Some people need a combination of these treatments to shake them out of SAD. Many need to start their therapy each fall and continue to late spring.

I admit that right now I’m in Brazil, and it’s about 30 degrees (centigrade, about 86 F.) It’s the middle of summer, and I don’t think anyone here suffers from SAD (unless they have “reverse SAD”, a subject for a later blog.)

So, to my friends and readers up north, I’d recommend—if you can swing it—a trip down here or somewhere south to avoid SAD next year. You might ask your accountant: if you get a doctor’s prescription, could such a trip be tax-deductible? But if you’re ever planning to run for political office, don’t even think about it…

In one sense, aging well means minimizing or better—preventing—any irritations that can arise as you get older. One of the most common of these is ringing in the ears, or tinnitus. Usually not a result of any serious disease process, it’s typically due to excessive noise exposure over years, which damages the hair cells in the cochlea (inner ear).

Next week’s edition of the New Yorker magazine (available online now) has an article by Jerome Groopman, M.D. regarding his adventures in trying to stop his head noises. Much of the discussion revolves around soldiers in Afghanistan and Iraq, and how gunfire and explosions have turned hearing loss and tinnitus into the number one cause of disability claims for these soldiers. Apparently, they are not using earplugs consistently, and in many cases (like body armor) the military hasn’t provided adequate protection.

But it’s not only soldiers who suffer life-long hearing loss and ringing. It also commonly arises from noise at work, and from listening to iPods at too high of a volume. As a general rule for iPod use (and for most other portable music players), if you put the volume at 80% of maximum, don’t listen for more than 90 minutes a day. At 100% volume, you will suffer inner ear damage after only 5 minutes of exposure! In general, try to limit your iPod to 70% or less of maximum volume.

If you regularly go to loud clubs or concerts, avoid future hearing loss and ringing by investing in a set of good earplugs with an adequate Noise Reduction Rating.   Consult this article for much more data about safe earplug use, including a table of recommended loudness x listening time.

So your best defense to avoid the irritation of tinnitus is prevention. Minimize—beginning when you are young but it’s never too late to start—unnecessary exposure to loud noise. But if you already have ringing, get an appointment with an otolaryngologist (ear-nose-throat specialist) and get a hearing test to find out what’s the cause and what can be done to treat it. If you want more detail, check out this guide to ear ringing.