Scientists have discovered that—surprisingly—people who undersleep tend to get fat, and one way to keep at a good weight is to make sure you are getting enough sleep. Only with enough sleep will our body have good healthy responses to ghrelin and leptin.

Maybe they sound like new diseases: ghrelin and leptin…but, ghrelin is a hormone we all have that’s formed in the lining of the stomach, and after being secreted, it goes deep into the brain and excites the same mechanism that causes some people to become addicted to say, food or alcohol. The other one, leptin, is a hormone secreted by our fat cells (!) that puts the breaks on appetite by acting on our brain in the opposite fashion. You can only imagine that biotech drug companies are racing to find and sell a pill that acts like leptin.

Bottom line: if you don’t sleep enough, you tinker with this leptin/grhrelin balance in a bad way; the tendency is to get fat. Many of us suffer, at least occasionally, from sleep problems, and I’m briefly covering this issue so that if you are one of those sleep-poor people, well…let’s think about the problem in a more serious way, with more attention to fixing whatever are the underlying issues.

I’m curious if my readers are interested in hearing more about sleep, and about what happens if you don’t get enough, such as the effects on your blood pressure and heart (besides the diabetes and obesity issues). Leave a comment if you are, and if readers say they want,  I’ll write a more detailed report in the near future.

Drugs can be classified as to their “safety margin”, which refers to a comparison of the dose of a drug needed to be therapeutically effective compared with the amount of the drug needed to produce toxicity. Some drugs, for example, penicillin, are considered to have a rather wide safety margin because a relatively small dose of these drugs can be therapeutically effective (here, cure an infection), but normally you need a very large dose to get serious toxicity.

On the other side of the safety margin scale are drugs like acetaminophen, which have a NARROW margin of safety, meaning, the difference between a normal therapeutic dose and a dose that will produce toxicity or even death is relatively small (“narrow”).  So you need to be extra careful when taking a drug with a narrow safety margin, like Tylenol. Overdosage is common, and serious Tylenol overdosages are NOT easy to treat or reverse. Sometimes the only treatment is a liver transplant. Milder overdoses that occur over a period of time might not even be recognized by the patient, but result in chronic liver damage.

Shockingly, acetaminophen overdosage is the “leading cause of acute liver failure in the United States”. Meaning this drug is worse than alcohol for causing acute liver failure (note that “acute” in a medical sense does not mean serious, rather, acute means a condition that arises or appears over a very short period of time).

Severe liver damage from this OTC drug can occur from a dose that you might not consider excessive. A person who already has some level of liver problem—for example from chronically drinking too much alcohol—can suffer irreparable liver damage from taking only four or five 500 mg. tablets over one 24 hour period.

Currently, the maximum safe dose (as listed on the product label) is 4000 milligrams per day, meaning: a maximum of two-500 mg. “extra-strength” tablets every 6 hours for a day. But…how often do you think this dose is exceeded, if not by you, by others in pain who, rather than wait 6 hours between doses, take a new dose after only, say, 4 hours? It’s happens a lot.

So at the FDA meeting later this month, the group will consider a recommendation to lower the maximum daily dose from 4000 mg. to 2600 mg., and cut the size of the biggest allowable tablet from 500 mg. to 325 mg. No matter what they decide, take caution with this drug, especially if you already have any liver disease, have elevated “liver enzyme” blood levels, take statin drugs to lower cholesterol, or you drink a moderate or greater amount of alcohol daily. It’s not clear at what level of daily alcohol use you have to be concerned; the Tylenol label says to “ask your doctor if you drink more than 3 drinks per day”, but many experts believe if you drink less than that you should be extra careful with acetaminophen.

Your physician should be able to answer any questions about your liver function with some simple blood tests, and if you have concerns about your daily alcohol intake combined with acetaminophen.  For everyone however, even those who drink rarely, if you “binge”—drink significant alcohol at any one time—don’t use acetaminophen to try to treat a headache or hangover (however aspirin is not great either, because it can irritate the stomach).

Be aware that acetaminophen (or paracetamol or APAP as it is known in some countries), is not only found in the Tylenol brand, but is a component of many other common OTC medications… over 200 formulations contain acetaminophen but don’t carry the Tylenol label, and the presence of acetaminophen is only discovered by reading the fine print on the back. Consult this list for examples; and better, read the ingredients of every pain or anti-fever medication you take to see what’s inside. You might take Tylenol in the evening, then at bedtime take a slug of, say, Nyquil, not realizing it too contains the same drug.

I will let you know what the FDA decides after their meeting at the end of June, but for an interim FDA report, with more details about acetaminophen, click here (pdf).

In summary, acetaminophen can be a wonderful drug, but with a narrow “safety margin”, it deserves special caution.

I think that the list is interesting and helpful, but should not be relied on completely. Some hospitals that are widely recognized as among the nation’s best, such as the Mayo Clinic in Minnesota, John’s Hopkins in Baltimore, and the Cleveland Clinic, did not appear on HealthGrade’s list. I was also interested to see that the list states: “Distinction cannot be used without a Licensing Agreement from Health Grades, Inc.”.  What does that mean? HealthGrades is a for-profit entity which is listed on the NASDAQ stock exchange, and if you want to see an attempt at hospital ratings from a non-profit entity—the U.S. Department of Health and Human Services—check out this site called “Hospital Compare”.

Another widely recognized and well-regarded yearly ranking of hospitals appears in the magazine U.S. News and World Report, and you can access the 2008 report here.

If you look at all three rankings, you will see that of course none of them agree, though some hospitals appear on more than one list. Each ranking uses a different complex formula to reach their conclusions, and I certainly can’t say which is the best. For finding a good or “the best” hospital in my area, I would consult various rankings before I reached my conclusion, and these rankings would be only part of my information… like most medical studies, to get a “ranking of the best”, you can assemble whatever data you choose, then statistically analyze (some people say “massage”) the data in many different ways to reach a conclusion.

Today’s post is dedicated to the people in the Eastern United States who are now being blanketed with up to 10 inches (25 cm.) of snow, along with temperatures down to 12 degrees F (-11 C)…what a miserable way to start a week. We wish them a quick end to their long cold winter, and now, speaking of “colds”…

If you ask people what vitamin they think of to prevent or treat the common cold, most people will answer: vitamin C. But a review by the Cochrane Collaboration (an international, non-profit group of scientists who develop unbiased recommendations based on analysis of the best accumulated research), found that in most cases, vitamin C has at best a mild effect in preventing colds, and doesn’t do much to treat colds. The biggest benefit was for people exposed to very cold weather or extreme exercise situations.

For sure, the subject of the common cold and vitamin C will continue to be studied and be controversial, but a very new study from Harvard Medical School strongly suggests that people with low levels of vitamin D in their blood get colds significantly more often.  People with a low D levels were 40% more likely to suffer from colds than people with the highest vitamin D levels. And people with pre-existing respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) seemed to have an even stronger beneficial effect from higher vitamin D levels—people with asthma and low vitamin D levels were five times more likely to suffer from colds than people with high levels. Those with COPD and low D levels were two times more likely to have cold symptoms.

This study was a retrospective analysis (it looked at data from the past), and for that reason the Harvard scientists couldn’t say whether taking additional vitamin D would cut your risk of getting a cold. To know if taking extra vitamin D cut one’s risk of getting a cold, a study would have to start with a large group of people, randomly separate them into two equal groups, then give one group vitamin D pills, and the other group an identical looking/tasting placebo pill, and study over time if one group got colds less frequently. Best if this study was “blinded” to cut the risk of researcher bias, meaning the researchers themselves wouldn’t know which group an individual person was in, so each study participant would be identified only by a code or number, and the code broken only at the end of the study. Such a study has yet to be done.

Still, the lead author in the recent Harvard study, Dr. Adit Ginde, stated “I think we can say that most Americans probably do need more vitamin D for its effects on bone health, as well as for its general benefits with respect to the immune system.” So the reason that vitamin D seemed to help cut the risk of colds is that vitamin D helps strengthen the immune system.

Vitamin D is one of the more difficult vitamins to get from the average diet….stay tuned to LLAW for how to!  (If you want lots of information on how to get vitamin D now, go to the Vitamin D Council link on the LLAW right sidebar under “Nutrition”).

(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.

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.

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.

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.

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…

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.