Great Smokies Medical Center of Asheville

Archive for September, 2005

A Time-Honored Tradition in Treating Hypothyroidism by Dr. Wilson

Monday, September 12th, 2005

The road one travels while treating hypothyroidism based on laboratory tests is strewn with potholes. Every doctor who treats hypothyroidism sees discrepancy when comparing blood test results with how the patient reports feeling. This failure to find an explanation for a patient’s symptoms may result in the physician determining that the patient has a psychosomatic illness.
Years ago, before blood tests and synthetic drugs were available, doctors relied on patients’ histories and physical exams to diagnose and treat them. If patients presented with symptoms and physical findings that fit the clinical picture of hypothyroidism, they would then be prescribed the only agent available at that time, whole glandular thyroid from pig (porcine) thyroid. This preparation, known as U. S. Armour Thyroid, contains mostly T4 as well as some T3.
A small but growing group of doctors have continued this tradition of listening to patients’ symptoms while carefully taking their history and performing a physical examination in addition to using blood tests. They have continued to treat hypothyroidism with natural, whole, desiccated glandular thyroid.
This natural time-tested approach more often results in improvement in mood and mental functioning–symptoms often not improved by the more commonly used prescription drugs.
An article in the New England Journal of Medicine reported research suggesting Synthroid use resulted in no improvement in 17 parameters measuring memory, mood, language, and learning. The use of Armour thyroid however, resulted in improvement in 6 of the 17 parameters. (NEJM 1999;340:424-429, 469-470.)

Laboratory Testing of Hypothyroidism

Monday, September 12th, 2005

Doctors have traditionally measured blood levels of thyroid stimulating hormone (TSH), T3 Uptake, Total T4 and Total T7 to both diagnose thyroid imbalances and monitor the effectiveness of thyroid hormone therapy regimens. The problem with this laboratory assessment is that most of the total T3 and T4 are bound to proteins that render them unavailable for use by the body.
Alternatively, doctors can measure Free T3 and Free T4 that reveal the parts of Total T3 and Total T4 that are not bound to proteins and are thus biologically active. These more sensitive tests enable a doctor to more accurately and safely customize dosing of T3 and T4 to optimize functioning of the patient.
We recommend having a TSH, Free T3, Free T4, and thyroid antibodies drawn as baseline to test for hypothyroidism. To monitor thyroid replacement therapy in a person taking thyroid hormone, the doctor can usually monitor with a simple free T3 or T4. The time of day that blood specimens are drawn is important. Have your thyroid blood level tests drawn about eight hours after taking your morning dose of thyroid, about 3:00 p.m. to 4:00 p.m. for most people. Thyroid medication should be taken upon waking and when fasting.

The Medical Treatment of Hypothyroidism by Dr. Wright

Monday, September 12th, 2005

Hypothyroidism is treated by replacing thyroid hormone in pill form. Most physicians use synthetic, bio-identical T4 (Synthroid, Levoxyl, or Unithroid). T4, so named because each molecule contains four molecules of iodine, is a mostly inactive precursor hormone that is made in the thyroid gland. Before it can be useful in the body, T4 has to be converted into triiodothyronine (T3), the biologically active form of the hormone that contains three iodine molecules. The conversion of T4 to T3 occurs outside of the thyroid gland in the body’s cells. For several reasons, including deficiency of zinc, copper, selenium, or iron, and excess cortisol (the adrenal stress hormone), many people can’t efficiently convert T4 to T3. For such a person, taking Synthroid, Levoxyl, or Unithroid will not likely result in improvement, as the body cannot convert synthetic T4 to T3 any better than it can convert its own natural T4 to T3. Unfortunately, in this situation, the blood tests that doctors routinely use to check thyroid status may be normal, which could cause a physician to miss the diagnosis. The patient all too often ends up with the symptoms of hypothyroidism and the doctor’s bill.
Cytomel is a synthetic prescription form of T3, while Thyrolar contains both synthetic T4 and T3.
Because deficient cortisol results in a speeding up of the conversion of the inactive T4 thyroid hormone to the active T3 form, failing to treat adrenal fatigue either before or at the same time hypothyroidism is being treated can result in the patient feeling jittery or anxious, and then wrongly thinking thyroid is bad for them. What may really need addressing is the cortisol deficiency.
Because symptoms of hypothyroidism are also symptoms of other general syndromes and specific diseases and doses required to treat an individual can change from time to time, I recommend regular ongoing monitoring of thyroid blood levels.

Signs and Symptoms of Hypothyroidism

Monday, September 12th, 2005

The following symptoms are associated with hypothyroidism:

Low body temperature
Slow to waken in the morning
Weight gain and difficulty losing weight
Depressed mood
Poor mental function
Difficulty feeling warm, especially hands and feet
Dry skin
Orange discoloration of palms and soles
Menstrual cycles irregularities

Thinning or disappearance of outer third of eyebrows
Edema (swelling) of face, tongue, ankles, and fingers
Dry, lusterless, coarse, brittle hair
Dry, brittle nails
Hair loss
Slow or absent reflexes on physical exam
Personal history of high birth weight or family history of tuberculosis
New onset of snoring
Increased cholesterol levels

Health Risks of Obesity

Monday, September 12th, 2005

If you need a dose of reality about the health risks associated with diabetes, check out this formidable list: Type 2 diabetes, gallbladder disease, high blood pressure, high cholesterol and lipids, sleep apnea, coronary artery disease, osteoarthritis of the knee, fatty liver disease, gastroesophageal reflux disease (GERD), gout, low back pain, impotence, and some cancers, notably breast, uterine, and colon. The risk for these health problems to occur with obesity are strongest before age 55, and after age 74, there is no longer an association between obesity and the aforementioned diseases.

Dying For a Good Night’s Sleep?

Monday, September 12th, 2005

Each night across America, an estimated 15 million people are, in effect, being asphyxiated in their own homes.
Obstructive sleep apnea (OSA) is a much more serious health problem than just the annoyance of snoring. When lying down to sleep at night, the airway can actually collapse or can become physically obstructed, resulting in a life and death struggle for oxygen. People afflicted with OSA may be unaware of their own apnea, but others in their households are not, as they may also become sleep deprived from long nights of their loved ones’ gasping respirations and physical restlessness.
Sleep apnea is defined as 10 or more episodes per hour of cessation of breathing in excess of four seconds. They must be accompanied by a four percent or greater decrease of oxygen levels in the blood and be followed by frequent awakenings in an attempt to breathe.
The body interprets the decreasing oxygen levels as an emergency and releases the stress hormone adrenalin to counter this perceived life-or-death situation. An excess of adrenalin contributes to high blood pressure, which is known to afflict about 50 percent of OSA sufferers. Failure of blood pressure to lower during sleep is a sign that high blood pressure may be caused by OSA.
Middle-aged men are more commonly afflicted than women of the same age, as are obese or overweight individuals. A neck circumference greater than 17 1/2 inches in men and 16 1/2 inches in women suggests risk for OSA.
Sleep apnea is associated with many health problems and can even be fatal, most likely from heart arrhythmias or motor vehicle accidents from driving while tired. Symptoms associated with sleep apnea include headaches on waking and dry mouth. The lack of deep, restorative sleep results in irritability, hallucinations, and inability to think clearly, which can lead to stressed relationships and poor job performance. Blood vessels in particular suffer under sub-optimal blood oxygen levels, contributing to angina, coronary artery disease, stroke and impotence. OSA can be aggravated by sleep deprivation, the use of alcohol, tobacco, and some drugs, and allergies that cause swelling of tissues in the nose and throat.
Sleep apnea is diagnosed by monitoring breathing cessation (apneic) events and lowered levels of blood oxygen (hypopneic) events in a sleep lab. For many, being wired, observed, and sleeping in an unfamiliar bed does not mimic a routine night of sleep. Years of research has revealed that the tone of small arteries (peripheral arterial tone) in the fingers directly correlates with apneic and hypopneic events. An FDA-approved computerized device is available at GSMC for at-home monitoring to diagnose OSA. Simply wearing a specialized glove that holds a tiny computer and two devices that are worn on the fingers allows monitoring of heart rate, respiration rate, and oxygen saturation.
Once diagnosed, sleep apnea is routinely treated by Continuous Positive Airway Pressure (CPAP), which delivers room air under pressure by a facial or nasal mask. CPAP can effectively address the lowered oxygen levels. However, more than 40 percent of people with OSA cannot tolerate CPAP and others will not use it due to the aggravation.
Since the symptoms of OSA are more severe when people sleep on their backs, simply strapping a tennis ball to the back can inexpensively and effectively train people to sleep on their sides, resulting in great improvement of milder cases of OSA. Other treatments for OSA include weight reduction, desensitization to allergies, and specialized mouth splints that open the airway by pulling the lower jaw forward. In severe cases that do not respond to medical intervention, surgery may be necessary to reduce the volume of tissue in the throat.

The Secret Life of Fat

Monday, September 12th, 2005

Who would have imagined that a seemingly passive slab of belly fat could turn on its accommodating host by deploying sophisticated biochemical weapons that undermine health?
Though this "Attack of the Killer Fat" sounds like the title of a low budget movie, understanding the concept may go a long way toward removing the stigma of a presumed deficit in motivation or character so often directed at obese individuals by leaner, although under-informed, people.
The vital role of fat in assuring survival of the species results in the body’s no-holds-barred tactics that are a formidable opponent for any strategy (e.g., a very low calorie diet) which opposes it, resulting in the body’s survival switch, in effect, becoming stuck in the "on" position, perpetuating a vicious cycle designed to maintain fat stores at all costs.
Researchers have found that adipocytes (fat cells) are part of a living, sophisticated organ (fat) that secretes powerful hormone-like chemicals which determine how we feel and function. Fat has important work to do . . . and it never sleeps.
Chemical signals are broadcast from their fatty bunker and enter the general circulation where they influence immune function, mood, energy production, appetite, reproduction and, in particular, inflammatory responses that can result in pain and chronic illness.
These chemical signals are emitted by fat cells and macrophages. Macrophages are specialized white blood cells that reside in tissues where they perform their job of walling off and cleaning up debris from infection, injury, and toxicity. They surround and "eat" the offending threat, secrete potent chemicals to destroy it, and promote healing. In addition to these life-sustaining, beneficial tasks, macrophages are also involved in harmful inflammatory processes when their response to injury or infection becomes out of proportion to the threat.
Macrophages are probably most notorious for their presence in plaque, that ticking time bomb in the walls of arteries. When the thin cap over plaque ruptures and the plaque spills into a coronary artery, macrophages in the plaque spew their inflammatory brew of chemicals into the blood stream causing a clot to form, resulting in a heart attack. (Heart disease is more accurately depicted by a model of inflammation than by the simplistic model of sludge accumulating in a pipe.—Ed.)
Inflammatory chemicals secreted by macrophages in fat may explain the well-known association of obesity with many diseases—hardening of the arteries, Type II diabetes, arthritis, high blood pressure, and most cancers.
Among the many chemicals secreted by fat cells and macrophages is the beneficial adiponectin, which enhances metabolism and burns fat. Adiponectin levels fall as obesity increases. Cytokines are another example of chemicals released by fat that increase the likelihood of clot formation, heart disease, insulin resistance, cancer, and other inflammatory states. Cytokine levels rise as obesity increases.
The study of obese mice by researchers at Columbia University determined that the fat of leaner mice contains only a few macrophages, while the fat of extremely obese mice is composed of a remarkable 40 to 50 percent macrophages. Researchers theorize that as obesity increases, overstuffed fat cells can burst, requiring even more macrophages to clean up the debris.
Pharmaceutical companies will likely be tripping over themselves to develop the first miracle drug on the block that targets and stops the inflammatory consequences associated with obesity.
But, don’t rush to be first in line at the pharmacy counter for these new drugs.
Because inflammation is essential to a healthy immune response, any drug that interferes with it will most certainly have undesirable side effects. Vioxx, the anti-inflammatory drug recently pulled off the market because of the increase of heart attacks and strokes in its users, not only intervened with the adverse effects of inflammation (resulting in pain relief), but also interfered with the critical immune-protective functions of macrophages (resulting in side effects).
The spare tire that hangs over the belts of 15 million obese Americans is a particularly obvious sign that predicts increased risk for inflammatory illnesses. However, even lean people can have visceral fat, the dangerous fat hidden in and around the abdominal organs that is associated with risk of heart disease and other inflammatory diseases.
What is the relevance of all this in the life of an obese person?
While some obese people have no obvious health problems, many others have a variety of inflammatory disorders that occur as a direct result of being fat, leaving them stuck in a vicious cycle of obesity, poor health, and a quality of life that defies the expression "fat and happy."
Can obese people with inflammatory disease regain their health? Since being fat results in inflammation, it is only fair that losing that same fat results in reduced inflammation.
However, it is no longer considered adequate to treat obesity with a simplistic "calories in, calories out" approach. Because we are each biochemically unique, no one diet will fit all. A focus including nutrient-dense foods (such as fish and colored vegetables) and excluding nutrient-deficient foods (such as sodas, processed foods, and sugar) forms the foundation of various successful diets.
Two simple blood tests that measure inflammation (hsCRP and fibrinogen) can help identify and monitor those at risk from obesity-driven inflammation. Researchers have found that these inflammatory markers decrease with reduction of body weight and waist girth attained by exercise and dietary changes.

Tips to Prevent Mold Growth

Monday, September 12th, 2005

Thoroughly inspect any home for mold contamination before buying it. Mobile homes are particularly vulnerable to mold growth.
Treat mold contamination by addressing conditions that support mold growth: lack of ventilation, darkness and, especially, moisture.
Ventilate high moisture areas: the kitchen, bathrooms, and laundry. Use fans to exhaust moisture from the laundry, bathroom, and kitchen to the outdoors, not the attic or crawl space.
Insulate windows and doors, pipes, walls, and attics to prevent condensation. Dehumidify basements and other damp areas to attain 50-55 percent relative humidity.
Provide ample drainage of water around the foundation of a home by using drain tile and rain gutters, backfilling the foundation, and sloping the land away from the house. Install vapor barriers and assure adequate cross ventilation in crawl spaces. Because water seepage through concrete and cement block may be imperceptible, avoid flooring and wall covering that prevent evaporation of moisture.
Air conditioning reduces the humidity in a home. Molds grow best between 77-86 degrees Fahrenheit, though they can grow at temperatures as low as 32 and as high as 95 degrees. Open closets to air condition (and dehumidify) them when you are not home. Keep clutter (old shoes, books, rags, etc.) at a minimum. Keep condensation trays for dehumidifiers, refrigerators, and air conditioners clean to prevent mold growth.
In the event of a flood, spill, or leak, clean up the water within 24 hours and use dehumidifiers, fans, and ventilation to thoroughly dry wet areas. Determine and correct the cause of the flood or leak, when possible.
To prevent mold growth and to clean up a moldy area: Keep it clean, keep it dry, air it out, and disinfect it. Some believe that stachybotrys-contaminated penetrable materials such as wood cannot be adequately treated by surface disinfecting. Therefore removal, disposal, and replacement of such molded materials may be required. Severely affected homes may be permanently uninhabitable.
Remove and replace heavily contaminated materials. Clean surfaces with a stiff brush and hot soapy water and rinse with clean water. Then use a 10 percent bleach solution to clean surfaces. Allow to dry thoroughly. Do not mix bleach with ammonia. Use good ventilation and respiratory and skin protection when using any cleaning solutions.

Is Your Moldy Home Making You Sick?

Monday, September 12th, 2005

We’ve all seen the dramatic footage on the evening news. An entire family finds themselves homeless, prohibited from entering their dream-home-turned-moldy-toxic-EPA-nightmare.
Could molds be putting your health at risk? For more and more people across the nation, the answer is yes.
More than 200,000 species of molds have long been associated with health problems, the most common of which include respiratory illnesses (coughing, asthma, and bronchitis) and skin problems (ringworm, athlete’s foot and fungal disorders of the skin and nails).
Molds reproduce by releasing spores, which land on surfaces and thrive when the conditions are right: the right material combined with poorly ventilated, dark, warm, and moist environments.
Molds require organic matter (straw, soil, paper, dry wall, wood, food, leather, tile, natural fibers, etc.) for growth. They may be visible as green, black, orange, white, or gray discoloration, and may have a slimy or dry, fuzzy visible surface growth. Molds emit an unpleasant, musty odor.
Even more toxic than molds are 400-plus toxic chemical metabolites produced by mold called mycotoxins. The impact of one agricultural mycotoxin, aflatoxin, on humans and livestock is well researched. The Food and Drug Administration (FDA) and the U.S. Department of Agriculture (USDA) routinely monitor aflatoxin levels of crop foods. Produced by the mold Aspergillus flavus that infests many crops including corn and peanuts, aflatoxin causes liver and kidney toxicity and is a known potent liver carcinogen.
Indoor molds and mycotoxins that result from tighter, energy-efficient residential construction practices are also a concern. Such practices cause decreased air exchange, trapped moisture, and recirculation of contaminated air.
Between 1993 and 1998, physicians in Cleveland saw an unprecedented 37 cases of pulmonary hemorrhage in infants. Nearly all required intensive care and artificial ventilation for breathing difficulties. Because the symptoms recurred when the infants were returned to their homes, researchers suspected that something in the homes was responsible for their symptoms.
Centers for Disease Control and Prevention (CDC) researchers found evidence that the homes were contaminated with Stachybotrys chartarum, a mold known to produce numerous mycotoxins. Stachybotrys, called "black mold," requires low nitrogen, high cellulose materials for its growth. Dry wall, paper, dust, lint, fiberboard, and wood are thus ideal substances for stachybotrys’ growth. Researchers hypothesized that mycotoxins from stachybotrys contributed to the respiratory ailment that ultimately resulted in the deaths of 12 of the infants. Varying susceptibility of individuals who are exposed and the volatile nature of mycotoxins make their study difficult.
Symptoms of stachybotrys exposure result from immune system suppression: coughing up blood, non-traumatic nosebleeds, memory loss, cognitive changes, hair loss, sore throat, infections, muscle aches, nausea, rashes, headache, mood disorders, and fatigue.
Many other molds affect indoor air quality. For example, Cladosporium is a common indoor and outdoor mold that grows on paint, textiles, plants, soil, and the fiberglass liners of ductwork. It is allergenic and a well-known cause of asthma. Chronic exposure may contribute to emphysema.
Several species of Aspergillus are suspected carcinogens and contribute to fungal nail infections, ear infections, kidney and liver disease, and aspergillosis, a serious fungal lung infection.
To determine if your house is making you sick, take a weeklong trip to a non-moldy environment and see if your symptoms decrease. The answer may be apparent only upon the return of symptoms when re-entering your home.
Seek the opinion of a certified environmental specialist before making costly remediation decisions, keeping in mind that the best solution may be relocation. If necessary, consult a physician who understands the roles molds play in health problems.

Blinded By Double-Blind Scientific Studies

Monday, September 12th, 2005

Evidence-Based Medicine (EBM) is the latest buzzword used to describe an emerging model of healthcare that advocates applying data from scientific double-blind studies to "real" patients in clinical practice.
The double-blind study, the gold standard of scientific research, is a process by which two similar groups of people are studied. One group is given an actual treatment, while the other is given a placebo or "sugar pill." Neither participants nor researchers know which group is which until after the study is completed, hence the term "double-blind."
Proponents of EBM believe that applying research in practice will result in better treatment outcomes.
However, some physicians have concerns about applying scientific research data in their practices. They recognize the limitations of scientific research and thus don’t want to risk over-reliance on it, because doing so could expose their patients to both known and unknown risks.
What are some of the limitations of scientific research?
For starters, study participants may not be representative of people who will be likely to take the drug in real life. Study participants may be younger or healthier, and elderly or sick people do not respond to drugs in the same way their younger, healthier counterparts do.
Also, considering the potential for huge profits in drug sales, the pharmaceutical industry’s funding of research has been shown to buy biased results that, in the opinion of some, resemble paid advertising more than scientific research.
Additionally, even in the most scientifically-sound studies, group statistics do not apply to individuals, because people aren’t test subjects, but are complex and dynamic individuals.
Furthermore, contractual agreements between clinical researchers and drug companies can take away the scientific independence of researchers and tie their hands from freely reporting unfavorable data.
Also, the very treatment a patient needs may never be researched. For instance, natural substances cannot be patented and thus don’t have the potential to produce the huge profits necessary to recover research costs, which are routinely in excess of $300 million.
The reliability of scientific research is regularly questioned. Many drugs have passed rigorous scientific studies and clinical trials and gained FDA approval only to be taken off the market because of side effects that became apparent only when the drug was given to "real" patients. Indeed, there is less risk when taking "tried-and-true" drugs that have withstood the test of time than there is from taking newer drugs that have been in the marketplace for only a short time. According to a report released by the General Accounting Office of the U.S. government in 1990, of the 198 drugs that the FDA approved between 1976 and 1985, a staggering 52 percent proved to have “serious post-approval risks.”
Practicing doctors can end up being spoon-fed whitewashed research data, unwittingly becoming the third "blinded" group.
Historically, most major advances in medicine have not resulted from scientific research, but instead from reasoning of individual physicians’ basic observations of the patient and his disease.
Throughout history, the real movers and shakers in medicine have been free-thinking individuals who were unbound by the influence of research money and restrictive political-based regulations.
What’s a patient to do? Cautiously walk, don’t run, toward the latest research. Get second, and third, opinions when needed. Go to physicians who practice integrative medicine, who utilize treatments other than drugs, who get to know their patients as individuals, and who value both the science and the art of medicine.

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