Reviews: The Importance Of The Circadian Rhythm

Our bodies have evolved in a binary environment that cycles between day and night, which impose different demands for the optimal functioning of our bodies.

In the daytime, we typically explore, fight and eat. In the night time we rest and digest.

We have an unconscious, or autonomic, nervous system, that helps us adjust, the sympathetic nervous system revving us up for the daytime, and the parasympathetic, including the vagus nerve, slowing us down at night time. Sleep has apparently evolved to repair, cleanse and grow our bodies at night, in a process called anabolism. In the daytime, we have wear and tear, and use more energy to survive in a metabolic process called catabolism.

Hormones and Neurotransmitters help time and facilitate these cycling processes.

Light In the morning, operating through the central “zeitgeber”  in the supachiasmatic nucleus, synchronizes the circadian rhythm present in each of our cells, and drives down melatonin. Cortisol rises to help with stress, adenosine rises because of muscular and neural activity, the sympathetic nervous system is more active to help with alertness and raise the blood pressure, pulse rate, and body temperature.

As the light decreases at night, the melatonin Increases to facilitate sleep. Cortisol decreases, allowing the immune system to become more active, with immune lymphocytes going into the lymph nodes to start  dealing with any infection that has been encountered during the day. The daytime diet is being digested, replenishing the ATP and glycogen energy stores in muscle, brain and other tissues. Growth hormone signals cells to divide, and helps children grow.

Medical science makes use of this information in a field called chronotherapy. Cancer treatment with radiation and radiomimetic drugs are best done at night, when the cells divide.  Asthma medications are often given at night, because asthma is more common with a decrease in cortisol. GERD medications, such as proton pump inhibitors, are best given at night, because gastric acid builds up then, and lying flat encourages any acidic food to reflux into the esophagus.

As I have always mentioned, sleep, diet, and exercise are important for best health.

A sleep hygiene routine, going to bed by 10 PM and getting 7 to 8 hours of sleep is critical to give the body time to repair itself. Getting enough exercise will increase adenosine and facilitate a good nights sleep, along with countless other beneficial effects. Avoiding blue light from television and computer screens in the evening will help melatonin increase for good nights sleep. Avoiding food for three or four hours before bedtime will allow time to get the food out of the stomach and reduce gastroesophageal reflux.

TRE, or time restricted eating, is a form of fasting, which correlates with longevity.

Help the body synchronize its circadian clocks by well-timed, regular habits, and you will have a far better chance to be healthy. You are on dangerous grounds if you foul up the circadian rhythm by staying awake until the wee hours, eating an unhealthy diet and snacking all the time on lots of carbohydrates with little fiber, and sit around without exercising. Obesity, metabolic syndrome, diabetes, and gastrointestinal illnesses, as well as cancer can result.

Night shift work, for example, disturbs our biological clock, and has recently been labeled as carcinogenic.

—Dr. C.

Reviews: Robotic Knee Replacement Surgery

Penn Medicine Videos (July 14, 2023) – Penn Orthopaedics offers multiple options for joint replacement surgery, including the latest robotic knee and hip replacement technologies.

In this video, Dr. Travers, Director of the Penn Orthopaedics Robotics and Navigation Program, discusses what robotic joint replacement surgery is and how it differs from traditional joint replacement surgery, as well as the benefits of this procedure.

We also hear from three patients who recount their personal experiences before and after robotic knee replacement surgery.

Fungal Infections: The Spread Of Candida Auris

Candida auris is a type of fungus, a yeast in this case, that is increasing in frequency and spreading geographically, apparently due to warmer temperatures. This organism is fairly common in hospitals, where it often is on the skin. It is lethal if it gets into the body, and often difficult to treat. Las Vegas, Nevada, in particular is having almost an epidemic of these infections, with more than 500 infections and 100 deaths since the fall of 2021.

An alarming number of cases are misdiagnosed when patients first come to the emergency room; fungal infection is certainly not the first thing a doctor thinks of when she sees a patient with a febrile illness. On the flipside of that, any delay in diagnosis, particularly with a bloodstream infection, can be lethal. There are a few good laboratory tests for the diagnosis of fungal infection, and many of these take highly trained technicians with a microscope.

Fungi are opportunistic infections, which means a healthy person is unlikely to be seriously affected. With cancer treatments and organ transplants, increasing numbers of people are on immunosuppressive drugs which means they are more susceptible. Hospitals deal with this very sick people, and frequently use central catheters inserted into patients veins, and opportunistic fungi, like candida auris, get a free ride into the body. With fever, most doctors, think first of bacterial infections, and give antibiotics; these antibiotics can actually worsen fungal infection, since they remove bacterial competitors.

Many medical schools do not teach their students about fungal infections, and in 4 years of medical school, doctors in training are lucky to get two or three hours on this subject. Fungal infections are thought to be rare.

In these days of high-tech, corporate medicine, it is good for a patient to be her own advocate. Don’t be afraid to ask the doctor if she has thought of fungal infection as possible cause if you are not improving with your treatment, particularly if you’re in the hospital.

—Dr. C.

Skin Conditions: A Review Of Urticaria (Or Hives)

One out of five people experience hives in their lifetime. These are itchy bumps, which are surrounded by a field of redness, and itch like crazy.

Hives are caused by the release of histamine from mast cells in the tissues, or basophiles in the bloodstream.

Itching is the chief annoyance, which can cause sleep loss, as well as misery severe enough to distract from normal activities. Hives are sometimes associated with angioedema, which is swelling in certain areas, such as the throat and windpipe, which can be fatal. Extensive hives, with leaking of fluid out of the blood vessel’s can also cause low blood pressure, which can be fatal, especially if you’re in a precarious situation, such as swimming.

The topic has been increasingly understood, and therefore growing increasingly complex, and I will only touch on some high points. I would recommend the review of Dermnet from New Zealand, which is included below if you want more complete and reasonably understandable information.

I have had hives only one time, after being stung by a bee for the third or fourth time. Within a few seconds, I started itching all over my body, but had no dizziness so apparently didn’t lose much fluid from my blood vessels. The hives went away after taking an antihistamine. I sometimes get itchy after wearing a tight belt, which is probably caused by histamine release due to “ pressure urticaria. As mentioned in previous articles, I also get itchy skin without hives if I let my skin get too dry, helped by lubricants, and have itchy ears for which I take drops of mineral oil into my ears, and wash the wax out every few months.

Urticaria, or hives, can be in a limited  area or all over the body, can last a few days or come and go indefinitely, and can be mild or incapacitating. They can be caused by a huge variety of known things, from infections, such as upper respiratory infections, foods such as peanut, drugs such as antibiotics, contactants, such as latex gloves, and stings or other injectants, which  can generalize into severe and sometimes fatal anaphylaxis.

Adrenaline, and antihistamines, are needed immediately in these situations. You may have heard of the rapidly injectable EpiPen, which you must carry with you if at risk.

Often with chronic urticaria, the cause remains unknown or “idiopathic”. As an allergist, this used to drive me almost as crazy as my patients, A lot of progress has been made in the last few decades. About half of the unknown causes turns out to be antibodies directed towards the allergic antibody, IGE, which can be treated by yet another antibody, omalizumab, or some other expensive new medications.

If you have urticaria that continues, and interferes with your enjoyment of life, You can help your doctor out by carefully remembering the circumstances, under which the hives occur, and the places on your body where they are the most annoying. Ask your relatives if they have any autoimmune diseases, like lupus, or vitiligo. Know exactly what medication you are taking, and bring a list with you.

Angioedema can be fatal due to blockage of breathing and demands immediate attention. ACE Inhibitors can cause these swellings, which often occur without itching.

Once again, go to the excellent and understandable article by Dermnet/urticaria/an overview.

—Dr. C.

Basal Metabolic Rate (BMR)

Cleveland Clinic (June 9, 2023) – The truth is that your body NEVER STOPS burning calories. That calorie blaze might resemble a five-alarm fire at certain times of the day, like when you’re exercising, but the flame is always lit.

Over the course of a day, your body’s natural calorie burn without any activity can range from 1,300 to more than 2,000, depending on your age and sex. (More on that in a bit.)

So, how and why do you burn calories reading, sleeping or logging long hours as a couch potato? Let’s do the math with endocrinologist and weight management specialist Marcio Griebeler, MD.

Why your body burns calories

With so much talk about “calorie burn” focused on weight loss, the true reason behind your body’s calorie needs often gets overlooked. It’s not about the numbers on the scale. It’s about survival.

“To live, you have to burn calories,” says Dr. Griebeler. “Your body burns calories to pump your heart, to breath, to think … to do everything.”

That constant burn to keep your body going is known as your metabolism. To get a little more specific, your basal metabolic rate (BMR) refers to the minimum number of calories your body needs to function.

So, as you’re doing nothing, your body is still busy and burning calories to keep all systems operational.

Calculating your metabolic rate

While we all have a BMR, we don’t all share the same BMR. It’s not some standard formula like the Pythagorean Theorem. (That’s A² + B² = C², in case you’re rusty on your middle school math lessons.)

BMR, also known as your resting metabolic rate, varies widely based on factors such as:

  • Age.
  • Height.
  • Weight.
  • Sex.
  • Muscle-to-fat ratio.
  • Genetics.

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Lung Cancer: Advantages Of Low-Dose CT Scans

Annual low-dose CT scans are now recommended for smokers with 20 pack years, who are over 50 years of age and have stopped smoking within the past 15 years.

The screening test is progressively becoming more advisable because of improvements in technology, such as endoscopic biopsy, and improved criteria to prevent overtreating false positives.

The advantage of the test is that cancer can often be caught early, at which time 60% is curable, compared to only 7% five-year survival if the disease has spread.

It’s startling to realize how a few people take advantage of this test, currently averaging only 6%. Family practitioners have been slow to embrace this valuable preventative screening, and the American Lung association has increased It’s outreach to doctors and patients alike.

Lung cancer is still the nations top cancer threat,  killing upwards of 127,000 people in the United States each year, although the toll has lessened recently thanks to the declining smoking rates and new treatments.

—Dr. C.

Women’s Health Review: Mammogram Guidelines

Mount Sinai Health System (May 31, 2023) – When and how often to have a screening mammogram is a choice you must make. Different expert groups do not fully agree on the best timing for this test.

Before having a mammogram, talk to your provider about the pros and cons of having the test. Ask about:

  • Your risk for breast cancer
  • Whether screening decreases your chance of dying from breast cancer
  • Whether there is any harm from breast cancer screening, such as side effects from testing or overtreatment of cancer when it’s discovered

Mammography is performed to screen women to detect early breast cancer when it is more likely to be cured. Mammography is generally recommended for:

  • Women starting at age 40, repeated every 1 to 2 years. (This is not recommended by all expert organizations.)
  • All women starting at age 50, repeated every 1 to 2 years.
  • Women with a mother or sister who had breast cancer at a younger age should consider yearly mammograms. They should begin earlier than the age at which their youngest family member was diagnosed.

Mammography is also used to:

  • Follow a woman who has had an abnormal mammogram.
  • Evaluate a woman who has symptoms of a breast disease. These symptoms may include a lump, nipple discharge, breast pain, dimpling of the skin on the breast, changes of the nipple, or other findings.

Review: Gastrointestinal Bleeding Management

Upper gastrointestinal bleeding (UGIB) refers to gastrointestinal blood loss whose origin is proximal to the ligament of Treitz at the duodenojejunal junction. Acute UGIB can manifest in a variety of ways, with or without hemodynamic compromise, including hematemesis, coffee-ground emesis, the return of bright red blood through a nasogastric tube, melena, and, rarely, hematochezia (bright red blood per rectum). Hematochezia is typically only seen with an extremely brisk UGIB; significant hemodynamic compromise is common in these patients.[1][2]

Causes are multiple, but in developed countries bleeding is usually secondary to peptic ulcer disease (PUD), erosions, esophagitis, or varices.

UGIB results in more than 250,000 hospital admissions annually in the US, with a mortality of up to 11%.[3][4] Ordinarily, mortality is secondary to hypovolemic shock. Rapid evaluation, hemodynamic resuscitation, and appropriate pharmacologic and endoscopic interventions are the cornerstones of therapy.

Immune System: Is It A Guard Dog Or Wolf?

Without an immune system, we wouldn’t be here. Even the simplest creature, like bacteria, have types of defensive systems.

However, as we learned with Covid, the immune system can become mistimed, and be a detriment. Covid retards the innate immune system, and unleashes it later on when it no longer serves a useful purpose and actually damages tissue. In certain illnesses, like the common cold, most of the symptoms are actually CAUSED by the immune system.

in the case of allergies, symptoms are caused by the operation of our th2 immune system against a harmless entity, like pollen. With organ transplantation, our immune system recognizes the transplant as foreign; it has no reasoning capacity to realize that the transplanted tissue is necessary for us to live, and  to proceeds to reject the transplant.

In the case of the previous post, hydrocortisone, the prototypical shotgun that tamps down the immune system, benefited severe pneumonia.

With public health, immunizations, and a clean environment, infection is no longer the big killer is once was. Our immune system, designed to defend against a much more infectious world, is currently a real source of danger and disease.

Just like our coagulation system, once critical to stop the more frequent blood flowing in a violent world, Is now a bigger danger than ever because of our development of atherosclerotic blood vessel disease as we live longer.

Anticoagulants and anti-immunity treatments, some of them very expensive, are finding increased utility.

Please press the magnifying glass on the green field, and type in “immune system”. There are a number of previous posts of a more specific and detailed nature.

— Dr. C

Empowering Patients Through Education And Telemedicine