January 27, 2012 | 6:46 pm

Major Study Examines Causes of Morgellons

Posted by Albert Fuchs, M.D.

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CDC headquarters in Druid Hills, Ga. Photo by Wikipedia

The name Morgellons originated in 2002. That year a mother took her young son to doctors reporting that he was complaining of “bugs” in his skin. He had sores under his lips and the mother reported seeing fibers in these sores. She named her son’s illness Morgellons and started a website to raise awareness and research funding for the disorder. The boy’s doctors found no specific abnormality and believed that the mother was suffering from a psychiatric condition.

Since then many patients have presented to medical attention reporting disturbing skin sensations (sometimes described as something crawling on top of or under the skin), skin sores, and various forms of solid material coming out of their skin, frequently fibers or threads. Many of the physicians examining these patients believed that they suffered from delusional infestation (also known as delusional parasitosis), a disorder in which patients are convinced that they are infested with parasites or other germs. Delusional infestation (DI) has been described for over a century and is very difficult to treat. All tests checking for an infectious or allergic cause are of course negative, but patients are not reassured by the normal results. They are agitated that the physician has (again) failed to discover the cause. The patients never respond well to factual evidence arguing against their delusion and typically refuse psychiatric referral.

The generally recommended approach in DI is for the dermatologist or primary-care physician to build a trusting relationship by acknowledging the patient’s distressing symptoms and the disruption that the symptoms cause in the patient’s life. (This is neither patronizing nor dishonest. Patients with DI are frequently quite fixated on their symptoms and the disease frequently strains relationships and careers.) Rather than confront patients with the diagnosis of DI, doctors are encouraged to use the synonymous but less judgmental term “unexplained dermopathy”. Occasionally physicians are able to convince patients to try antipsychotic medications by offering them as a way to decrease the skin symptoms and explaining that others with the same disease have done well with this medication. Some patients achieve relief with these medications, though it’s not clear how frequently.

So DI is a particularly difficult condition to treat, because a defining characteristic of the condition is the unwillingness to accept the diagnosis. That makes the doctor-patient relationship very difficult, since the physician needs to earn the patient’s trust without being fully transparent. Imagine if one of the universal characteristics of diabetes was the refusal to believe that one has diabetes.

Add to these difficulties the wonders of the internet. Patients with Morgellons, feeling wrongly dismissed by doctors who diagnosed them with DI and confident that their disease is caused by an infection or an environmental exposure, have used the web to organize and lobby Congress for a study to determine the cause of their affliction. So between 2006 and 2008 the Centers for Disease Control did just that, in the largest study of Morgellons to date. The findings of the study was published this week in PLoS ONE and summarized on the CDC website.

The study enrolled 115 patients in Northern California with symptoms matching Morgellons. Patients were put through a systematized and extensive diagnostic work up, including a detailed demographic survey, a comprehensive history and physical examination, photographs of the whole body and of individual skin lesions, skin biopsies, analysis of any foreign material found on the skin, and numerous lab tests of blood, urine, and hair.

The results show that Morgellons (or unexplained dermopathy) is rare, affecting about 4 people in 100,000. Three quarters of patients are female, and three quarters are Caucasian. Most are middle-aged. The exhaustive evaluation failed to find a common infectious or environmental cause of the disorder. Significantly, the patients’ residences don’t cluster geographically, which would be expected with an infectious illness.

The skin lesions varied substantially and didn’t demonstrate one homogenous type. The location of the skin lesions was fascinating. Most arm lesions were on the back of the arms with sparing of the front surfaces. Back lesions usually spared the center of the back. Lesions that originated in the skin would be expected to be more uniform in distribution. A disease that originates with scratching otherwise healthy skin will show lesions where people preferentially scratch. Skin biopsies showed mostly the consequences of chronic scratching, bug bites, or the effects of chronic sun damage that is common in California. The fibers were mostly cotton fibers common in clothes.

Psychological testing showed abnormal attention to bodily symptoms in two thirds of patients. Half had recreational drugs detected in their hair samples.

The authors conclude:

This unexplained dermopathy was rare among this population of Northern California residents, but associated with significantly reduced health-related quality of life. No common underlying medical condition or infectious source was identified, similar to more commonly recognized conditions such as delusional infestation.

In the absence of an established cause or treatment, patients with this unexplained dermopathy may benefit from receipt of standard therapies for co-existing medical conditions and/or those recommended for similar conditions such delusional infestation.

This is very helpful information obtained through much meticulous work. But how will it be received? What happens when the internet, a global engine of transparency and information sharing, collides with a disorder that reacts poorly to the truth?

Learn more:

CDC Study Finds Fibers Aren’t Cause of Morgellons (Wall Street Journal Health Blog)
Morgellons not caused by infectious agent, CDC researchers say (Los Angeles Times Booster Shots)
CDC Study of an Unexplained Dermopathy (Centers for Disease Control and Prevention)
Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy (PLoS ONE)
Morgellons (Wikipedia)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

January 20, 2012 | 7:44 pm

How Frequently Should You Have Your Bone Density Checked?

Posted by Albert Fuchs, M.D.

A machine to measure bone density to check for osteoporosis in the elderly and other vulnerable subjects. Photo by Wikipedia/Kevin Vrrrreeeeeeeeee

Breaking a bone is frequently a catastrophic injury for an older patient. A hip fracture or a vertebral fracture frequently leads to a permanent decrease in mobility which starts an inexorable decline in health and independence. For that reason, fracture prevention is a critical part of the care of older people.

Osteoporosis, which is severely decreased bone density, is a major risk factor for fractures, especially in women over 65. Osteoporosis is also treatable, and there is good evidence that treating osteoporosis with bisphosphonates (a family of medicines which includes Fosamax, Actonel, and Boniva) prevents fractures.

So we know that testing bone density is important in women over 65. But we don’t know how frequently we should be recommending the test. Medicare pays for the test every two years, and in the absence of scientific information about how frequently the test is valuable, that has become the accepted default.

This week’s New England Journal of Medicine published a study that helps shed some light on the question. Almost 5,000 women 67 years of age older who did not have osteoporosis at the beginning of the study were enrolled. The women had periodic bone density studies for up to 15 years. The goal of the study was to find the length of time between tests that would safely detect most cases of osteoporosis before a fracture occurred.

Not surprisingly the safe testing interval depends a lot on the initial bone density. For women with advanced osteopenia*, a testing interval of only 1 year was required to detect osteoporosis in time. For women with moderate osteopenia, retesting in 4 years was adequate. Women with mild osteopenia or normal bone density could wait 15 years before the next test. The intervals also varied with the age of the women, with younger women losing bone density more slowly than older women.

These findings should be validated in large studies before put to use. But if the general theme is right, women in their 60s with normal bone density can safely defer their next test for a decade.

Learn more:

Patients With Normal Bone Density Can Delay Retests, Study Suggests (NY Times)
Many Older Women May Not Need Frequent Bone Scans (Shots, NPR’s health blog)
How Often Should Women Be Screened for Osteoporosis? (Wall Street Journal health blog)
Bone-Density Testing Interval and Transition to Osteoporosis in Older Women (New England Journal of Medicine article)
Medications for Osteoporosis (my summary in 2008)

* Definition of various levels of bone density according to T score
Bone Density         T score
Normal               greater than -1
Mild osteopenia       between -1 and -1.5
Moderate osteopenia between -1.5 and -2
Advanced osteopenia between -2 and -2.5
Osteoporosis           less than -2.5

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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January 13, 2012 | 9:51 am

Why Losing Weight Is So Hard

Posted by Albert Fuchs, M.D.

I’ve written many times that losing weight is the second hardest thing I ask my patients to do. (Breaking an addiction like smoking or alcoholism is the hardest.) The frustrating thing is how little we know about how to lose weight successfully. But we are learning more all the time about why losing weight is so difficult.

Much about dieting and weight loss is poorly understood, but let’s first lay out some facts that are well established.

Weight loss and weight gain are caused by an imbalance between calories ingested and calories burned. That’s not controversial. If you eat fewer calories than you use in exercising, you will lose weight. If you eat more, you will gain. How many calories it takes to simply maintain one’s weight varies between individuals and the mechanisms behind that variation are still being explored, but for every person there is a number of ingested calories below which weight loss will happen. That means that if someone else is in control of what you eat (for example in a prison in a totalitarian country) and doesn’t provide you enough food, you will lose weight.

That makes it sound fairly simple, right? If you eat less, you lose weight. Since eating is a volitional behavior, overweight people should simply choose to eat less, and their failure to do so simply reflects poor judgment or weak willpower.

Wrong.

Permit me a brief digression about control systems. I think about them a lot because of my engineering background. Our body has many mechanisms that very tightly regulate certain biological parameters, like the sodium concentration in our blood, or the amount of light that is shining on our retinas. Many of these mechanisms are entirely out of our conscious control. For example, if we walk into a brighter environment our pupils automatically constrict, letting less light hit our retinas. That happens without our attention or knowledge.

The control of our breathing is a very interesting example. Our breathing is usually not under our conscious control. Our brain monitors the amount of carbon dioxide (CO2) in our blood from moment to moment. When the level of CO2 increases we take a breath, lowering the CO2 level. The cycle repeats continuously even in our sleep. Without our attention or intention the CO2 level in our blood is kept within a fairly narrow range. But anyone who plays a wind instrument or sings can tell you that breathing is also volitional. You can take a breath purposefully between sentences and blow through a horn exactly when you want to. So which is it? Is breathing voluntary or not?

The answer depends on the time scale. From second to second you can control your breathing. You can hold your breath for a few seconds or you can hyperventilate for a few seconds. But over minutes you will not be able to override the drive to keep your CO2 at a certain level. That is, if you try to hold your breath or slow down your breathing over minutes, your CO2 will slowly climb and your urge to breathe faster will eventually prove to be irresistible. Similarly if you try to hyperventilate over minutes, your CO2 will fall and your urge to slow your breathing will eventually overwhelm your conscious control. So breathing is voluntary over seconds but entirely involuntary over minutes or longer.

Are you getting a sense of how this may relate to control of weight?

Long ago researchers began suspecting that there were control mechanisms responsible for maintaining weight within some range. Just as there is an internal set point for our blood sodium concentration that the kidneys maintain, and a set point for our CO2 concentration maintained by our breathing, researchers argued that there must be an internal set point for our weight. A set point simply means a normal level of some measure that a control mechanism tries to achieve – the temperature that the thermostat is set to, for example.

I first discovered the idea of a possible weight set point in a fascinating paper by Seth Roberts, a psychologist. He cites much evidence that weight must be controlled by an internal set point. For instance, many people occasionally fast for a day. This results in a small weight loss. Without an internal set point for weight, that weight loss would be permanent or would fade very slowly. But weight loss after a fast usually disappears within a few days, suggesting that hunger is increased for the subsequent few days until the weight renormalizes.

The general idea is that the quantity of fat stores in our body is monitored by our brain (perhaps using hormones released by fat cells) and compared to some set point. Whenever our weight (or fat stores) falls below this set point various hormonal mechanisms increase hunger and decrease physical activity. Research is currently attempting to unfold the details of these mechanisms. The current understanding and consequences of this theory is explained in a illuminating article in the New York Times Magazine – The Fat Trap. If you’re trying to lose weight, I urge you to read it.

The article cites several studies including a study published in The New England Journal of Medicine in October. The study enrolled 50 overweight or obese adults and for 10 weeks put them on a very low calorie diet. They lost an average of 30 lb. Before the study and periodically for a year after, the levels of hormones thought to mediate hunger and satiety were measured. The subjects were also asked for their subjective levels of hunger and appetite.

The results showed that the hormones that cause hunger and weight gain increased after the weight loss and remained increased a full year later, even after most subjects had partially regained their lost weight. More sobering is the fact that the subjects’ self-reported sense of hunger rose after the weight loss and didn’t return to baseline levels throughout the one year study.

The authors state that the result

“supports the view that there is an elevated body-weight set point in obese persons and that efforts to reduce weight below this point are vigorously resisted… suggesting that the high rate of relapse among obese people who have lost weight has a strong physiological basis and is not simply the result of the voluntary resumption of old habits.”

For now, this isn’t a particularly helpful discovery, but it helps explain a lot. It explains, for example, why the myriad diets on the market all have approximately the same lousy long-term success rates. It also explains that eating, like breathing, and like refraining from scratching that patch of eczema, is a voluntary behavior only on short time scales. I can choose whether to have a snack now or not, but I can’t choose to fast for three days or to eat much less than my caloric needs for a month.

Overweight people have a “weight thermostat” that is turned up too high. We need researchers to to find a medical solution to reset this set point or to break one of the mechanisms that mediate hunger.

The best we have to offer overweight patients at this point is the advice to diet and exercise, though in the long term this seems to be effective only for a small minority of patients. For the morbidly obese, surgery for weight loss is an increasingly evidence-based option.

Perhaps the best advice we can learn from this is to at least encourage patients not to gain more weight. We now know that losing it will be much more difficult and that maintaining the current weight after weight gain and loss will be harder than never gaining in the first place.

Learn more:

The Fat Trap (New York Times Magazine)
Long-Term Persistence of Hormonal Adaptations to Weight Loss (New England Journal of Medicine article)
What Makes Food Fattening? A Pavlovian Theory of Weight Control (Seth Roberts, unpublished paper)
My previous posts on weight loss

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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January 6, 2012 | 5:54 pm

Home Exercises or Chiropractic Care Beat Medications for Neck Pain

Posted by Albert Fuchs, M.D.

Neck pain is a very common problem. Many of us have woken up with a painful neck and found that we couldn’t turn our head because of painful muscle spasm. Doctors use various treatments for neck pain. Pain medication, spinal manipulation by a chiropractor, and physical therapy for stretching exercises are all popular remedies, but there is very little scientific evidence to support any of them. I frequently used to prescribe anti-inflammatory pain medications as an initial treatment, but not anymore.

This issue of Annals of Internal Medicine published a study that sheds some light on the issue. Researchers recruited 272 patients suffering from neck pain for at least two weeks. They were randomized to three groups, each of which were assigned a different treatment for 12 weeks.

One group was prescribed medication by a physician. Medications included anti-inflammatory pain medicines (like ibuprofen or naproxen), acetaminophen (Tylenol), muscle relaxants, and even narcotics if the doctor thought they were indicated. The second group saw a chiropractor once or twice per week for spinal manipulation. The third group met twice with physical therapists who taught them to do home exercises. They were asked to continue the exercises for the 12 weeks of treatment.

All patients were followed for a year after the start of the study to periodically measure their pain and range of motion.

Surprisingly, both the home exercise group and the chiropractic spinal manipulation group did much better than the medication group. And there was not a significant difference in outcomes between the home exercise group and the chiropractor group.

So the next time you get a crick in your neck, check out the home exercises in the supplement to the Annals study. If you can’t figure them out yourself, get a physical therapist to teach them to you. Or see a chiropractor. And I’ll still prescribe pain medicine if pressed but first I’ll recommend the more effective treatments.

Learn more:

For Neck Pain, Chiropractic and Exercise Are Better Than Drugs (NY Times, Well column)
Neck Pain? Skip the Pills, Just Stretch Like a Chicken (Wall Street Journal, Health & Wellness)
Is Spinal Manipulation an Effective Treatment for Neck Pain? (Annals of Internal Medicine, Summaries for Patients)
Neck exercises (Annals of Internal Medicine, supplement)
Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain (Annals of Internal Medicine article)
Pain in the Neck: Many (Marginally Different) Treatment Choices (Annals of Internal Medicine editorial)

Tangential Miscellany

Five years ago, I had the inexplicable and probably misguided idea that what the world really needed was one more physician blogger. In the interim I’ve been delighted to build a readership of people who send me frequent ideas for stories and lots of feedback about my posts. This is my 300th post, and I wouldn’t keep doing it without the wonderful encouragement and praise from all of you. Thank you very much for reading.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment