With mirth and laughter, let old wrinkles come

“Bear with my weakness. My old brain is troubled. Be not disturbed with my infirmity”, says Prospero in Shakespeare’s Tempest. But at what age does one become old? And if we could answer that without resort to comparisons would it be a useful thing? Or does it, in fact, require perspective to sort it out? The famous passage in the King James version of the letter Paul wrote to the biblical Corinthians declares, ‘When I was a child, I spake as a child, I understood as a child, I thought as a child: but when I became a man, I put away childish things.’ Really? I’ve always thought of the journey through the years as more the chiaroscuro in a painting. I can still see shades of childhood, despite my age, in the bright colours of a laugh, or the shadows of a memory. Indeed, I’ve come to see my life as a pentimento -nothing wasted, nothing forgotten, merely painted over as best I could.

I am drawn, therefore, to others who recognize their own plasticity and smile when the veneer of time is chipped. The patterns underneath persist -or would, if encouraged with a little wipe. It has become fashionable to talk of today’s ‘seventy’ being our parents’ ‘fifty’, although, again, a comparative rather than an established fact. A trope, rather than a datum. But, there are hints that this is changing, as an article in the BBC reports: http://www.bbc.com/news/health-43308729

‘Doing lots of exercise in older age can prevent the immune system from declining and protect people against infections, scientists say. They followed 125 long-distance cyclists, some now in their 80s, and found they had the immune systems of 20-year-olds.’ As a long-time runner, and avid cyclist, I am happy to hear this kind of thing.

‘Prof Janet Lord, director of the Institute of Inflammation and Ageing, at the University of Birmingham, and co-author of the research, said: “The immune system declines by about 2-3% a year from our 20s, which is why older people are more susceptible to infections, conditions like rheumatoid arthritis and, potentially, cancer. Because the cyclists have the immune system of a 20-year-old rather than a 70- or 80-year-old, it means they have added protection against all these issues.”

‘The researchers looked at markers in the blood for T-cells, which help the immune system respond to new infections. […] They found that the endurance cyclists were producing the same level of T-cells as adults in their 20s, whereas a group of inactive older adults were producing very few. […] A separate paper in Aging Cell found that the cyclists did not lose muscle mass or strength, and did not see an increase in body fat – which are usually associated with ageing. “You don’t need to be a competitive athlete to reap the benefits – or be an endurance cyclist – anything which gets you moving and a little bit out of puff will help.”‘

A few months ago I was driving back from a day of cycling along some forest trails in the mountains, and feeling rather smug that I had managed to avoid the rain now pounding down on the car. I was still on a narrow, pot-holed asphalt road winding through the trees, and even though my bike was securely fastened to the rack on the trunk, I had to drive slowly. Visibility was limited because of the meandering road in the rain, and more than once I confused a tree, waving its limbs in the wind, for someone standing along the side of the asphalt wanting a lift.

And then I saw him -or rather it: a figure walking slowly along the side of the road with its head down. It didn’t acknowledge my approach, and I couldn’t really tell if we were heading in the same direction. The figure was sodden in the driving rain and walked with a pronounced limp. Wearing a rather thin jacket and a toque, it slogged doggedly on as if it didn’t mind the weather.

I don’t usually offer rides to hitchhikers, and especially not here in the wilderness, but sometimes conscience beats down harder than rain. I slowed, and rolled down my window enough to shout at the bedraggled figure. On first glance he appeared to be a thin man, but as I stared inquisitively I could see long grey hair streaming across the face, almost covering a pair of bright, but suspicious eyes inspecting me.

“Do you want a ride?” I yelled, trying to be heard above the din of rain pounding on the metal of my car.

The eyes, alternated between wariness, and disinterest as they inspected first me and then the car. And finally, when I could see them resting on the bike on the trunk, they suddenly softened. “Yes… Thank you,” said a very female voice.

We were both silent for a while as we wound along the endless sinuous road, each of us waiting for the other to speak. Finally, my curiosity won out. “So, why were you walking along a lonely forest road, so far from town?” I asked. She was probably in her nineties and certainly not dressed for the weather.

Her eyes made the trip to my head at last, but danced about trying to find a place to settle. Finally, they chose my cheeks. “I try to go for long walks each day…” she said slowly, obviously trying to decide how much to tell me. She was, after all, a vulnerable elderly woman, in a car with a stranger.

I smiled. “I was out for a rather long ride today myself,” I said, trying to open up the conversation further.

She smiled in return and stared out of the window at the rain for a while. “My husband and I used to ride our bikes every day -even in the snow…”

She trailed her sentence off again, like she didn’t know how much she should reveal to me. “And now you walk?”

She nodded and I could see her sigh with the memory. “My husband had an… accident,” she said, looking out the window again.

“I’m sorry.” It was the right thing to respond, I suppose, but it sounded so anemic, so empty, in the full fury of a May storm.

She looked down at her lap, her face contorted for a second before she wiped her cheek with a damp sleeve.

I glanced at her out of the corner of my eye as I drove slowly and carefully along the bumpy road through the increasing fury of the wind-driven rain.

“We didn’t mind the rain,” she began again. “It was a challenge to see how far we could get before one of us noticed the other was tired. Neither of us would ever admit we were, of course.” She sighed again, this time deeper -as if it was a relief valve for things that were building up inside her. “But we always looked out for each other.”

I was concentrating on the road in the worsening conditions, but I could tell she was watching me carefully.

“We were always like that,” she continued, as if she had to let me know. “We’d ride until we were exhausted.” I could feel her eyes poking at my cheeks like little birds. “In our younger days, we’d take a tent and strap some supplies on the bikes and just take off. It didn’t matter where… Just to be together on a new adventure, not knowing where we’d end up…” She sighed again -this time loudly. Then she was quiet, as we both listened to the rain on the windshield and the wipers pretending to help.

“I really miss him,” she said suddenly, her voice barely audible as the car visibly shivered in a gust of wind. “It will be a month tomorrow since he died…”

I risked a glance at her. Sorrow was written like a paragraph across her face, but her eyes were resting on me in a coda of gratitude, and I think I blushed.

She took a slow deep breath and exhaled it softly. “I wasn’t going to turn around, you know,” she said, suddenly. “I was just going to keep going…” A gentle smile slowly formed on her lips and she closed her eyes and sat back on the seat, relaxed and relieved that she’d been able to talk about him. “Then I saw your bike…” she sighed again. “He had one just like it.”

And then uncertain quite what to do, she reached out and touched my arm. “I know he was telling me to turn around…”

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The Colour of my Baby

What a great idea: a bandage that tells you when what it is hiding, is itself hiding something –an infection.  http://www.bbc.com/news/health-34808273

I suppose it was an idea looking for a platform. When bacteria are growing, they often invent ways to keep doing just that. Sometimes they overwhelm by sheer numbers to defeat the body’s defences, at other times it’s toxins that break down tissues and help them invade. The body, for it’s part, has its own bag of tricks. In the end, infections are often simply a kind of parry and thrust contest –a fencing match, if you will.

Most bodies are not unduly challenged by wounds, however –keep them clean and cover them with some sort of dressing, and they heal. Antibiotics are seldom required. The problem, of course, is that sometimes the foes are not evenly matched. People on immune suppressants (transplant patients), or those with already compromised immune systems –whether from disease or immaturity (babies, for example)- may not be able to mount a suitable response to bacteria in a wound and are at risk of severe infections. These are the ones in whom a timely and appropriate antibiotic would be prudent.

Sometimes, though, antibiotics are used like soap: if it looks dirty, or if it might turn out to be dirty, why not use an antibiotic? Just in case. Well, the simple answer is that the body is usually pretty good at dealing with bacteria. After all, we are all exposed to bacteria from day zero. It starts with the journey down the obviously non-sterile birth canal, and progresses to crawling along things, tasting things… none of which could be said to be free of bacteria of some sort or other. Bacteria are what we do, where we live… Bacteria live in our mouths, in our bowels, on our skin. There are more bacteria in our intestines than cells in our bodies; we simply cannot get rid of them all.

Nor should we. I’ve written before about the benefit of these usually commensal creatures and the benefits they provide both for continuing health and development: https://musingsonwomenshealth.wordpress.com/2014/05/15/the-human-microbiome/

But let’s not be naïve about bacteria –they don’t give a fig about us -they are amoral. A bacterium prefers to live with others –family. They grow and prosper with no regard for boundaries or house rules. Without suitable checks and balances they would take over. Like pouring water in a cup -too much and it merely overflows the constraints and moves on. That’s an infection. That’s when the body may need some help.

The trick is obviously intervening when it is necessary, but monitoring when it is not. Why? Well, treating every wound, say, with an antibiotic might get rid of the truly sensitive bacteria, but leave behind those that don’t respond quite as easily or quickly. The result of the treatment may therefore be to select for those bacteria that don’t mind the antibiotic –the resistant organisms. That’s how it happens.

So in those people who may not be able to deal with bacteria efficiently, it would be helpful to know when –or if– to intervene. That’s where the bandage that changes colour when bacteria in wounds begin to proliferate and infect would be helpful. There are other ways, of course: the old Latin aphorism I was taught in medical school, for example: Tumor, Dolor, Rubor, Calor – Swelling, Pain, Redness (inflammation), Warmth (infection). But sometimes it’s nice to have another tool in the kit that may detect a problem earlier -before these signs are present. Or, in the case of a body incapable of even producing the signs- when an infection would be catastrophic.

Clearly a lot of work needs to be done to detect the mischief of different types of bacteria –they don’t all produce toxins, and even if they did, there would likely be differences in their structures that would have to be accounted for in the detection mechanism. But this may be the bandage of the future –a Facebook band aid that is constantly posting. Almost like refrigerators that tell you what you need, or coffee pots that turn on when they hear the toilet flush in the morning. A brave new world.

It is ‘a hit’, as Osric, a courtier, says of Hamlet’s thrust as he is dueling with Laertes, ‘a very palpable hit.’ Let us hope so.

 

Fertility options

Some people would do anything to become pregnant: undergo painful procedures, borrow money, mortgage their homes –anything, it seems, to have a child. While this is certainly understandable –parenthood is perhaps the raison d’être of our genes- it seems a shame that fertility would be something denied to some while granted to others. Arbitrary at first  glance, it sometimes remains so even after extensive investigations. And yet there has been a lot of progress in understanding the mechanisms that both allow fertilization to occur and, maybe even more importantly, implantation of the egg and subsequent successful development of the pregnancy.

Obviously, there is a whole cascade of events each having to unroll in the proper order –such things as development of a viable and healthy egg in the ovary; its ovulation and successful encounter with a (hopefully) normal sperm; a clear and unimpeded route to an appropriately developed uterine lining… And these are just the early requirements for the long journey to l’accouchement. But, like a planning a trip, it is more likely to arrive at its destination if the car is sound and there is gas in the tank.

There are many roadblocks along the way, however, not the least of which are the body’s defence mechanisms which try to destroy foreign proteins that might pose a risk to the health of the organism. A fertilized and developing egg contains a mixture of just such foreign material from the male, and so in some cases might be construed as an attack. Although the uterine cavity is designed as an immunologically privileged site to thwart such a mistaken identity, for some reason it doesn’t always work. While this can be a subtle issue and difficult to detect, it can be an even more difficult thing to correct. There have been attempts to do this with medications to increase success during IVF (in vitro fertilization), but with few breakthroughs so far.

Sometimes my patients know more about this than I do, or perhaps pay more attention to disparate media reports that view every paper published, even in obscure journals, as fodder -landmark achievements. The job of journalists is to interest their readers, not to critically analyze the data and research whether or not the findings were merely a one-off that has not been validated by others in the field. A crash is news; a non-crash is not. Or am I being too cynical?

Last year, I remember seeing Janice, a woman who had been trying to become pregnant for several years. She told me that all of her tests that her GP had ordered had been normal as were those of her partner. Because she was already approaching 40, I immediately suggested that she would likely benefit from being assessed at an infertility clinic to see if they could expedite things. I wasn’t sure that I could help.

She shook her head. “I’ve already been to a clinic…” she said, with a sad expression on her face. “They wouldn’t listen to me.”

“Listen to you? What do you mean?”

She probed my face with her eyes for a moment to see if I was likely to listen to her. Then, apparently reassured, she sighed and sat back in her chair. “Well when they saw the normal test results they added their own versions of the same things but still couldn’t find anything wrong. So they suggested IVF. Time’s running out, they said.” She straightened in the chair and uncrossed her legs. “We can’t afford IVF,” she said, all the while staring at her lap where she was alternately wringing her hands and straightening the fabric of her dress. “They basically shrugged and told me to think about it and come back if I changed my mind.”

I waited for her to continue. There must have been some reason her doctor had referred her to me.

“Anyway,” she said after a long thoughtful pause and a quick gulp of air, “I went on the internet to do some research on other options…”

I managed to stop my eyes from rolling but I have to admit she caught me holding my breath. I never know how to react when a patient innocently offers a totally unorthodox and largely un-researched idea that they’ve found on some website lying in wait in a dark corner of the web.

But she noticed my expression and chuckled at my obvious discomfort. “You must get this all the time from desperate women, eh?” I smiled, embarrassed at being caught. “I’d been trolling through some weird stuff and then noticed a reference to a paper published in the journal Science –it was dated 2015, so not very old. It was only the abstract, though, and I wasn’t really all that sure that I understood it correctly…” she said, no doubt to head off any criticism before I could formulate it. “But there was also a reference to a BBC article talking about it so I looked at that as well.” She handed me a piece of paper with its address so I could look it up as well:  http://www.bbc.com/news/health-34857022  and then to show she meant business, the abstract from Science: http://www.sciencemag.org/content/350/6263/970

When I didn’t immediately punch it in on my computer, she decided to explain. “There’s a parasite that increases a woman’s fertility, doctor,” she said, now intently studying the panoply of expressions that flitted, untended, in quick succession across my face. “Not all of them do, of course,” she added quickly, to show me that she wasn’t that foolish. “I mean, I don’t want to try one, or anything. I just wanted to know what you thought of the idea.”

While I gathered my thoughts, she explained. “I went back to the fertility clinic and asked their opinion about the worm… Ascaris lumbricoides –I memorized the name,” she said and immediately blushed. “Anyway, when I mentioned it to the clinic doctor, he just laughed at me. I don’t think he meant to, but it just kind of escaped from his face before he could stop it…” Janice suddenly leaned across my desk with a serious look on her face. “Of course I thought the doctor was being rude and dismissive, so I walked out on him and headed over to my GP’s office. At least she was more patient with me, but I could still read the disgust in her eyes. We managed to talk about it for a few moments, and then she decided to refer me to you. You’d listen, she assured me and then walked me out of the room…escorted me, almost. I think she just didn’t know how to handle the idea so she passed the buck.”

There was a sudden twinkle in Janice’s eyes that I almost missed –a mischievous expression that flirted briefly with her mouth, then disappeared. “My GP obviously didn’t think I needed an urgent appointment –although I did remind her of my age- so it took me a while to get in to see you.” She smiled a more ordinary smile this time, although it was still nuanced. “Several months, in fact.” I could hear the italics around the word from across the desk. “You’re a busy man, doctor.” I think I blushed.

She waited for a moment to let the thought embed itself in the desk. “So, what do you think of the worm idea?”

I struggled for words initially. It was an unusual idea, but I remembered a brief flurry of rumours when I was in medical school about fashion models infecting themselves with intestinal parasites to help them to stay thin. Perhaps they were just that: rumours, but the idea at least was not without precedent. “Well, I suppose if we could be sure that it wouldn’t affect the developing baby in any way… or you!” I paused for effect. “And that we could reliably get rid of the parasite when it had done its job –again without harming you or the baby- then…” I had run out of words. I had no intention of endorsing the idea, but I didn’t want to dash her hopes entirely. Hope is what keeps us going. I leaned across the desk towards her and smiled. “Let me just say that if you were my daughter and you had honoured me by asking for my opinion, I would have to say that some things are just not worth the risk.”

“You mean you’d advise against it?” She seemed relieved.

I nodded carefully, sensing I was being led into a trap.

A smile almost split her face in two and her eyes lit up and sparkled like lights on a Christmas tree. “Well, I’m pregnant now,” she said, italicizing the important word again and leaning across the desk as well. “It took so long to get to see you, I thought I’d use the time constructively.” My eyes must have betrayed something, because she suddenly extended her hand and grasped my arm. “Don’t worry, doctor, my husband and I decided against the worms. He said he was really worried about them…”

I relaxed my expression and was about to say something about a caring partner, when I noticed another twinkle in her eyes. “Yes,” she added before I could open my mouth. “He was afraid of getting them from me.”

Resistant Organisms

I’m not sure that patients are any smarter than they used to be, but they certainly come pre-loaded with more facts. Sometimes these are relevant, often they are contextually unrelated to the reason for their visit. Contiguous, perhaps, yet only distantly attached –second cousins once-removed. Sometimes they seem to be variations on a word, a disease, or a belief; Google’s explanation for one symptom drawn from a bouquet of  complaints  –helpful maybe, but only in the setting of an accurate diagnosis of the cause: the condition responsible.

This is not to admonish the patient for trying to help, nor to disparage the often disparate droplets of assistance, but merely to acknowledge that it is possible to drown in a wading pool. Quantity does not equate to quality when it comes to facts. Nor does it equate to knowledge, unfortunately. If not intelligently –knowledgeably- selected, only some of them are flowers worth looking at; most are weeds.

But weeds are often what grow the fastest, and once they’ve taken hold, they are hard to get rid of.

“My doctor told me I have yeasts,” said Janice, the tiny woman sitting across the desk from me. She had seemed pleasant enough at first, and had even smiled at me as I shook her hand in the waiting room and led her down the corridor to my office. But once  the door was closed and she was settled in a chair, her face hardened and she glared at me as if she were going to attack. She was dressed in an ankle length patterned skirt with a white blouse. It was fraying at the cuffs, but she wore it so ostentatiously that maybe it was supposed to look like that. Her brown, pony-tailed hair was pulled so tightly across the top of her head from her forehead, I wondered at first if her facial expression was because her skin was hurting.  Actually, it was anger.

I had a peek at the referral letter to soften the interrogation her face was attempting. ‘Recurrent yeast infection’ it said. ‘Nothing works’. Great: an offload.

Before I could say anything, I felt the desk move as she leaned against it to sigh. “I’ve been on at least six forums about yeast, and I’m convinced I don’t have yeasts in ‘there’. She said the word ‘there’ softly, warily, so as not to shock me. “So I didn’t take any of the medications she prescribed.” Janice studied my face carefully for a reaction. I think she was disappointed I didn’t react to the dropped gauntlet.

But it was meant as a challenge. An audit. I was being screened.

I tried my best to take a history from her, but it was like trying to pry water out of a box. She knew what she had and anything else about her that didn’t directly address it she deemed irrelevant. I could understand why her family doctor had referred her. She only admitted to feeling itchy ‘down there’, and immediately closed her eyes as if she’d given away a secret. “But there’s nothing else, doctor,” she added quickly, lest I suspect some lack of regional care on her part.

I glanced at the the referral information again, but it was running a close second to Janice in disclosures. “Ahh… well, did your family doctor send off any swabs from the area?” I thought I’d better not use anatomical terms, because she hadn’t.

She eyed me suspiciously, no doubt wondering whether I was trying to prove her wrong. Then, after a long, contemplative pause, she nodded. “Only grew normal flowers…” She considered it for a moment, “I’m sure she said ‘flowers’ but I think she used the wrong word,” she said, obviously contemptuous of anybody who would do that.

Flora, she meant,” I suggested as humbly as I could manage without laughing out loud. “The normal kinds of bacteria that grow in the region,” I added, to assuage her skeptically tight brow.

“But not yeasts,” Janice added to hammer home her point. “I’m very particular about cleaning myself, so there’s no way stuff like that could have crawled in.”

I tried not to react, and when the horror had receded from her face, I suggested I would like to see if I could resolve the issue for her, once and for all.

Another suspicious glance, a moment of closed-eyed silence, and then a nod. “But I want your nurse in with us,” she managed to whisper through gritted teeth and lips that looked as though they’d been sewn shut. I readily agreed; I was going to suggest it myself.

As it turned out, I was unable to find any evidence of a yeast infection when I looked at samples from the vagina under the microscope. Just some areas that appeared white, like a thin veneer on the skin near the vagina. She was so elated at the vindication and the wisdom of those online forums that she even agreed to let me do some cultures and a couple of biopsies.

A different Janice walked through the door a week later to discuss the results. Her face was relaxed, and so was the hair that now hung loosely and in curls to her shoulders. No more frayed blouse, no ankle length skirt –just jeans and a grey, baggy sweat shirt. Maybe it was the real her.

“Well, doc, what’s the news?”

“No yeast,” I answered, scanning the reports. “And no STIs,” I added with a grin, that was magnified by a chuckle on her part. “No cancer…”

She sighed loudly and a bit theatrically. “I didn’t come back here to discuss what I don’t have, doctor.” But she said it with a twinkle in her eyes. ‘At least we don’t have yeasts,’ they whispered to each other almost conspiratorially, as only eyes can do.

“The biopsies showed a skin condition called lichen sclerosus,” I explained. “It’s a thinning of the skin, probably caused by the immune system…”

“Not an infection?” She was immediately suspicious again.

I shook my head.

“So what’s the treatment?” Wariness once more surfaced on her face, hardening it into little wrinkles.

I smiled to diffuse the tension. “A steroid ointment you have to apply daily to the area for a few weeks. It turns off the immune response causing the skin problem.” I had to tread a bit carefully with this; to tell the truth I wasn’t sure this was the entire mechanism.

“Does it affect yeasts?” her face knotted up even further. “Because you have to be careful about that, you know.”

I raised an eyebrow as a form of silent question –one that I hoped would encourage her to expand on her concern.

“You know what we’re doing to bacteria..?” I wasn’t sure whether she wanted me to answer, but fortunately she resolved the question by answering it herself. “We use so many antibiotics we’re encouraging resistant germs: Superbugs!” She said the last word with such horror, it was as if she had just mentioned the Devil. I almost expected her to cross herself as a protection. “It’s all you read about nowadays. And we’re running out of effective antibiotics!” She stared at me with needle eyes, daring me to contradict the wisdom of her forums.

I scuffled around inside my head for the proper expression to wear. I finally settled on a serious, yet hopeful demeanor. Then I decided to draw her out. “Yeast are not bacteria, Janice… And anyway, they’re not your problem.”

“Doesn’t the immune system keep yeasts in check?”

“Well, in the vagina, lactobacilli help a lot…”

“What about people who get AIDS? Don’t they get overwhelming yeast infections?” She crossed her arms, certain she’d scored a point. “And don’t they have a turned-down immune system?” she added as a finishing coup.

I sat back in my chair, wondering where she was going with this. “And what is it you are concerned about, Janice?” I said when she seemed satisfied she had bested me.

Superyeasts!” she answered defiantly. I could almost feel the italicization.

I had to chuckle; I couldn’t help myself. “You mean a yeast infection that is resistant to every known treatment?” I knew I was going to need to look that concept up later.

She nodded, satisfaction written across her body in bold letters. “Can you imagine a life lived with a permanent itch? Where scratching doesn’t work?” She had finally made her point –and, she hoped, maybe another convert. She knew she had to spread the word. Save the world from resistant stuff…

http://www.ncbi.nlm.nih.gov/pubmed/17906120 Candida drug resistance

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC105901/  Candida resistance in HIV