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Paradigm Shifts

By Dr. Jim Ferguson

“The questions never change, just the answers.”  Sometimes I don’t remember if I’ve written something, read it somewhere, or just thought it.  Perhaps my stories and life  have merged into one composite.  You need to pray for my wife, Becky, because she’s my sounding board as well as my “editress.”  She’s very patient with her contemplative husband.  I trust her opinions, especially grammatical ones, and I trust her to tell me when I’m way off base.

I’ve repeated the quote above so often that I considered it mine.  However, to be sure I Googled the quotation and found a similar quote by Albert Einstein.  I’ve observed that very few thoughts have not been thought before.  Case in point “my” quote that was actually Einstein’s.

The experts of hypertension have again spoken.  For almost forty years the JNC or Joint National Committee on hypertension has published guidelines about every five years on the prevention and treatment of hypertension.  JNC 8 is now belatedly here and replaces JNC 7 which we’ve used since 2003.  The reason this is an important issue is because about 30% of Americans have hypertension, a persistently elevated blood pressure, that accelerates vascular disease and kidney failure.

I won’t bore you with the science or the rigorous methodology behind the recommendations, but I will emphasize the word “guideline.”  The major take home points of the JVC 8 are simpler guidelines and a somewhat more pragmatic approach to therapy goals.  In this day of government mandated “metrics” that purport to define “best care,” practitioners run the risk of treating the number instead of the patient who is, after all, unique.  A fragile eighty year old does not need to trade perfect blood pressure readings for a fall precipitated by an excessive drop in blood pressure when she stands.  Additionally, the experts now say a blood pressure of 150/90 instead of 140/90 is the threshold for treatment in those sixty or more years old.  The guidelines also recommend that younger patients and those with diabetes and kidney disease begin treatment when blood pressure readings rise consistently beyond 140/90.

The academic phrase for a changing model or concept is a paradigm shift.  This phrase  does have a nice ring and is undeniably erudite phraseology.  I thought I understood the modern concept of heart attacks.  Apparently, I only understood the physiology of Type I myocardial infarction.  This occurs when a fatty plaque within a coronary (heart) artery ruptures and is complicated by a blood clot that occludes the vessel.  Cardiologists now recognize Type II heart attacks which can occur in normal coronary arteries.  The mechanism is a significant drop in blood pressure which leads to insufficient blood flow through the heart arteries, depriving the heart muscle of oxygen and nutrients.  The same imbalance of supply and demand can occur with a sustained, rapid heart rate.  I was certainly surprised to learn that perhaps 25% of heart attacks are of the Type II variety and not caused by the usual mechanism.  I guess the answers do continue to change.

As I’ve said in previous essays, I’m a fan of the Seinfeld show.  One of my favorite characters is George’s father, Frank Costanza.  I remember one show where Frank defended the twin beds in his bed room.  Apparently, his wife, Estelle, has “the jumpy legs,” which disrupts Frank’s sleep.  “OK, Ferguson, where are you going with this?” you ask.

Restless legs syndrome (RLS) is not an uncommon malady.  As many as 7% of Americans and Europeans have this disorder that was described in 1945 – or perhaps as early as 1672!  Some doctors even doubted their patient’s complaints until 2011 when RLS was codified as a true disorder and renamed Willis-Ekbom disease.  The condition causes an urge to move the legs, relief when the legs are moved, and worsening symptoms with rest and at night.

No one understands the cause of this problem, but it has been associated with iron deficiency as well as problems of neurotransmitter dysfunction.  Our nervous system is an interconnected neural net of 10 billion nerve cells.  Imagine an octopus with eight arms.  Now imagine a nerve cell, with a body analogous to an octopus, but possessing  hundreds of arms all reaching out to touch the tentacle tips of its neighbor.  The nerve cells signal each other by releasing chemicals (neurotransmitters) at the tentacle tips.  There are five or more families of neurotransmitters including dopamine, the one thought to be dysfunctional in RLS, but also problematic in Parkinson’s disease.  Other neurotransmitter associated diseases include Alzheimer’s disease and depression.

Even the treatment for RLS is problematic.  It is important to look for and correct iron deficiency as a prelude to other remedies.  The mainstay of RLS treatment has been drugs that modulate dopamine function.  These help, but strangely they can lead to worsening of the condition over time referred to as augmentation.

A new therapeutic option comes from a Johns Hopkins’ study which demonstrates that the drug Lyrica (pregabalin), used in another enigmatic disorder, Fibromyalgia, is more efficacious than other agents.  Unfortunately, Lyrica can also be associated with augmentation, so more work is necessary to understand the illness and hopefully design better therapies.

The final take home lesson is that you never quit learning.  In fact, a friend of mine often quips that “you’re either growing or you’re dying.”  I suspect he’s right, and there’s no rest for me in these shifting paradigmatic times!

 

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