Dear Doctor: I've suffered joint pain for years. Being prescribed 15 milligrams of meloxicam has been wonderful. What are your thoughts on meloxicam use?

Dear Reader: Meloxicam (Mobic) is a non-steroidal anti-inflammatory drug (NSAID) that, like all such drugs, inhibits the formation of the enzyme cyclooxygenase (COX). This inhibition leads to a decrease in the production of molecules that boost inflammation and help the blood clot.

There are two forms of the COX enzyme, aptly named COX-1 and COX-2. COX-1 is involved in protecting the lining of the stomach, promoting the blood's clotting ability and aiding kidney function. COX-2 is involved in the inflammatory response in the body. Many of the side effects seen with older NSAIDs such as ibuprofen, naproxen and diclofenac are related to the inhibition of COX-1. The side effects include gastritis or gastric ulcers, blood thinning and kidney damage. Inhibiting COX-2 leads to a decrease in inflammation and a decrease in pain.

Meloxicam at low doses (7.5 milligrams) inhibits COX-2 and not COX-1. That means it can reduce pain and inflammation without irritation of the stomach lining or an increased risk of stomach ulcers. Research has found that serious upper gastrointestinal events at the 7.5 mg dose occur in fewer than 1 in 3,000 people. But note that follow-up studies didn't last more than 60 days, so it's unclear if these rates would hold up over the long term.

Further, at low doses, meloxicam may not trigger the kidney problems that other NSAIDs cause. The rates of heart attacks appear comparable to those of other NSAIDs, with a slight increase in risk at all doses.

However, when meloxicam dosage is increased to 15 mg, the medication does inhibit COX-1, leading to a significant increase in the rates of serious upper gastrointestinal events.

One study found that, while the number of events was less than with the NSAID naproxen, the number of events at 15 mg was six times higher than the lower dose of meloxicam (1 in 500 people). Another study showed a greater proportion of people taking 22.5 mg of the drug for 12 weeks had a slight decrease in kidney function. This was not seen at the 15 mg dosage.

Lastly, for people on two types of blood pressure drugs -- ACE-inhibitors and angiotensin receptor blockers -- meloxicam (like other NSAIDs) may make those medications less effective.

In summary, meloxicam works well for pain and swelling. The higher doses do decrease pain more than the 7.5 mg dosage, and the medication is comparable to the NSAID diclofenac for both pain relief and decreasing inflammation. I have frequently recommended the medication for joint inflammation, bone bruises and pain from fractures and tendonitis, and it's worked well for the majority of my patients. For older adults, I lean toward the 7.5 mg dose, but I have recommended 15 mg in more severe cases. Some of the latter group have complained of gastrointestinal discomfort, but this stopped when they discontinued the medication. I rarely give this medication for greater than one month, but have had some patients with severe arthritis who have been on this medication for years.

I don't know how frequently you are using meloxicam, but if you're using it on an as-needed basis, it should be safe. If you're using this medication daily, you should consider its potential for side effects.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: I've been hearing on the news that researchers have discovered that when stress causes a heart attack, it all begins in the brain. How does this work? And is it even possible to control the way our brain responds?

Dear Reader: Before we dive into the details of the intriguing revelations regarding stress and heart health, we'd like to share some soothing news. The same mind-body connection that researchers believe plays a role in heart attack may also offer a measure of protection through techniques like meditation, yoga and mindful relaxation.

Let's start with the known risk factors for cardiovascular disease, which have been front-page news for decades. Obesity, high cholesterol, hypertension, diabetes and smoking -- we doubt any of our readers are surprised by that lineup. And while mental and emotional stress have long been suspected to contribute to heart disease, the exact mechanism has remained a mystery.

Now researchers from Harvard Medical School have identified the part of the brain that plays a significant role in cardiovascular disease. Known as the amygdala, it's a small, almond-shaped area associated with processing emotion. The amygdala receives and interprets input from throughout the brain. When incoming signals point to danger, the amygdala reacts instantly, bypassing conscious choice. It sets the sympathetic nervous system, which regulates the fight-or-flight reflex, into action.

Using imaging techniques to measure brain activity, the researchers could link increased activity in the amygdala to increased production of white blood cells by the bone marrow. This led to inflammation in the arteries, which is a risk factor for heart attack and stroke.

The good news is that by using techniques to reduce the stress response, we not only feel more calm and serene, but the benefits can also extend to cardiovascular health. So be good to your amygdala (and to your heart) and consider some options.

Many workplaces, community centers, university extension programs and senior citizen centers now offer stress-reduction programs. At the very least, they will bring you together with like-minded individuals. Social isolation is associated with increased stress, so simply becoming part of a community with a common goal is a step forward.

Yoga has long been shown to reduce stress and promote physical, emotional and mental well-being. In fact, studies show that individuals who practice yoga regularly have lower levels of certain stress chemicals in their blood than those who don't do yoga. And although many forms of yoga have sprung up over the years -- some of them quite fast-paced and with a mindset that is almost competitive -- we recommend the gentle and measured approach of basic hatha yoga.

Meditation is also quite effective at reducing stress. Again, studies have shown that people who meditate regularly for just as little as 20 minutes per day reduced their blood pressure and reported feeling less stressed than did their non-meditating counterparts.

Tai chi, Pilates and deep breathing are also good for stress reduction. And don't forget the healing power of the natural world. A contemplative walk in the woods or a park will help you leave your worries behind.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctor: One of the schools in my area has been the focus of news reports about a bacterial meningitis case. How contagious is this disease?

Dear Reader: Bacterial meningitis cases in school-age children, adolescents and college students are predominately caused by two different organisms: Streptococcus pneumoniae and Neisseria meningitidis. Streptococcus causes nearly 50 percent of meningitis between the ages of 2 and 18, while people in their teens and college years face an increased risk of meningitis caused by Neisseria meningitidis. In fact, 46 percent of meningitis cases between ages 11 to 17 are due to N. meningitidis.

The Streptococcus pneumoniae bacterium is spread by close contact with people who cough or sneeze. Upon inhalation, the bacteria adhere to the back of the nasal passage in an area called the nasopharynx. Normally, there the bacteria sit, colonizing the nasopharynx without causing any problems. A study of 2,799 Italian children younger than 7 years of age found that 8.6 percent had S. pneumoniae colonizing the nasopharynx; the biggest risk factor for colonization was a sinus infection over the previous three months.

In most people with this colonization, the immune system keeps the bacteria from invading the cells of the body. However, when the immune system is weakened or when the body is fighting a viral infection, such as influenza, the bacteria can then invade the cells. From there, the bacteria can enter the bloodstream and cross through the blood-brain barrier, replicating readily in the cerebrospinal fluid, leading to the symptoms of meningitis.

The Neisseria meningitidis bacterium is passed from one person to another by secretions from coughing or by saliva from kissing. It's also passed easily among people in close contact. Like Streptococcus, Neisseria also settles in the nasopharynx, where the immune system similarly keeps the bacteria from invading into the cells of the body. People can carry the bacteria for several months within their nasopharynx and unwittingly pass it on to others.

In fact, 5 to 10 percent of people in the United States carry this bacteria in the nasopharynx. Military recruits in closed quarters can have carrier rates up to 40 percent. College students in dormitory situations have carrier rates of 14 to 34 percent. If one person develops meningitis from N. meningitidis, other people with whom they are in close contact are at greater risk.

Again, the bacteria that cause meningitis are quite contagious, but a person's general risk of developing the illness is very low. In addition, children and adolescents are vaccinated for three types of bacteria that can lead to meningitis: Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b. These vaccinations have significantly decreased the rates of meningitis, so make sure that your child gets these vaccinations.

Lastly, if your child has been exposed to somebody with meningitis, watch for fever, neck stiffness and lethargy. If he or she begins to exhibit these symptoms, all potential signs of meningitis infection, take him or her to a doctor as soon as possible.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)