Sunday, 29 November 2015

How Long Should We Live?

Spending Thanksgiving with my two sons/daughters-in-law and five grandchildren made me more aware than usual about the generations, the passage of time, and mortality. Those musings led me to look at a post I'd written for the (now discontinued) Over 65 blog. I'm republishing that post followed by some further reflections:
Why I Hope Not to Die at 75
By James Sabin
I feel uniquely qualified to comment on Zeke Emanuel’s much-discussed article “Why I Hope to Die at 75.” I’m smack in the middle of the year he hopes will be his last. In addition, many years ago I wrote a book about health care organizational ethics with him (and Steven Pearson). I loved working with Zeke and admire the creative work he’s done on medical ethics and health policy.
Zeke says, correctly, that with limited exceptions, as we pass beyond 75 we typically lose physical and mental capacities, with the result, in his view, that “by 75, creativity, originality, and productivity are pretty much gone for the vast, vast majority of us, resulting in diminished productivity.” Although Zeke recognizes that we “accommodate [to] our physical and mental limitations” by diminishing our expectations and “restrict[ing] activities and projects, to ensure we can fulfill them,” at 57, he is horrified by the vision of diminution.
In Zeke’s view, to be remembered “framed not by our vivacity but by our frailty is the ultimate tragedy.” If a patient said this to me, I’d respond, “We can understand that losing vivacity and becoming frail is sad, but how can we understand why being remembered that way is ‘the ultimate tragedy’ for you?” Over the years, with patients who didn’t want to live beyond a particular age, we virtually always found highly personal fears underlying their picture of what the age meant.
We 75ers know from experience that Zeke has the facts right. I’ve experienced most of the changes he attributes to the age. But as is the case even for people who experience vastly more severe challenges than diminished aerobic capacity and declining productivity, most of us ferret out opportunities to contribute to the world and derive satisfaction. Many posts on Over 65 speak to this effort.
Zeke’s facts may be right, but what about the values he espouses? If Zeke were 17 his article would read as the exuberant outpourings of a brilliant adolescent. But he’s not 17 – he’s one of the leading bioethicists and policy experts in the world. As a result, rather than being understood for what he’s doing – presenting an unflattering view of himself in order to provoke thought in others, the Twitterati see him as telling others what values they should adopt. Even more foolishly, some claim that his highly idiosyncratic perspective, which I believe he will ultimately come to see as misguided, proves the truth of the “death panel” lie.
Many readers of Over 65 will agree with Zeke’s critique of American culture as too focused on the duration of life and too inattentive to the purposes of our lives. He calls this cultural type the “American Immortal.” But very few are likely to emulate his prediction that even if he is in excellent health at 75 he will decline all medical interventions except for relief of pain. No flu shots. No antibiotics for pneumonia.
If that view holds for the next 18 years, which I doubt will happen, I hope that when Zeke declines a flu shot or an antibiotic for a treatable infection his physician will be guided by “Four Models of the physician-patient relationship,” an article Zeke wrote in 1992 with his then-wife Linda. Here’s how they described the “deliberative model”:
“The aim of the physician-patient interaction [under the deliberative model] is to help the patient determine and choose the best health-related values that can be realized in the clinical situation . . . The physician’s objectives include suggesting why certain health-related values are more worthy and should be aspired to . . .” (emphasis added)
The values Zeke anticipates applying are not “the best health-related values” for a healthy 75 year old. It is not “worthy” to invite healthy life to end sooner than need be out of fear that we will be remembered as a frail elder, not as a vigorous youngster. That would be neurosis, not wisdom.
I mentioned above that I had the privilege of working on a project and writing a book with Zeke. I understood him to be a warm-hearted person and a gifted teacher who evinced respect and affection for a wide range of humanity quite independently of whether they were “creative” and “productive.” I believe the article he is being roundly attacked for is actually a gift. Zeke wants us to think seriously about what we value in life. By presenting views that many have found repugnant, and that I see as understandable but wrong, he’s achieving his purpose of provoking thought and discussion.
Zeke gives himself an out in the final paragraph of his long (5,000 words) article: “I retain the right to change my mind and offer a vigorous and reasoned defense of living as long as possible.” (I trust by that he means “as long as possible” in a state in which he can appreciate life and respond to others in a meaningful way.) I’m prepared to bet that when Zeke turns 75 he will no longer regard youthful vigor and stunning productivity as the only values worth living for. If I’m alive, I’ll look forward to his contributions to Over 65 when he hits that birthday in 18 years!

This morning the New York Times carried an article on "Mothering my Dying Friend." The author - Catherine Newman - presents a powerful picture of what it was like to care for her best friend who was dying of ovarian cancer at 47. It's an excellent piece. If you want to read about the experience of (a) caring or (b) dying, follow the link.

I focused on (b). To me, Zeke Emanuel's wish to die at 75 in order to avoid the waning of intellectual and physical energy, seems more like a younger man's phobia about vulnerability than wise thinking about life. But I agree with Zeke that it's important for us to think about how we want to handle aging, illness and death before trouble hits the fan.

I know from many conversations with friends in their 70s and 80s that a majority wish for a more rapid demise than Catherine Newman's friend experienced. Physician assisted suicide is the most talked about approach to hastening death, but VSED, ("voluntary stopping eating and drinking") is a more common practice. When we're close to the end of our lives, we typically experience less hunger and thirst. While some clinicians and facilities are reluctant to honor a patient's decision to stop eating and drinking, there's a strong emerging trend in law and ethics to honor VSED when chosen by competent adults, as evidenced by the strong recommendation made in a recent review of literature on the topic:
...we think that the issue of suicide, euthanasia and hastened death should not be regarded as a last resort option. They have to be discussed early with the affected persons and not in the last days of life. If options of prematurely ending one’s life are known beforehand, VSED is an expression of autonomy and control, and therefore a sign of the patient’s competence. 
Thinking about mortality over this holiday weekend led me to add a codicil to my advance directive. In an aging society, clinicians, health care organizations, and the wider public, need to reflect of values and policies. I'll be writing more about the topic in the future.

Wednesday, 25 November 2015

How to Have Your Cake and Eat it Too – Holiday Edition

Lori M. Noble, MD
Lori M. Noble, MD, a primary care physician at Spruce Internal Medicine, located at the new Penn Medicine Washington Square building, offers tips on how to satisfy your sweet tooth this holiday season - and do so in a healthy way.

Last year, I wrote a blog post proclaiming my addiction to all things sweet and shared some tips and tricks that have allowed me to satisfy my sweet tooth without breaking the sugar bank. Well, now the holidays are just around the corner and that can only mean one thing – delicious, decadent food will be all around us, just waiting to wreak havoc on healthy lifestyles everywhere (cue sinister laugh track)!

That may sound a little melodramatic, but the holidays are notoriously a time when people give up healthy eating habits because the temptation is just too great. So this year, I thought I would share some tips that will make it easier to prepare, and enjoy, all those savory and sweet holiday treats – without the guilt.

Call for a Substitute

Recipes often call for heavy, high-calorie ingredients. Most of the time, these can be substituted for much healthier options without sacrificing taste.

For instance, baked casseroles can sometimes call for as many as a half-dozen eggs. You can easily swap the eggs for egg whites (or egg substitute), which come prepackaged in affordable, easy-to-use cartons. This switch will help reduce the fat and cholesterol in many recipes.

Similarly, unsweetened apple sauce can be a replacement for oil in a one-to-one exchange in baked goods. Even that little tablespoon of oil has 120 calories. Those savings can really add up!

On the Side, Please

When preparing your next holiday feast, put all the extras on the side and allow your guests to put as much or as little as they’d like of each on their meal. That goes for dressing, sauces, gravy, extra cheese and any other condiment.

These can add many additional calories and we often don't even realize it. When food isn't smothered in these extras, each person has to be conscious about how much or how little to add and will often wind up using less.

Fruit Is Your Friend

Far be it from me to tell anyone not to indulge in a piece of pie at the end of a holiday meal. That would not be realistic. But, in order to help keep it to just one piece, load up the rest of the plate with a healthy fruit salad topped with low-fat whipped topping. Fruit is high in fiber and much lower in calories than the standard dessert. It helps keep you satisfied and is delicious – a true win-win situation.

Veggies Are Your Best Friend

I know I've made this recommendation before, but that's because it’s so crucial to healthy eating habits, so load up on the veggies! The fall and winter seasons are full of many delicious options – butternut squash, brussel sprouts, pumpkin, broccoli, cauliflower…the list goes on.

Sprinkle your favorite with some salt, pepper and fresh herbs, drizzle with heart-healthy olive oil, and roast in a pan, the oven, or on the grill for a filling, healthy addition to your meal. Anytime you want to go back for seconds of other food items, I challenge you to eat more veggies first and then ask yourself, "Am I still hungry?" More often than not, the answer will be no.

Cut Out the Extra

Many recipes call for more of certain ingredients than are really necessary, with the biggest culprit being butter.

For example, my mom's sweet potato casserole is a must at our holiday dinners, but the recipe calls for almost two sticks of butter! I cut out over half of the recommended amount and no one could tell. Shhh! (If you're nervous about this, do a test batch using less of the selected ingredient so the recipe can be made without a hitch on the real day.)

This year, try some or all of these tips to make your holiday meal flavorful and filling without sacrificing your health.

Interested in developing a personal fitness plan that includes good nutrition?

5 Home remedies for sunburns

When we are exposed to the sun for long, our skin becomes tanned, red, painful and may start to peel. Light skinned people are more prone to sun burns than dark skinned people.  Here are some home remedies to alleviate the pain and get rid of sunburns

1 Cucumber

Cucumber contains analgesic and anti-oxidant properties. It is able to relieve pain from sunburn and promote healing very fast.
Slice some cucumbers and place on your skin. After a while, flip the cucumber and place the other side on your skin.  You may also blend cucumber and apply as a mask on your skin if you are comfortable with applying paste on your skin.

2 Aloe vera

Aloe Vera is a very powerful medicinal plant and has excellent healing properties. It is used for rashes on the skin and is also used to treat and alleviate the symptoms of sunburn. 
Get some fresh Aloe vera leaves and open it up in the middle, as if you are peeling a banana. Place the fleshy liquid part on your sun burn. If your sunburn is on a large area of your skin, you might consider scooping out the Aloe Vera gel and applying on your body.  You may choose to allow the gel on your body or wash it of after an hour. Do this twice a day until your sunburn is healed. You can also buy Aloe Vera gel from a shop, Use Aloe Vera soaps and creams to take a bath.

3 increase your intake of water and fruits
Hydrating the body is very important in speeding up the healing process. 
 
4 Apply vinegar on your sunburn

Applying vinegar to your skin cools it down, stops the burning sensation and hydrates your body. you can also chose to add vinegar to your bath water.

5 Baking soda paste
image source:armandhammer.com

Get some baking soda depending on the amount of skin affected by sun burn. Add cold water to it little by little until it becomes a paste. Smear it on the sunburn till you feel relieved. You can then rinse it off with clean water. 

Monday, 23 November 2015

Gambling and Brain Frontal-Striatum Connections

For the remainder of 2015, Brain Posts will focus on pathological gambling and also highlight the top-viewed posts for the year.

Functional connectivity is a relatively recent brain imaging technique that provides a new look at brain circuitry at rest and with tasks.

Resting state connectivity using fMRI provides a snapshot of brain connections in each individual. There is increasing study of resting connectivity in individuals with disorders in neuroscience medicine compared to control populations.

Saskia Koehler and colleagues in Germany recently published a study of resting fMRI connectivity in a group of problem gamblers and controls.

Problem gamblers (PG) in this study were recruited via advertisement on the internet and posted notices in casinos. PB was assigned based on a questionnaire for problem gambling that included DSM-IV and ICD-10 diagnostic criteria.

The key findings in the PG compared to the controls included:

  • Increased connectivity in PG between the right middle frontal gyrus and the right striatum
  • Decreased connectivity in the PG between the right middle frontal gyrus and other prefrontal regions
  • The right ventral striatum region showed enhanced connectivity to the right middle and superior frontal gyrus and the left cerebellum

The striatum is a brain region known to be linked to the reward system. The authors note in the introduction:
"Immediate reward seeking behavior has been linked to regions of the mesolimbic system, since subcortical areas such as the ventral striatum (including the nucleus accumbens) are highly active during reward processing."

It makes sense that individuals with PG show hyperactivity between brain executive decision-making regions (frontal cortex) and the brain reward regions of the striatum. The fact that these increased hard-wiring effects can be seen at rest supports the strength of the brain connectivity finding. 

The study also found correlations between the frontal-striatum hyperactivity and two psychometric measures assessed in the study: nonplanning impulsivity and gambling craving subscores.

The increased connectivity between the right frontal cortex and the striatum have been previously demonstrated in substance abuse. In the current study, alcohol intake and cigarette use were match in PG and control to address potential confounding addiction variable effects.

The authors note their study supports research into therapies (psychotherapy and drugs) that target frontal-striatum connectivity in developing innovative interventions in PG.

Readers with more interest in this study can access the free full-text manuscript by clicking on the PMID link in the citation below.

Figure in this post is an original photo with impressionism filter from the author's files. Photo may be reproduced with link to the site.

Follow the author on Twitter: WRY999 

Koehler S, Ovadia-Caro S, van der Meer E, Villringer A, Heinz A, Romanczuk-Seiferth N, & Margulies DS (2013). Increased functional connectivity between prefrontal cortex and reward system in pathological gambling. PloS one, 8 (12) PMID: 24367675

Priests and Physicians who betray their trust

If you’re a moviegoer, don’t miss Spotlight, which opened earlier this month. It tells the story of the Boston Globe investigative team that broke the story about sexual abuse of children by priests. For Bostonian’s it’s a must-see. But it’s such a well-acted, well-directed film that even those with no interest in Boston or priestly behavior should find it engaging.

Sexual abuse of children is and should be a crime, whoever perpetrates it. But the story of priests who betray their calling sheds light on the most-read topic on this blog: doctor-patient sex. The further back in time we go, the more overlap we see between medicine and religion. Jesus, Muhammad and Buddha all healed sickness as well as sin. In every religion priesthood is a calling. The priest is literally called by God. I think of health care as a secular calling to which practitioners may be “called” by fidelity to our common humanity.

Spotlight shows how, priests, like physicians (especially psychiatrists), are the object of transference, that can endow them with enormous power in the eyes of their congregants/patients. When that transferential power is combined with recurrent private contact – whether in the church or the consulting room – we have the potential for great benefit or great betrayal. For too-many priests, the combination of sexual temptation in the presence of parishioners who idealized them was a devil’s brew.

For Catholic priests, celibacy adds an additional risk factor. Dylan Thomas nailed the challenge the young priest must contend with:

The force that through the green fuse drives the flower
Drives my green age: that blasts the roots of trees
Is my destroyer.
And I am dumb to tell the crooked rose
My youth is bent by the same wintry fever.

Spotlightdramatizes that while individual priests sinned, the system of the church protected them and neglected their victims by moving the offending priests from parish to parish. It required a diligent and courageous reportorial team to blow past the cover-up. Psychiatrists who betrayed their profession and exploited patients were not protected to the same extent, but it required the brave feminists who outed the offending physicians to stem the psychiatric abuse that was more prevalent in the 1960s and 1970s.


In an especially powerful moment, Spotlight shows a reporter speaking with Father Ronald Paquin. In a strangely dissociated manner, Father Paquin acknowledges that he “played around” with children, but never “raped” them and did not “gratify” himself, as if these claims exonerated him. Self-delusion is a powerful human capacity, and perpetrators frequently find ways to “justify” their actions. Last month Father Paquin, now 72, was released from prison. (For an earlier story, see here.)

It’s comforting to the rest of us to dismiss offending priests and physicians as bad apples. But that excuses us from our own responsibilities for governing the professions of priesthood and medicine. When the bystanders wanted to stone the woman taken in adultery, Jesus rebuked them: “He that is without sin among you, let him cast a stone at her.” Believers and atheists should agree that this was a true teaching.

Saturday, 21 November 2015

Caution! Holiday Eating Ahead

Lori M. Noble, MD, a primary care physician at Spruce Internal Medicine, located at the new Penn Medicine Washington Square building, discusses some healthy eating tips for the holiday season.

With the holiday season upon us, if you're anything like me, you just can't wait to get into the festive spirit by puting on that cozy, bulky sweater to keep warm. It also helps to camouflage those few extra holiday pounds the sweet potato casserole and stuffing are likely to leave behind.

But, have no fear; this season can still be enjoyed without needing to buy a new wardrobe when it's over. With a few simple tips and some pre-meal planning, you can still eat the foods you love without the fear of adding the "festive 15."

Keep Your Plate Green

This is actually a great tip for any meal, not just around the holidays! If you dedicate half of your plate to healthy veggies, you've already won half the battle. You can’t give in though. If you go back for seconds, remember the half-plate rule. Veggies are high in fiber, so they will keep you feeling fuller longer and help to prevent over-indulging on some of the less healthy options.

If you intend on bringing a dish to someone’s home, volunteer to bring roasted veggies or a big salad. This way, you know you will like the healthy option.

holiday eatingDon't Leave the House Hungry

One of the most common mistakes individuals make during the holidays is skipping breakfast in an attempt to "save up" calories for big meals. This tactic actually slows your metabolism to a halt. When you do eat, your body wants to hold onto every last calorie it can. Plus, when all that delicious food is put in front of an empty, growling stomach, it becomes an irresistible temptation to overeat. Be sure to eat a healthy, satisfying breakfast, such as oatmeal with a handful of dried fruits and nuts or egg whites with veggies and low-fat cheese.

Pick your "Poison"

We all have our "Achilles heels" when it comes to holiday meals - mine happens to be...well, anything on the dessert table. If you know what you're likely to over-indulge in, you can make a plan to keep yourself on track. For instance, if you're a sweets or carbohydrate-lover like me, you might avoid the "pre-dinner" snack foods and limit the stuffing and sweet potatoes at dinner to one serving each (~1/2 cup). This allows you to have that nice piece of pie for dessert without any guilt!

Keep the Food off the Table

This is a sneaky trick that I have used for years. If the food isn't kept on the table, grazing isn't nearly as easy. In order to get seconds, you have to make the conscious effort to get up from the table, get more food and maybe even heat it up if it's gotten cold. You'll be forced to ask yourself, "do I really want to get up from the table?" rather than just picking at whatever tasty treat is casually left in front of you.

Don’t Forget about Liquid Calories 

Holiday cocktails and wine with friends add up to a lot of empty calories. For example:
  • One cup of eggnog – without added liquor – has about 350 calories and 19 grams of fat.
  • One cup of champagne has about 182 calories.
  • One, four-ounce serving of red wine has about 100 calories.
Try to stick to water or unsweetened tea. If you do choose to have “a drink”, stick to wine, low-carb beer or spirits.

So, enjoy your holidays. Just remember, a little preparation and a modest amount of self-control can go a long way. What better way to start the New Year than with a positive resolution.

Interested in learning more helpful tips?

Thursday, 19 November 2015

Managing Holiday Stress

Lauren Strohm, DO, a primary care physician at Penn Medicine Valley Forge, discusses healthy tips for managing stress during the holiday season.

Lauren Strohm, DO
As the brilliant colors of the fall foliage fade and the crisp winter air settles in, a flurry of activities begin and it is now time to prepare for the holidays.

The holiday tradition started as a period of time set aside for religious or cultural celebrations. Today, many of us have an unrealistic or overly romantic notion of what the holidays should be, and often aren’t.

To help, here are a few tips to rekindle the holiday spirit:

Planning

  • Put together a list of what you expect from the holidays and be realistic with what can be accomplished.
  • If you’re looking to take it easy over the holidays, consider a vacation or simply a ‘stay-cation.’ Take it easy and relax, refresh and re-energize.
  • If family, friends and feasts are on your holiday horizon, prioritize commitments and schedule them on your calendar. Don’t forget to include time for rest and relaxation.
  • Plan your travels – purchase tickets in advance and arrive early for departure.

Holiday Gatherings

holiday stress
  • If you’re hosting a holiday party, divide up the menu and give guests an opportunity to prepare and “show off” one of their favorite dishes.
  • Prepare in advance – I have a patient who bakes 20 pies the week before her holiday parties in preparation to give to friends and relatives.
  • Those who break bread make bread together - Share in the peeling, dicing, chopping and cleanup in the kitchen. It is a great opportunity for everyone to catch up while preparing the meal.
  • Purchase prepared menu items to reduce the amount of cooking and increase the amount of family time.
  • Avoid overindulgence - have a healthy snack before your holiday parties, continue to exercise and get a good night’s sleep.

Gift Giving

  • Set a budget. You will be surprised how creative you can be with a budget in place.
  • Ask people what they want for the holidays. This eliminates the guesswork and holiday returns.
  • Online shopping – Shop at your leisure. Last year, I did most of my shopping online while on the train to/from work!
  • Get creative with gift-giving. During my medical training, I gave my brother and his wife a “gift certificate” redeemable for a weekend of babysitting my nieces and nephews.

Holiday Blues

  • Surround yourself with family and friends if you’re feeling lonely and sad. Reminiscing about the past, the loss of loved ones or being away from home during this time of the year can be difficult.
  • Volunteer – Helping others can help us better appreciate what we have.
  • Despite your best efforts, if you find yourself feeling severely anxious, persistently sad or hopeless and these feelings are affecting your daily activities, please talk to your doctor.
The holidays are an exciting time celebrating with family and friends. With some planning and a positive attitude, it is possible to be jolly during this season and to find peace and joy as we celebrate.

Happy Holidays!

Any tips you'd like to add?
Leave your thoughts below.

Wednesday, 18 November 2015

Holiday Heartburn

Eileen K. Carpenter, MD, an internal medicine physician at Penn Medicine Washington Square, discusses how to avoid holiday heartburn and when you should get it checked out.

Eileen K. Carpenter, MD
Eileen k Carpenter, MD
Some food for thought: Every Thanksgiving night, there are many cases of emergency room visits due to chest pain.

Something else for you to chew on: Most of these visits can be prevented.

The most common reason for chest pain is gastro-esophageal reflux disease (GERD) – stomach acid washing backward up the esophagus (food pipe). And while the stomach is designed to handle strong acids, the esophagus is not. If the refluxing acid doesn’t get swallowed back down promptly, it can cause a painful chemical burn in the esophagus.

Thanksgiving is a perfect storm of GERD risk factors. People’s stomachs are way too full by the end of dinner. Then, they top the evening off with a late dessert of high-fat pie, ice cream and a cup of coffee. Caffeine and fatty meals predispose you to reflux, and if your stomach isn’t empty by the time you go to bed, gravity pushes the acidic stomach contents up the esophagus.

Can you prevent acid reflux?

refluxLuckily, you can prevent reflux pain. The best way is to fast for two to four hours before lying flat and by timing your fatty or caffeinated intake to occur earlier in the day. Liquid antacids, like Maalox, Mylanta or Milk of Magnesia, provide near-immediate relief of reflux, so it’s a good idea to have a bottle in the house for the holidays. (The effective dose is two tablespoons.)

If there has been significant irritation of the esophagus, the pain may return a few hours later, and acid-suppressing medications like ranitidine or omeprazole will help heal it. If it takes more than two weeks for a reflux flare-up to resolve, it’s time to see your doctor to make sure there’s nothing else going on.

It’s important to keep in mind…

Chest pain due to the heart is also more common during the holidays. People are away from home and their usual medication routine; they’re drinking more alcohol and enduring more stress. If you are traveling, make sure to bring your medications and continue to take them as prescribed. Limit alcohol to one to two drinks a day for women and two to three drinks a day for men, or abstain completely.

If you think you have chest pain due to reflux, but the liquid antacid doesn’t knock it out immediately, call 911 to make sure it’s not your heart.

Interested in learning more helpful health tips?

Foods that Can Trigger Headaches

Roderick Spears, MD, a neurologist at Penn Neurology Valley Forge, discusses which foods to avoid in helping to prevent headaches.

Roderick Spears, MD
Roderick Spears, MD
Is there anything worse than that moment a headache strikes? You know the one, when that throbbing pain makes it difficult to do virtually anything.

Headaches, a pain in the nerves and muscles of the head and neck, are by far the most complained about issue at the doctor’s office. They are classified into two types:
  • Primary (not associated with an underlying medical condition), and
  • Secondary (associated with infections, fever, injury, etc.). 
While most recognize the connection between headaches and illness, many struggle to understand why they may be feeling fine one moment and suffering from a headache the next.

Would you believe that the horrible pounding in your head may actually be caused by something you ate or drank? And we aren’t just talking about the morning after partying. Caffeine, smoked meats and even cheese can cause you to feel like someone is using your head as a bongo.

Below is a list of some lesser-known food and drink-related headache triggers.

Coffee and Chocolate

Coffee and chocolate can both be headache triggers and inhibitors. Regular caffeine consumption – found in both – can lead to a physical dependence, which manifests as withdrawal symptoms when a user abruptly stops their caffeine intake.

For example, a regular coffee drinker sleeps a little late on the weekend. She wakes up and decides she doesn’t need a cup of joe to get her day going. An hour passes and her head starts pounding. Why? Her blood vessels have dilated too much. When this occurs, caffeine can actually help to ease the pain.

Cheese

When it comes to cheese, older isn’t always better… for headaches.

If eating cheese makes your head hurt, it’s likely an aged-type like Swiss, Parmesan, Brie or cheddar. Aged cheeses are high in tyramine, a natural chemical found in some foods. Tyramine can cause headaches by constricting and dilating blood vessels.

Meats

Tyramine is once again the culprit. Try avoiding pepperoni, salami, summer sausage and mortadella, and limiting processed meats to four ounces per meal. Processed meats, such as hot dogs, deli meats and bacon can also cause your head to hurt due to synthetic food preservatives.

Soy sauce

Soy sauce also contains tyramine and sometimes monosodium glutamate (MSG). MSG, which is used as an additive in many other foods, has been found to cause cramps, diarrhea and headaches. Additionally, soy has large amounts of salt, which can lead to dehydration – and, therefore, to headaches.

Ice cream

I scream, you scream, we all scream… ugh, brain freeze!

We’ve all felt the terrible sensation before. That big bowl of ice cream is placed on the table, and you just can’t wait to dive in. You take a scoop or two and – boom – you get hit with the mind-numbing pain.

Here’s the scoop on how you got that brain freeze (which is in fact a form of a headache). When something cold touches the center of the palate, it sets off certain nerves that control how blood flows to your head. The nerves respond by causing the blood vessels in your head to swell up. This quick swelling is what causes your head to hurt. Luckily, these particular headaches tend to only last about a minute, and there’s an easy way to prevent them: Eat slower!

We know that the foods and drinks listed here likely make up a significant portion of your diet. You don’t need to cut everything out, but it may be wise to keep track of when you get headaches and what you indulged in prior to the pain.

Interested in learning more helpful tips?

Predictors of Poor Outcome After Traumatic Brain Injury

The outcome following traumatic brain injury (TBI) is often unpredictable and variable.

Two individuals with similar types of TBI can have quite different outcomes ranging from total disability to functional employment.

Torun Finnanger and colleagues from Norway and Australia recently reported on a study that examined a number of predictor variables on self-reported outcome following TBI.

In this study, 67 adolescents and adults with moderate to severe TBI completed baseline assessments and were followed for a period of 2 to 5 years. 

The key outcome variables in this study was self-reported executive, behavioral and emotional impairment at the follow-up time point. TBI subjects were compared on a variety of variables with a control group without injury.

Early assessment variables that were examined for correlation with outcome after TBI included:

  • Pre-trauma level of education
  • Brain injury severity rating: Glasgow Coma Score
  • Duration of post-traumatic amnesia
  • Brain imaging: presence of imaging markers for brain traumatic axonal injury on brain MRI with inclusion of diffusion tensor imaging (DTI) data
  • Neuropsychological assessment obtained three months after injury including: Motor function, information processing speed, attention, visual memory, verbal memory and executive function
  • Presence of the symptoms of depression using Beck Depression Inventory 3 and 12 months after injury

The key findings from this longitudinal predictor study included:

  • Self-reported impairment in executive function at 2-5 years follow up was linked to fewer years of education, early depression symptoms and traumatic axonal injury
  • Injury at a younger age predicted increased aggression and conduct disorder behavioral problems
  • Traumatic axonal injury and early depression symptoms predicted increased depression and anxiety symptoms at follow up.

The authors conclude their study supports inclusion of self-reported executive, emotional and behavioral assessments in the monitoring of TBI subjects.

Additionally, they note early MRI imaging assessment of axonal injury (in the first two weeks following TBI) and early assessment of depressive symptoms add information to standard neuropsychological assessment batteries.

They note accurately defining high-risk groups more poor outcome may allow targeting of more aggressive treatment strategies
"Furthermore, psychological and/or pharmaceutical interventions, with a focus on depressive symptomatology may be helpful in reducing the long-term problems experienced by persons sustaining a TBI.."

This study is filled with a ton of data. Readers with more interest in the study can find the free full-text manuscript by clicking on the PMID link in the citation below.

Follow the author on Twitter WRY999.

Image of brain white matter pathways is an iPad screen shot from the 3D Brain app from the authors files.

Finnanger TG, Olsen A, Skandsen T, Lydersen S, Vik A, Evensen KA, Catroppa C, Håberg AK, Andersson S, & Indredavik MS (2015). Life after Adolescent and Adult Moderate and Severe Traumatic Brain Injury: Self-Reported Executive, Emotional, and Behavioural Function 2-5 Years after Injury. Behavioural neurology, 2015 PMID: 26549936

Avoid the Turkey Knockout

This Thanksgiving, millions of Americans will join family and friends around the table. We’ll share what we’re thankful for and engage in that time-honored Thanksgiving tradition of enjoying a huge meal of turkey, stuffing and mashed potatoes, followed by pumpkin pie… and a nap in front of the TV.

Along with those traditions comes one almost as popular: blaming turkey, specifically tryptophan, for the reason no one can seem to keep the party going.

So, are they right? Is turkey the culprit for Thanksgiving sleepiness?

tryptophan
What is tryptophan?

Tryptophan is an amino acid, an essential nutrient in our diet that the body can’t produce. The body uses it in the process of making vitamin B3 and serotonin. While vitamin B is important for digestion, skin and nerves, serotonin is a chemical that impacts our moods. Serotonin can help create a feeling of well-being and relaxation. And what do you tend to do when you are relaxed? Perhaps take a little snooze?

Tryptophan is not unique to turkey. It’s found in other meats, chocolate, bananas, mangoes, dairy products, eggs, chickpeas, peanuts and a slew of other foods. And, some of these foods, such as cheddar cheese, actually have more tryptophan per gram than turkey.

You’re probably thinking: I eat many of these other foods and don’t struggle to stay awake. Why is it that on Thanksgiving, I can’t wait to find a comfy spot to close my eyes?

What is to blame for our need to nap?

Well, there are actually a few things at play.

Because many of the foods associated with Thanksgiving are high in fat, the body redirects blood to your digestive system to allow you to digest it. Since you have less blood flow elsewhere, you feel less energetic.

Additionally, the holidays can be a bit stressful; the most relaxing part is once all the preparation, traveling and planning is over and you can eat. While eating, you have the opportunity to sit back and relax. Add alcohol to the equation and the result is you feeling drowsier than usual.

Can you fight the urge to snooze?

The easiest thing to do is eat less food. That’s probably not going to happen, so the next best option is to ease up on high-carbohydrate foods (potatoes, stuffing, etc.). These foods tend to cut short the insulin response that fights tryptophan.

Also, plan some type of activity after your meal, such as a brisk walk or a game of touch football. This will help you digest the food a bit better and reenergize you. And if the weather isn’t cooperating, simply volunteer to do the dishes just to stay on your feet and be active.

Any type of activity that keeps you moving will allow you to spend more time with your loved ones, and isn’t that what the holidays are all about anyway?

Happy Thanksgiving!

Interested in learning more helpful tips?

Monday, 16 November 2015

Smell Test in Screening for Parkinson's Disease Risk

Molecular model of polypeptide parkin
Identification of early or prodromal stages of the diseases of neuroscience medicine is an important clinical and research goal.

Identification of prodromal illness allows for enhanced surveillance and initiation of secondary prevention interventions.

Impairment of smell or olfactory sensation is a key early clue for Parkinson's disease (PD).

Danna Jennings and colleagues recently published an important study of the role of smell impairment in prodromal PD.

This manuscript represents one finding from the Parkinson's Associated Risk Syndrome Study.

In the published study, 4,999 subjects completed Tier 1 assessments of a multi-tier study. Subjects were recruited from 16 movement disorder clinics.

Tier 1 included olfactory testing and questionnaires. Tier 2 assessments include neurologic examination, brain imaging for dopamine transporter (DAT) function and other biomarker testing. 

The DAT is considered a valid marker of brain dopamine function and marker for prodromal PD.

Olfactory testing consisted of the 40-item University of Pennsylvania Smell Identification Test (UPSIT). Subjects scoring in the lowest 15% of smell function were classified as abnormal or hyposmic.

The key findings from this study including the following points:

  • Hyposmic subjects had higher rates of subjective smell impairment (47% versus 10% of controls)
  • Hyposmic subjects did not have greater scores on current PD symptoms
  • Hyposmic subjects had greater rates of DAT deficits on brain imaging (11% versus 1%)
  • Combining hyposmia status along with male gender and presence of constipation identified a high-risk PD group where 40% had DAT deficit

A take home conclusion from the study is that elder men with constipation (< one bowel movement per day) and self-reported or UPSIT smell impairment have increased risk for PD.

Clinicians with more interest in smell testing kits can find information and purchase kits from Sensonics, Inc. The link for this test is here. Sensonics did not sponsor or provide financial incentive for this post.

Readers with more interest in this research can access the free full-text manuscript by clicking on the PMID link in the citation below. 

Follow the author on Twitter @WRY999

Figure in post is a molecular model of the crystal structure of the polypeptide parkin. Figure reproduced under terms of Creative Commons License. Figure published in Wikipedia is created by author JFtrempe. Parkin gene effects appear to contribute to risk for PD.

 Jennings D, Siderowf A, Stern M, Seibyl J, Eberly S, Oakes D, Marek K, & PARS Investigators (2014). Imaging prodromal Parkinson disease: the Parkinson Associated Risk Syndrome Study. Neurology, 83 (19), 1739-46 PMID: 25298306

Walking Meditation and Health Care Ethics

Health care can be frantic. Emergency rooms, intensive care units, and surgical suites are obviously high paced, but so is "ordinary" hospital and outpatient care. In my busy days of practice I sometimes had 18 appointments in 10 hours. It's not surprising that clinicians report high levels of tension.

Tension can sharpen our focus, but when it's sustained over time it can lead to irritability and distraction. These create hazards to patient safety and contribute to burnout. That kind of tension is bad.

Insofar as the conditions of practice can be modified to reduce tension, doing what's needed and possible should obviously be done. But clinical practice inevitably brings tension. For our own sake and for the sake of our patients, we need to develop ways to chill out. As the late Ken Schwartz wrote in "A Patient's Story," "...in a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver’s inherent compassion and humanity." To be truly effective caretakers, we need to cherish our capacity for "compassion and humanity"!

For some, meditation is a tremendously valuable tool!

Unfortunately, meditation is often thought of as a touchy-feely matter of sitting in an uncomfortable lotus position and chanting mantras. That view confuses external practice with the internal objective. If meditation is taken to mean sitting in a quiet space for 20 minutes or more to carry out the practice, not many health professionals will make use of it.

That's where walking meditation comes in. In hospitals, doctors and nurses typically walk a few miles - in short bursts - during a shift. In my outpatient practice I often walked from my office to classrooms where I taught and to meetings at the nearby hospitals. I could even take a few paces in the office between appointments. I tried to use these interludes as opportunities for meditation.

There are excellent on line guides to walking meditation. (See here, here and here for examples.) But no approach fits everyone. I found that the excellent descriptions of how to focus on body sensation and the experience of walking didn't work for me. My mind kept wandering to matters I was fretting about. That got me riled up, not settled down.

I recently found a technique that works well for me. I like to look around as I walk. Here's what I learned to do:
  1. Breathe in, and, at the same time focus my eyes on some aspect of the external world, as by saying "look at the trees," or "look at the clouds," or "look at the people."
  2. As in all forms of meditation, the aim is to experience the trees, clouds, people passing by, or some other focus, not to think about them.
  3. I found that for my obsessional nature, it helped to say numbers sequentially as I breathed out - one number for each cycle. That seems to help me stay with the experience rather than drifting off into ruminations. I also like to keep track of how long I can sustain the process before my mind gets filled with trivia.
I present my experience to make the point that it's kosher to develop an approach that works for us. Gurus can be helpful teachers, but the wise ones don't look for slavish followers. If walking meditation clicks for a person it can fit into the interstices of the day. Parents give children a "time out" for the child to regain some composure. Walking meditation has potential for potentially stressed out health professionals to create mini "time outs" for ourselves. When it works it serves us and our patients well! That's good ethics!



Friday, 13 November 2015

The Invisible Hand Slaps Valeant Pharmaceuticals and the Sequoia Fund

Over the years I've been a staunch critic of seeing the health care "industry" as a commodity that should be governed by market forces. But fairness and honesty compel acknowledgement when the invisible hand acts wisely and supports good ethics.

Today the New York Times reported that two of the five independent directors of the Sequoia Fund resigned in protest over the Fund's decision to increase its already large stake in Valeant Pharmaceuticals, a company whose entirely legal but ethically disgraceful business strategy is to buy drugs and impose huge price increases. When Valeant's business practices hit the front page its stock fell from $260 to $75, and Sequoia's shares fell 22%.

Here's what David Poppe, president of the firm that manages the Sequoia Fund, said about Valeant: "...we thought Valeant was aggressive but stayed within the lines. To say they're immoral is pretty strong."

Sometimes statements that are "pretty strong" are also "pretty true." Let's hope that the lesson the market is sending about exploitative pharmaceutical business practices is widely heard. So far the invisible hand has been dealing out slaps. Next time - the fist!


Thursday, 12 November 2015

Screening for Cognitive Impairment in Parkinson's Disease

Sunset in Blanchard, OK courtesy of Dr. Tim Yates
There is a significant need for improvement in the tools available for screening for cognitive impairment in a variety of disorders in neuroscience medicine.

The Mini-Mental State Examination Score (MMSE) is a widely used 30-item scale for screening dementia and other neurological conditions.

However, the MMSE has some significant weaknesses for use in the clinical setting.

Jin Qiao and colleagues from China recently published a study testing the MMSE to screen for cognitive problems in a group of patients with Parkinson's disease (PD).

A score of 24 or lower is commonly used as a marker for evidence of cognitive impairment in adults from typical educational backgrounds. This would mean individuals with scores above 24 would typically be screened as not having significant cognitive impairment.

In the Chinese study, a series of PD subjects with scores over 24 were studied in detail with more intense neuropsychological testing including the Montreal Cognitive Assessment (MoCA). The MoCA tests seven cognitive domains including visuospatial/excutive, naming, attention, language, abstraction, delayed recall and orientation.

The key findings from this study included:

  • 65% of the subjects screened cognitively normal with the MMSE had evidence of cognitive impairment on the MoCA (score <26)
  • Cognitive impairment domains in screened impaired PD subjects included: visuospatial/executive, attention, language, abstraction and delayed recall
  • Analysis of the MMSE screening data supported raising the threshold for screening impairment in PD subjects from a score of 24 to a score of 28 in higher educated samples

This is an important study with implications for practice assessment and management of patients with PD. The study supports using the MoCA over the MMSE for screening cognitive impairment in PD.

Additionally, this study highlights the need to study screening tools in specific disease populations. Screening thresholds and best cognitive screening practices may be disease specific.

More information and a paper copy of the MoCA can be found here.

Readers with more interest in this study can access the free full-text manuscript by clicking on the PMID link in the citation below.

Photo of sunset in Blanchard, Oklahoma is provided courtesy of Dr. Tim Yates

Follow the author on Twitter @WRY999

Qiao J, Zheng X, Wang X, Lu W, Cao H, & Qin X (2015). Neuropsychological profile in Chinese patients with Parkinson's disease and normal global cognition according to Mini-Mental State Examination Score. International journal of clinical and experimental medicine, 8 (8), 13755-61 PMID: 26550322

Tuesday, 10 November 2015

Brain Inflammation in Dementia with Lewy Bodies

The role of inflammation in the brain is receiving increased attention in dementia and other disorders in neuroscience medicine.

Dementia with Lewy bodies (DLB) is the third leading cause of dementia. This disorder has received increased attention with the finding of the condition in the autopsy of comedian and actor Robin Williams.

Patrick Ejlerskov and colleagues from Denmark, Sweden, Germany and the United Kingdom recently published an informative study in the journal Cell on this topic.

Cytokines include a group of substances that modulate immune and inflammation. Included in this group of substances are interferon, interleukin and various growth factors. Many cytokines promote inflammation in response to a variety of triggers. However, some interferon compounds, including interferon beta appear to dampen or reduce the inflammatory response. A lack of interferon beta may allow excessive unopposed pro-inflammatory responses.

In the current study, the role of interferon beta in brain inflammation was studies in a model model. The key findings from this manuscript included:

  • Mice with no interferon beta (using a knockout model) showed evidence of behavioral and cognitive impairment along with signs of brain neurodegeneration
  • Interferon beta was essential for neuroplasticity markers including neuronal survival, neurite outgrowth and branching
  • Interferon beta knockout mice showed disruption of pathways associated with neurodegeneration
  • Low interferon beta levels demonstrated defects in the dopamine pathway in the brain nigrostriatum. This pathway is known to be disrupted in Parkinson's disease (PD).
  • Lack of signaling of the interferon beta pathway produces brain Lewy bodies
  • Lack of interferon beta disrupts the brain cleansing process known as autophagy
  • Disruption of autophagy results in the accumulation of the Lewy body-associated protein known as alpha synuclein
  • Mouse gene therapy with the interferon beta gene prevented dopamine neuron loss in a familial model of PD

This study presents a pretty impressive argument for the role of interferon beta in the modulation of brain neuroinflammation pathways found in DLB and Parkinson's disease.

The authors conclude in the discussion section:
"Our data strongly support an essential role for interferon beta signaling in the preventing neurodegenerative pathology and suggest (interferon beta knockout) mice as a model for nonfamilial, sporadic neurodegenerative diseases, particularly PD and DLB, with potential for testing future therapies."
Readers with more interest in this topic can access the free full-text manuscript by clicking on the PMID link in the citation below.

Photo of Lewy bodies under the microscope is from Wikipedia and is used under the terms of the Creative Common License linked to the following citation:

"Lewy Koerperchen" by Dr. Andreas Becker upload here Penarc - Own work. Licensed under CC BY-SA 3.0 via Commons - 

https://commons.wikimedia.org/wiki/File:Lewy_Koerperchen.JPG#/media/File:Lewy_Koerperchen.JPG

Follow the author on Twitter @WRY999

Ejlerskov P, Hultberg JG, Wang J, Carlsson R, Ambjørn M, Kuss M, Liu Y, Porcu G, Kolkova K, Friis Rundsten C, Ruscher K, Pakkenberg B, Goldmann T, Loreth D, Prinz M, Rubinsztein DC, & Issazadeh-Navikas S (2015). Lack of Neuronal IFN-β-IFNAR Causes Lewy Body- and Parkinson's Disease-like Dementia. Cell, 163 (2), 324-39 PMID: 26451483