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Guest Post on Concussion: The Neuropathology of CTE in the United States

Introduction by Dominic A. Carone, PhD, ABPP-CN

These days, it is difficult for someone to turn on the television, open a newspaper, or surf the internet without coming across a story on the dangers of concussions, particularly repeat concussions. This has caused a great deal of concern among many athletes and their loved ones regarding participation in sports.

One of the greatest concerns that has emerged is the possibility of developing CTE (chronic traumatic encephalopathy) – which is described as a degenerative brain disorder caused by repeat brain trauma. But how much do we really know about CTE? Recently, Dr. Ann Mckee (neuropathologist) and colleagues published a review of CTE and other topics in a paper entitled “The Neuropathology of Sport.” While McKee and colleagues discuss CTE as an established disease entity, contrasting opinions exist in the literature on the associations between athletic head trauma and neurodegenerative disease.

A neuropsychologist colleague of mine, Dr. Jim Andrikopoulos has been one of the most vocal critics of the existence of CTE. Below is a response by Dr. Andrikopoulos to the aforementioned article by Dr. McKee. Dr. McKee will be contacted and given a chance to respond. Presenting this material in blog format provides maximal exposure to the public, most of whom are not avid consumers of health care journals. Respectful comments are welcome.

Note: The views expressed by guest authors on this blog are not necessarily those of my own. For my own review of CTE and dementia pugilistica, see Carone, D., Bush, S. (2014). Dementia pugilistica and chronic traumatic encephalopathy. In R. Dean & C. Noggle (Eds.), The Neuropsychology of Cortical Dementias. New York: Springer, pp. 303-326.

The Neuropathology of CTE in the United States

Jim Andrikopoulos, Ph.D., ABPP-CN

This letter is in reference to a recent review by McKee et al. (1). To judge the validity of the core observation made in the review one needs an understanding, particularly non-Americans, of the current sociological context in the United States as it relates to contact sports. McKee begins by outlining the physical, emotional, cognitive and health benefits of sports. This can be contrasted with the current state of affairs in the United States, especially in American football. McKee reports that contact sports “rarely” results in the development of chronic traumatic encephalopathy (CTE). However, McKee found CTE in 34 of 35 professional football players, all nine college players, six high school athletes, and all four professional hockey players (reference 128 in [1]).

Despite McKee stating the incidence of CTE is unknown; her message to the American media is different: “I am really wondering, on some level, if every single football player doesn’t have this” (2). CTE in contact sports in the United States is now an “epidemic.”Since 2010, participation in youth football has dropped by 9.5% (3). What is the merit of the science that has created this concussion craze?

The symptoms outlined by McKee bear no clinical likeness to the CTE of the last century. CTE is now characterized as a mood and behavioral disorder. The clinical features of CTE are parkinsonian and speech symptoms at a relatively young age. McKee treats these hallmark features in her review as a historical footnote, mentioning them once. The observations of Martland (references 118 in [1]) defined the disease through the 20th century only for CTE to now to be morphed into an unrecognizable clinical entity.

While classic papers are cited, the parkinsonian clinical descriptions are ignored (references 38 and 44 in [1]). The seminal epidemiological study that confirmed this parkinsonian phenotype and addresses prevalence is not cited at all (4). CTE is now artificially dichotomized. McKee proposes those with an early onset tend to have mood and behavior symptoms and later onset patients cognitive impairment. She states the earlier literature suggests this dichotomy. This is false based on my literature review and indirect proof is that no references are offered by McKee in support of this claim.

There is an observation that merits special comment because of its conspicuous absence. McKee has proposed four stages of CTE. There is no mention that the clinical features that accompany each progressive stage were not developed based on an examination of the patient. The clinical features were collected post-mortem. Alois Alzheimer was the first to give us a neuropsychiatric syndrome and a neuropathology to go with it. Remarkably, he did this in one patient.

As of today, McKee has conducted 85 neuropathological examinations and no clinical examination of a patient (reference 128 in [1]). Proposing a neuropathological entity in the absence of a clinical syndrome is unprecedented in neurological medicine as is being told that a presumably degenerative disease, CTE, cannot be diagnosed in the living patient but instead requires an autopsy.

What remains to be addressed is the neuropathology of CTE. The classic description was given by Corsellis in boxers (reference 38 in [1]). CTE in football was first described by Omalu(5). The publication was so contentious that some, rightfully, called for the paper to be retracted. Among a number of shortcomings of the paper was that the neuropathological case description bore no resemblance to Corsellis (6). In turn, McKee’s original neuropathological observations appeared at odds with Omalu (reference 127 in [1]). McKee has made no effort in her published studies to reconcile these differences. It would stand to reason that a neuropathological "discovery" with dissimilar descriptions would result in a collegial scientific exchange to reconcile any discrepancies.

What are these disparate neuropathological differences? Omalu initially commented on the absence of tau in the medial temporal lobes while McKee reported it as a preferential location(reference 127 in [1]). McKee added two observations not reported by either Omalu or Corsellis. Citing Hof, McKee reported tau to be found disproportionately in the superficial cortical layer II and the upper layer of III versus Alzheimer’s disease where tau is preferentially in layers V and VI (reference 91 and 92 in [1]). Second, citing Geddes, tau is observed in perivascular locations (reference 65 and 66 in [1]). In turn, Geddes who published her observations after Hof made no reference to the distribution of tau in the superficial layers but stated it was found in all cortical layers (reference 65 in [1]).

The last point is on what it means to be “encephalopathic,” a source of contention in the Omalu paper (6). Unlike Omalu and McKee, who consider a patient with tau to be encephalopathic, Geddes does not suggest an encephalopathy, only that the tau present at autopsy may suggest repetitive trauma as the cause. The encephalopathy in CTE refers to the symptoms in a living patient not a neuropathological finding.

Braak has reported the presence of tau in patients under 30 years of age (reference 15 in [1]). McKee’s criticism of Braak was that the sample was not screened for head injury. If we accept McKee’s logic, does that obligate Braak to render a postmortem CTE diagnosis in those he can show had an antemortem head injury or two? This is how the neuropathology of CTE is currently practiced in the United States.

References
 
1. McKee AC, Daneshvar DH, Alvarez VE, Stein TD. (2014). The neuropathology of sport. Acta Neuropathol. 127(1):29-51.

2. League of Denial: The NFL’s Concussion Crisis transcript. Frontline, PBS.

3. Pop Warner participation dropping. Chicago Tribune, November 14, 2013.

4. Roberts AH (1969) Brain damage in boxers: A study of prevalence of traumatic encephalopathy among ex-professional boxers. London: Pitman Royal College of Physicians.

5. Omalu BI, DeKosky ST, Minster RL, Kamboh MI, Hamilton RL, Wecht CH (2005). Chronic traumatic encephalopathy in a national football league player. Neurosurgery, 57(1): 128-134.

6. Casson IR, Pellman EJ, Viano DC (2006). Chronic traumatic encephalopathy in a NationalFootball League player. Neurosurgery,58(5): E1152.

Author Affiliations: Mercy Hospital Medical Center, Ruan Neurology Clinic, Des Moines, Iowa Corresponding Author: Jim Andrikopoulos, Ph.D. Ruan Neurology Clinic, 1111 6th Avenue, East Tower, Suite A100, Des Moines, Iowa 50314., Tel: 515 358-0020, Fax: 515 358-0099 neuroclinic@msn.com

Conflicts of Interest Disclosures: Dr. Andrikopoulos has provided expert testimony.

Infographic on Lyme Disease Incidence

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MedFriendly Publishes First Infographic: The Human Brain

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Tips for Treating Your Skin with Massage Oil

Human skin is amazingly resilient. It’s designed for both strength and flexibility, so that it can both stretch and maintain its shape. It also performs several vital functions including UV protection, moisture and body temperature regulation, waste elimination, and protection from disease.

Unfortunately, because it is so exposed, our skin is also prone to many of the effects of aging. Perhaps, one of the biggest effects is the loss of moisture, which can affect the strength and elasticity of your skin.

Massage therapy can reduce the effects of aging on your skin by improving circulation, stimulating oil production, removing dead skin cells, and providing external moisture from the use of massage oil. The good news is that you don’t have to spend hundreds of dollars getting a professional massage; you can get the same benefits by massaging yourself at home.

Massage for Healthier Skin

There are a few things that you need to consider if you are going to massage yourself at home, and the biggest is what type of oil to use.

Massage Oil

If you go to any massage store, or even a regular drug store, you will find that there are several different kinds of massage oil, in liquids, creams, gels and solids; and they all have different functions and benefits.

•  If your primary focus is moisturizing your body, then you will want to use a heavier oil, such as olive oil or apricot oil, which will coat the skin. You can also use a heavier cream or a body butter as long as it allows your hands to glide smoothly over your skin. Thinner oils can absorb too quickly, which would require you to use more to achieve the same effects.

•  If you are massaging your face, then you want to use a light massage oil specially formulated for faces. These oils are designed to absorb without leaving heavy residue which can clog your pores. You don’t need to use as much of these oils, as you would the oils for your body.

•  If you are looking to soothe sore muscles, in addition to making your skin more supple, you might want to consider massaging a medicated gel with menthol or arnica into the sore muscles, and then following with a medium to heavy massage oil, cream, or solid.

•  If you have allergies, then you want to avoid nut-based oils, and oils with heavy fragrances, and instead choose hypoallergenic oils like grape seed, soy, or jojoba.

•  Avoid mineral oils and petroleum-based oils, which tend to clog your pores and leave a heavy residue on the skin.

The other thing you need to consider is how you are going to use the oil.

•  If you are giving a massage to someone else, consider wearing a body massage oil holster, so that you don’t have to worry about the massage container being out of reach during the massage.

•  Put the amount of oil you wish to use in a separate container, such as a smaller plastic bottle or a small bowl. If you want to warm the oil, put the bottle or dish you wish to use into a larger container of hot water. Do not heat oil directly.

•  If you do prefer a scent, it’s better to add essential oils to the massage oil on a case-by-case basis rather than scenting the whole bottle.

•  Apply a small amount of the oil to your hand, and rub your hands together before applying the oil to your body. This will warm the oil, and will also prevent you from using too much. When using additional oil, always apply it to your hands first.

•  If you find that you have too much oil on your body, wipe your hands with a dry towel and then apply some hand sanitizer to them. That will remove the excess oil from your hands, and as you continue rubbing your hands will absorb the excess oil from your body.

•  If you are using several different types of oils, always wipe and sanitize your hands between each type of oil.

•  Store your oils in a cool, dry place. Excess heat and moisture can cause the oils to go rancid. Rancid oil will still work, but it will smell really bad.

This is a blog post by Nancy Evans.

Protecting Your Back at Work

If you have an office job you probably spend the majority of your day sitting behind a desk. In fact, 50 to 70 percent of people spend at least six hours a day sitting. On the surface it might seem a lot better, and easier on your body, than jobs where you have to spend the bulk of your time standing or walking around.

The truth is that spending a lot of time sitting is one of the worst things you can do for your body because of the long-term effects on your health.

The Long-Term Effects of Prolonged Sitting

Sitting takes its toll on all parts of your body, from head to toe.

Effects on the Spine

Starting with the spine, which tends to show the most immediate effects, prolonged sitting can cause trouble in your lower back, in your shoulders and upper back, and in your neck. When you sit, all of the muscles on the front of your body pull forward, which over-stretches the shoulder, back, and spinal muscles on the back of your body. In your lower back this can put you at greater risk for herniated lumbar discs; in your shoulders and upper back it causes pain and inflexibility; and, in your neck it causes muscle strain from you having to hold your head at an awkward angle.

Effects on the Rest of the Body

Sitting causes you to pull your shoulders forward and your chest down toward your lap, which compresses all of the organs in your torso. However, it’s actually the cardiovascular effects of sitting that have the worst effects.

Prolonged sitting constricts the blood vessels in your legs, leading to poor circulation. That poor circulation can lead to varicose veins in the legs, and also to a condition called venous insufficiency which can cause blood clots and damage to the valves in your veins. This poor circulation can also affect how efficiently blood returns to your heart for oxygen, and ultimately how well the muscles, organs, and other tissues in your body get the oxygen and nutrients they need.

Sitting can also lead to muscle atrophy in your core – specifically your upper legs, lower back, and abs – because these muscles often go unused when you sit. As muscles atrophy they use less energy, which affects the way they respond to insulin, which triggers the pancreas to produce more insulin in response.

These are just a few of the effects that sitting can have on your body, all of which can lead to a higher risk of developing certain cancers and a shortened life span. Luckily, there are things you can do to stop the decline, and counteract the effects of sitting.

Turning the Tables

The most important thing you can do is get moving. While going to the gym several times a week is a good start, it’s not enough to counter the effects of hours of sitting. You have to incorporate movement and standing into your routine all day, every day.

One option is to use motorized stand up desk with adjustable height, which will allow you to stand up to do your work. That way, even if you are chained to your desk for the day, you can still get some movement in – especially in the leg muscles that are so important for good circulation. Adjustable desks can also help you improve your posture to relieve the strain on your lower spine, upper back, neck, and shoulders. If an adjustable desk is not an option, then the next best thing is to stand up at your regular desk, and only sit down if you need to write or use your computer.

You also need to schedule periods of movement throughout the day. For example, you can set a reminder to get up and march in place for 60 seconds, every thirty minutes. You can get up and talk to people face-to-face instead of calling or sending emails. Another option is to give yourself minibreaks, after you finish each task, where you get up and move around before moving on to the next task.

If you absolutely must sit, then practice proper eating to reduce the amount of strain on your spine and organs.

•  The seat of your chair should be high enough that your thighs are parallel to the floor and your knees are bent at a 90-degree angle.

•  Your shoulders should be relaxed; your arms close to your sides, and your elbows bent 90 degrees when resting on your desk.

•  Your chin should be parallel with the floor, and your ears in line with your shoulders.

•  Your feet should be flat on the floor.

Your chair should also have lumbar support. If the support is not built in, then use a pillow or cushion. Your monitor should be at, or slightly below, eye level so that you don’t have to crane your neck or tilt your head out of alignment.

At the end of the day, you should do exercises that stretch out the front of your body, and help relieve the strain in your back, including:

•  Back bends;

•  Hip flexor stretches; and

•  Spinal twists.

You should also do exercises that strengthen your core muscles, such as Pilates, crunches, back extensions, squats, and lunges.

This is a blog post by Nancy Evans.

Diabetes: Eating on Vacation

In a recent article about planning to travel with diabetes, we touched briefly on the subject of food. Most travel food can be a diabetic’s nightmare, with very little fresh fruit and veggies, and a lot of sugary, salty snacks and fast food. Once you reach your destination you could also encounter issues with the local foods having more sugar, salt, and calories than is recommended for healthy people, much less diabetics.

Bringing your own food can make things easier, but it can also cause you to miss out on the local flavor. However, there are solutions that can help you enjoy some local delicacies during your vacation, without threatening your health.

The Diabetic Diet

The first thing you should realize is that having diabetes doesn’t mean that you have to deprive yourself. While it is true that you should seriously limit your consumption of foods that are high in sugar, or have a high glycemic index, that doesn’t mean that you have to completely avoid everything.

The key is in making healthy food choices so that you can include the occasional splurge, such as a cocktail with dinner or a starchy side dish. The American Diabetes Association has several useful tips for eating well on vacation including:

•  Keeping a schedule. The excitement of vacation often means we end up eating at irregular times. Noontime breakfasts and late-night dinners are often the norm. But for diabetics, a change in routine could mean serious blood sugar spikes or hypoglycemia. When on vacation, try to keep as consistent a dining schedule as possible. If you can’t then be sure to have healthy snacks on hand so that you can eat at the scheduled time, no matter where you are.

•  Check your blood sugar. Check your blood sugar frequently throughout the day. Keeping regular readings will let you know how well you are managing your blood sugar levels, and can help you determine if that piece of cake or glass of wine is in the cards for that day. Make sure you stock up on testing supplies before your trip, so that you don’t run out. If you can’t find the supplies you need for your particular brand of glucose meter, you can buy diabetic test strips at adwdiabetes.com and similar online retailers.

•  Watch portion sizes. If there is any time to turn in your membership to the clean plate club, it’s when you’re on vacation. Many restaurants have huge portions and it could be tempting to eat it all, especially if taking home the leftovers is out of the question. One way to avoid getting too much food is to ask if there are lunch portions available. Another option is to share an entrée with someone else.

•  Ask for substitutions. Many restaurants are willing to accommodate people who have special food needs, including making substitutions. Instead of having starchy potatoes as a side, you could substitute steamed vegetables or a salad.

•  Splurge with care. It’s ok to allow yourself the occasional treat. If that chocolate cake is calling your name, order a piece, and eat it wisely. For example, you could get an extra plate, take a few bites for yourself, and then share the rest with everyone at the table. Another option is to see if they have miniature or sugar-free versions of the same dessert. If you do eat the whole piece, and then make adjustments elsewhere in your diet to accommodate the extra sugar and calories from the cake. For example, if you know you’re going to have some cake, consider eating a low-calorie dinner that’s high in fresh vegetables, and low in sugar and fat to “make room” for the cake.

•  Eat in. If you are staying in a place with kitchen facilities, you can reserve a night or two where you prepare a meal in, and eat at home. Even if you are in an exotic location, you should be able to find some familiar staples like eggs, chicken, beans, and fresh vegetables, from which you can create a healthy, diabetic-friendly meal. Eating in will not only helps you manage your diabetes, it could also save you money.

As you can see, remaining diabetic-friendly on vacation does not mean that you have to feel deprived. It’s mostly a matter of being aware of how and what you are eating, and making the appropriate adjustments.

This is a blog post by Nancy Evans.

How to Make the Best Healthy Fried Egg White

Making a good fried egg white is a tasty and healthy alternative for people who want to avoid the cholesterol from egg yolks. While it may seem simple to do, you can quickly wind up with a filmy egg that does not taste good. Texture is very important when it comes to friend eggs. The goal is a restaurant quality sizzling egg white that can be seasoned with some salt, pepper, and other low fat ingredients such as hot sauce.

To make a great fried egg white, the first thing you need is a flat cooking surface such as a thin griddle pan or griddle. This is the griddle pan that I use. The reason you want the cooking service to be thin is because it provides more direct heat to cook the egg fast.

The second thing you need to do is spray the griddle at room temperature with a cooking spray. Then wipe the beads of spray off of the griddle with a paper towel or napkin so you just leave a thin film of oil on the griddle. If you don’t do this, when you heat the griddle the cooking spray will turn dark and will make the egg taste bad.  It will also steam up too fast and make the egg filmy.

Once you have wiped off the beads of cooking spray, turn the heat up close to the highest level (e.g., 5 out of 6). Keep the heat running for about two and a half minutes. This is very important because you want the egg whites to sizzle as soon as they hit the griddle. If you put the egg whites on the griddle too early, the egg will turn filmy and will not taste good. If you wait too long, the pan will begin to steam. If that happens, turn the power off until the steaming goes away and then turn it back up again and pour the egg whites on after a few seconds.

The way you know that you’ve got it right is as soon as the egg white hits the griddle, it will sizzle and begin to bubble. Once you see the bubbles, you know you are all set. If using a griddle pan be sure to tilt the handle upwards so that the egg stays centered in the pan. Once the egg white cooks more this will no longer be needed.

Egg white with ham and cheese.

Then just use a spatula and flip it over once it looks crisp (about 20 seconds or so). The other side will then cook fast and you will be done. You can then add whatever toppings you want.

As you can see to the right, I added some thinly sliced cheddar cheese, ham, salt, and pepper. Fold one half over the other if you want to place it on a bagel or English muffin. Enjoy!

The Different Types of Nurses

Most of us think we have a pretty clear idea of what nurses do. In a doctor’s office, they are usually the ones who take your vitals and medical history before you see your doctor, and they may even administer medication.

In a hospital, nursing home, or hospice setting, they usually take care of all the things that doctors don’t have time for, like taking patient temperatures, administering medication, and changing bed pans.

Nurses do all of these things, but they also do much more. Also, there are different levels of nursing, and each level has different responsibilities.

The Levels of Nursing

In the United States there are generally three different types of nurses: non-degreed, degreed, and those with advanced degrees.

Non-Degreed

• Non-degreed nurses are professionals who have not completed a college degree program. These nurses include Certified Nurse’s Aides (CNAs) and Licensed Practical Nurses or Licensed Vocational Nurses (LPNs or LVNs). While these types of nurses don’t have degrees, they do have to complete intensive training course and pass either certification or licensing exams to get their titles. CNAs usually have to complete an eight-week program, and LPNs usually have to complete a year-long program.

Degreed

•Degreed nurses have either associates or bachelor’s degrees.

•Degreed nurses usually become Registered Nurses (RNs) and, like their non-degreed counterparts, have to take a certification or licensing exam once they complete their program.

Whether the RN has an associate’s degree or a bachelor’s degree, the work tends to be similar. In addition to many of the responsibilities of the CNA and LPN, the RN also has the ability to choose a specialty, such as pediatrics or geriatrics. RNs might also have a greater range of responsibility when it comes to administering patient care.

One big difference between the bachelor’s and associate’s degree is that RNs with bachelor’s degrees tend to have more career opportunities; which is why some RNs start out with associate’s degrees from one institution, and then go on to another school to complete their bachelor's. Or, they start their careers and then finish up their bachelor's through an accelerated online program, like the one offered at Gwynedd Mercy, a great nursing school in PA.

Those with Advanced Degrees

Nurses with advanced degree have completed a bachelor’s program, and then gone on to complete a master’s or PhD program in a specialty field. These types of nurses can include Nurse Practitioners (NP), Certified Nurse Midwives (CNMs), and Nurse Epidemiologists.

Nurses with advanced degrees can have a variety of jobs, depending on their area of specialty. For example:

• Nurse Practitioners perform many of the same functions as medical doctors including ordering screening tests, diagnosing patients, and prescribing medication for minor illnesses. You can often find nurse practitioners at urgent care centers, or those medical clinics you find in grocery stores and drug stores. They might also work in rural communities, and other areas where medical doctors are scarce – such as a public health clinic in a mountain town. Nurse Practitioners usually work under the supervision of a medical doctor, although the doctor might not be on-site.

• Certified Nurse Midwives perform many of the same functions as obstetricians and gynecologists in that they provide care throughout all stages of pregnancy, including routine gynecological care during the pre-pregnancy stage, prenatal care during pregnancy, performing the delivery, and caring for the mother and child during the postpartum period. Like Nurse Practitioners, they can often be found in areas where the services of a medical doctor might not be available. They are also an alternative for women who prefer the services of a midwife over a hospital birth.

• Nurse Epidemiologists are a combination of nurses and research scientists. They perform regular nursing duties but they also conduct investigations, review patients for infection risks, and help develop protocols for preventing infection. Nurse epidemiologists can usually be found in hospitals and public health centers. They can also be found in the field, during disease outbreaks, providing care to the infected and working to prevent the spread of the disease. For example, Kaci Hickox, who was detained in New York in November 2014, was a Nurse Epidemiologist in Sierra Leone during the Ebola crisis.

These are just a few of the jobs that nurses can do with advanced degrees.

Conclusion

Nursing is so much more than just bedpans and thermometers. You can find nurses with advanced degrees in almost every aspect of the medical field, from the research and development in the private and academic sector, to community education.

This is a blog post by Nancy Evans.

Patient Retention: Tips to Improving Communication and Patient Experience

As physicians, you’re already equipped with the ability to communicate with your patients on a regular basis. Be that as it may, communications with doctors and patients today are not as they used to be in times past.

Why? Because as the need for medical attention increases around the country, the amount of patients you see in a given day can become overwhelming. As a result, the first things to suffer are communication and quality customer service.

As we know, communication and involvement with patients is what makes them comfortable – it’s what keeps them coming back. Statistics reported by Solution Reach suggest that doctors lose about 50% of their patients in a five year period.

So how do you lower those percentages in your practice? There are ways in which you can see all of your patients while still being an effective communicator and providing the best customer service. The key is to learn smarter ways to make use of your time. It requires the need to refine basic communication skills and make necessary adjustments that will work for you and your patient.

Make Necessary Adjustments

The average patient’s expectations have certainly changed. Therefore, having basic communication skills may not be enough to ensure patient retention. You see, the average patient wants to be a part of the health care process. They no longer want to be instructed on what to do. Patients are now more informed than ever and will want logic, reasoning, and proof as it pertains to their health and the decisions you make as a medical professional. So how do you make adjustments based on the various changes in patient expectation?

Be Reliable – Reliability is a major component of trust. An unreliable doctor essentially leads to a dissatisfied patient. So if you’ve told a patient that you will call them within a few days to brief them on their lab results, it is necessary that you carry that out. This lets patients know they can rely on you.

Be Available – Patients want to know that whenever they’re in need they can count on their doctor to be there. Being available is not always easy, but finding alternative methods for displaying your presence or concern for their needs is a must.

Quick Tip: Sometimes being physically there for your patients whenever they call is impossible. However, by utilizing technology to your advantage, you can show your patients you care whether they’re in your office or at home. Using platforms such as social media or patient portals can be a great way to do this. It allows patients to communicate with you 24/7 and view pertinent information about their health.

Provide Quality Visits – When a patient comes in to see you, they want the ultimate experience. A customer should be greeted with comfort every time they come to see you. Family Management Practice suggests that you don’t skip the pleasantries. Greet your patients with a smile, show concern, be an involved listener, and most importantly don’t rush them. The key to keeping patients satisfied is making them feel as if their needs were met and that they’re not just another dollar sign.

Quick Tip: A survey or evaluation provided to patients is a great way to measure their experience. Having new patients complete these surveys can keep you and your staff aware of all the areas in which you can improve your customer service and patient experience.

Follow-up/Stay Involved – Even after your patients have left the office staying involved as their doctor is imperative to opening up the lines of communication, building trust, and enhancing their experience as your patient. Find ways to follow up and stay involved with your patients. Whether you send out appointment reminders, send out notices of concern when you haven’t seen them in a while, and even sending out birthday emails or cards can show that you care about them as individuals.

Yes, it can be challenging at times to stay involved with each and every one of your patients, but it is absolutely necessary to ensure they prioritize their health and keep coming to you for treatment. To prevent losing your patients it is important to communicate often and provide them with the best experience possible both in and out of the doctor’s office.

This is a blog post by Nancy Evans.

Pregnancy In The 21st Century: A Non-Invasive Alternative to Amniocentesis

We're in an age ruled by science and technology, and your pregnancy is definitely going to be affected at some point in the near future - or currently - by the breakthroughs in modern medicine. One of the most popular trends in pregnancy-related science has been that of the noninvasive genetic testing. These prenatal DNA tests are able to test for multiple chromosomal abnormalities such as trisomy 21 (Down Syndrome) or trisomy 18 (Edward Syndrome).

These types of tests are most commonly performed on expectant mothers that are deemed as increased risk pregnancies, such as a mother that is over 35, or has had a previous family history of genetic birth defects. In this case, it wasn't at all uncommon for a physician to recommend an amniocentesis in order to test the baby for common genetic abnormalities. Amniocentesis is still used, but now it is just one of multiple options that your healthcare provider has in order to test for chromosomal abnormalities.

Amniocentesis is an invasive procedure, but until recently it was the only way to test for certain chromosome abnormalities, genetic disorders, or neural tube defects. Trisomy 21 (Down Syndrome) is the most common of these abnormalities but the test can also uncover additional chromosomal abnormalities such as those found in trisomy 18 (Edward Syndrome) or trisomy 13 (Patau Syndrome). Besides the uncomfortable nature of the procedure, another drawback with amniocentesis is that the family would typically have to wait until the fifteenth week of the pregnancy, and it isn’t unheard of to wait until twenty weeks to be able to do a safe amniocentesis. The obvious benefit to the prenatal DNA testing is both in speed (from lab to your healthcare provider's office in 5 days) and the fact that the tests are simple and more accessible than ever.

With an obvious need for noninvasive prenatal tests, doctors have begun using cell free DNA tests that can detect the some of the same sort of genetic issues as a traditional amniocentesis. Bioscience companies like Sequenom are making this sort of testing easily accessible by medical professionals who prefer a test without the risk of prenatal invasive procedures. It seems the problem in past years wasn't the procedural awareness - DNA sequencing and genetic testing has been around for more than a decade - but dealing with off-site laboratories that made this sort of testing accessible.

A simple prick from a needle and a small amount of blood now give lab technicians all they need in order to test for genetic mutation and deformities such as trisomy 21 (Down Syndrome), trisomy 18 (Edward syndrome) and trisomy 13 (Pateau Syndrome). In fact, the testing has success rates of 99-percent at detecting trisomy 21 pregnancies, 98-percent with trisomy 18, and about 65-percent with trisomy 13. With trisomy 13 tests, there is often a need for an amniocentesis or chronic villus sampling (CVS) with positive test results.

The test itself often relies on a simple blood test taken from the mother. A small amount of blood is drawn and sent to a laboratory and your healthcare provider will receive the results within 5 days from the date the laboratory received the initial sample.

The future is bright for early detection of all types of birth defects. These simple noninvasive procedures are set to revolutionize the way doctors test for complication in high risk pregnancies. In many cases, knowing about defects before the birth of the child helps the parents to prepare for the specific set of challenges they'll face after the baby is born.


This is a blog post by Nancy Evans.

Effects of Aging on the Skin

Human skin is amazing. Not only does it keep all of your organs inside your body, it performs other functions including:

•  Protects you from ultraviolet radiation and environmental irritants;

•  Prevents the moisture inside your body from escaping;

•  Helps regulate your body temperature;

•  Eliminates wastes; and,

•  Acts as the first line of defense against diseases and infections.

Because it performs so many functions, and is so exposed, your skin is often the first to show early signs of aging.

How Aging Affects Your Skin

Your skin is made up of three distinct layers, all of which help it perform its many functions.

•  The epidermis is the outer layer. It is made up of cells that overlap and stack on top of each other like tiny plates of water. When the epidermis is healthy and intact, it is water-tight and also prevents bacteria, viruses and other foreign substances from getting inside your body. The epidermis also contains melanin which contributes to your skin color and filters out UV radiation.

•  The dermis is the middle layer. It is the thickest layer and is made up of collagen, elastin, and fibrillin, which give the skin its strength and shape. It contains several structures like nerve endings for sensation, sweat to help regulate body temperature, blood vessels to feed the skin nutrients and regulate body temperature, and hair follicles. The dermis also contains glands that release an oily substance called ceramides, which moisturize the epidermis, and help form the barrier against water and foreign substances.

•  The hypodermis is the bottommost layer. It contains blood vessels to feed the skin and regulate temperature, fat cells for insulation, and connective tissue to anchor the skin to your body.

As you age, the layers of your skin stop functioning as well as they should. For example, the glands in the dermis could stop making enough ceramides, causing the epidermis to dry and crack.

Several factors can determine how quickly your skin ages, including as lifestyle, skin tone, ethnicity, and heredity. However, one major factor is UV radiation.

Although the skin is designed to be a UV filter, it is not immune to the effects UV radiation. Long-term exposure to UV radiation can damage all of the cells and structures in the skin, such as melanin cells, collagen cells, and even the glands that make ceramides. In the best case scenario, the damage prevents the cells and structures from functioning properly, leading to wrinkles, cracks, dark spots, and other signs of aging. In the worst case scenario, it can lead to cancer.

Protecting Your Skin

The best way to protect your skin is to avoid direct sunlight as much as possible, and wear sunscreen whenever you do go out into the sun. Stay hydrated, so that your sweat and oil glands have enough water to do their jobs, and moisturize your skin often.

If your skin is already showing signs of aging you could try one or more of the following:

•  Anti-aging cleansers, moisturizers, and serums that contain products that stimulate collagen production, such as peptides and Retin-A;

•  Phytoceramides. Phytoceramides are plant-based versions of the ceramides your skin naturally produces. Used topically, phytoceramides are supposed to hydrate the skin, and repair wrinkles and other signs of aging. Phytoceramides are available in the US as a dietary supplement, but they might not be available in all areas. You might have to talk to a dermatologist or skin specialist about where to buy phytoceramides.

•  Skin fillers, such as natural collagen. Skin fillers help fill in the creases and lines caused by collagen loss in the skin, and some of them also help stimulate your natural collagen production.

•  Microdermabrasion or skin peels. Both skin peels and microdermabrasion both remove some of the cells in the epidermis which immediately reduces the appearance of fine lines and wrinkles, and stimulates collagen production to help keep wrinkles at bay.

•  Laser skin resurfacing. Laser skin resurfacing uses pulses of light to plump up the skin and fill in wrinkles, lines, and ridges, and stimulate collagen production.

•  Your doctor or dermatologist. You should always consult your physician if you feel that your skin is aging too quickly, of if you are concerned that some dark spots and age marks are the sign of a more serious issue – especially if you have a family history of skin cancer.

This is a blog post by Nancy Evans.

School Shootings: Why Social Media Should be Monitored

Above: Washington school shooter's Twitter post days before the shooting. 

In the wake of the latest school shooting in the state of Washington, much attention has been paid to the shooter’s (Jaylen Fryberg’s) Twitter account. In fact, after a school shooting, social media sites are typically the first place that people go to learn about the assailant. While this is understandable, one has to wonder if any of these school shootings could be eliminated if someone had paid more attention to these shooters’ social media sites before the shootings.

Possible interventions ahead of time can include psychological counseling (outside and/or inside school) to teach adaptive and prosocial coping mechanisms to deal with stress and conflict, psychotropic medication consultation, more careful and close monitoring of the person’s emotional state by family and health care providers, and removal of firearms access by family members and others known to be close to the individual. Media accounts state that the firearm used by Fryberg belonged to his father.

Taking a look at Fryberg’s Twitter account, once can see that there is an incredible disconnect between how he portrayed himself online compared to how others appear to have viewed him in person. A student at his school, Alex Pietsch has been quoted as saying:

"It's weird to think about, because you see him and he is such a happy person." You never really see him be so angry and so upset. ...”

Yet on Twitter, here are a few of Fryberg’s comments made since June 2014, which show a disturbing trend:

On June 17, Fryberg  seems upset about something (“This Is a F***ing joke”), perhaps after doing some yardwork for a house he says “we” are not going to purchase. Or perhaps it was about something else.

The July 17th comment notwithstanding, it all seemed to go downhill on June 18 when Fryberg appeared to be having an argument with someone, suggestive of a relationship breakup. In fact, media reports state that he had broken up with a girlfriend recently. Posts that day include a long drawn out “F*** YOUUUUU!!,” and “You’re starting to piss me off” followed by an emoticon blowing out steam. Those comments were followed by:

“YOUR SO F****ING BRAVE!! JUST REMEMBER THIS IS F***ING IT!! NO MORE AFTER THIS” along with three angry emoticons.

The next day, Fryberg is still angry with the following posts: “WTF EVER!!” and a long drawn out F word in all caps with angry and sad emoticons and many exclamation points. The most ominous and threatening comment that day was this one:

“I Know Your Weaknesses And What Breaks You... And When That **** Happens... Just Know There's No Coming Back (emphasis mine)” followed by a sad face.

He then said he was going to a hospital, but no reason is given. Only one person asked him why.

On June 20th, Fryberg seems to express regret coupled with anger when he wrote,

“What The F*** Did I Just Do…F*** it.!! Might As well Die Now (emphasis mine).” 

Each of these sentences was followed by a series of sad faces, broken hearts, and steam coming out of an emoticon’s nose. Prior to that posting, Fryberg wrote numerous comments expressing infatuation with someone he appeared to be dating. After the break-up, he wrote posts that appear to reflect him missing being with someone romantically (presumably his girlfriend).

Only July 3rd, Fryberg’s post became more threatening: “It’s about to go down” followed by an emoticon of wide-eyes fear.

Fast forward to August 20th, in what could be considered a foreshadowing of events to come he wrote:

“Your gonna piss me off…And then some s****’s gonna go down and I don’t think you’ll like it…Your not gonna like what happens next!!" (emphasis mine) ” followed by emoticons with steam coming out of their nose.

Some of his posts also displayed an element of possessiveness, presumably over the girl he was dating. He then wrote on the same day, “I hate that I can’t live without you. “This comment was followed by emoticons of rage, sadness, disgust, worry, and blank expressions. That day, he retweeted a comment that the first heartbreak is “unforgettable.”

On August 23rd, Fryberg is angry again, with comments such as, “Sick of this S***!!” and “Oh My God This Is So F****ing Stupid!!” followed by angry emoticons.

On September 16, Fryberg wrote “Fml” which means F*** my life. He appeared to be getting more and more despondent.

On September 19, Fryberg gets into an online dispute with someone he was apparently pretty close to about his girlfriend. In one of the posts that day, he writes:

“Dude. She tells me everything. And now. I f***ing HATE you! Your no longer my "Brother!” He appears to feel betrayed. He then wrote, “Night f***ing RUINED.” 

On September 20th, Fryberg writes: “I Hate Hearin S*** Like That.. It Just Continues To F*** Me Up. I Just Feel Stupid Now.. Exactly What I Thought Was Gonna Happen Happened..”

He followed this up with two more posts that day: 1)"I HATE THIS S***” and 2) “I'm tired of this s***. I'm sooo f***ing done!!! (emphasis mine)” each containing emoticons of frustration.

On October 13, Fryberg retweeted a post saying “I miss you, and it's killing me” followed by an emoticon of anguish and a long drawn out “F*** you” with an emoticon of anger.

On October 21, Fryberg appears to snap when he writes,

“Alright. You f***in got me.... That broke me. It breaks me... It actually does...(emphasis mine) I know it seems like I'm sweating it off... But I'm not.. And I never will be able to...” 

Consistent with this timeline, media reports state that his demeanor changed markedly and that he refused to talk about it. He then wrote, “I should have listened.... You were right... The whole time you were right..” 

On October 23, the day before the shooting, Fryberg wrote, “It won’t last…it’ll never last…”

These postings are not consistent with someone who was a happy person over the past few months. In fact, he clearly was despondent, angry, and sad. Someone in this type emotional state, especially a minor, should not have access to firearms. If a family member of a child expressing such emotional distress owns firearms, the firearms need to be locked away with no way that the child can access the key.

If children under 18 are permitted to have a social media account, it needs to be monitored closely by the parent. By monitoring, this does not mean to allow the child access to a private account with the parent peeking over the child’s shoulder occasionally but it is what too many people do. Monitoring means that you are granted access to the child’s account by being part of their social media network. It should be made as a condition to permit social media access. You can promise not to post to the child’s account so as not to embarrass them, but they key is that you are monitoring it and interfering if you see signs of cyber-bullying, threatening comments (against or from the child), and/or signs of significant emotional distress. If the child does not agree to grant you access, then no social media account.

For counselors, it is definitely worthwhile to search for your client/patient’s social media profile so that timely interventions can be made. As this case shows, children (and adults) will sometimes present differently on the outside than they will when behind the safety of a computer (or smartphone) and a keyboard. It is important to note that it is not unethical to view these social media accounts as long as you are viewing publicly available information. You also do not need to have a patient sign a consent form to view publicly available information. Many children do not put any sort of privacy setting in place and allow the entire contents of their social page viewable to the public.

What a counselor should not do, however, is hack into someone’s private (non-public) social media account. If the account is locked to private, you are out of luck as a counselor but this is where the parent or guardian comes in as a safeguard. While we may not be able to stop all school shootings by checking social media websites, more regular social media monitoring is a potentially helpful way to prevent some of these shootings in the future. This should be integrated into a regular part of clinical practice for counselors in the future.

Here's What You Need to Know About Mesothelioma

Asbestos: The Cause of Mesothelioma

You can’t watch an episode of anything on Court TV without at least one commercial about mesothelioma.

If you or someone you love has been diagnosed with the condition, and you want more information about what to do next, read on:

Asbestos: The Gateway to Mesothelioma

By now, everyone knows that asbestos is linked to mesothelioma. The only real question is why did we use it for so long. For that matter, why are we still using it? Unfortunately, the cynical answer and the true answer are one and the same. Asbestos is a tremendously useful mineral that has all sorts of industrial implications. It is still cheaper for companies to lawyer up, and fight the legal battles, than to stop using asbestos altogether.

But how much do we know, and how long have we known it? In 1970, an asbestos company’s internal memo detailed the company’s knowledge of the level of asbestos exposure that would result in mesothelioma. They had conducted intense animal testing to show how asbestos effected humans. They even learned which types of asbestos were more harmful. They continued to use asbestos.

Yet another company revealed in a letter to the Gypsum Association Safety Committee, their intention to place the blame on the employees despite the fact that the company was fully aware of the dangers of asbestos. They continued to use asbestos.

As for when we knew, it was long before 1970. Set the wayback machine to 1906, and you will find the first proven case of an asbestos-related death to be reported and confirmed. The dangers of asbestos were known well before that.

Industrialization is a powerful motivator. Once we discover something as useful as asbestos, we find it difficult to relinquish, even long after we know it is killing people. As with a drug, once we get hooked, we rationalize while the people around us suffer.

How Mesothelioma Is Contracted

Here’s the good news: You cannot inherit mesothelioma. Unlike other cancers, it is not genetic. It cannot be passed on from one generation to the next. It is also not contagious. There, the good news ends. The simple and shocking fact is that we know of only one way to get mesothelioma, and that is through exposure to asbestos.

It is important to know that asbestos is a naturally occurring mineral. But people with mesothelioma didn’t catch it from a walk in the park. This is an industrial strength, industrially manufactured disease. To put it in no uncertain terms, humans cause mesothelioma.

Cancer, By Any Other Name

Mesothelioma is cancer. More to the point, it is a type of lung cancer. Pleural is the most common of three types of mesothelioma. This type effects the lungs, and can easily be mistaken for other ailments. Peritoneal and pericardial are the other two. They attack the abdomen and the heart respectively.
As with other cancers, there is no cure for mesothelioma, and it often presents later in life. Asbestos does not go away once in the body. It can hang around for 30 years before the cancer presents.

Who Is At Risk

According to the National Heart, Lung, and Blood Institute the following are most at risk:

•Miners
•Aircraft and auto mechanics
•Building construction workers
•Electricians
•Shipyard workers
•Boiler operators
•Building engineers
•Railroad workers

Add to that list anyone living in a house built before 1980. The condition of the asbestos is key, and can be assessed by a professional. To learn more about mesothelioma and lawsuits related to it, follow the link provided and check out the resources.

While Americans have greatly reduced their dependency on asbestos, it is still legal in this country, though 55 other countries have banned it. Though the dangers are as well-known as the benefits, developing nations are still using asbestos to help spur their own industrial revolution. Mesothelioma is the inevitable result of this reckless industrialism.

This is a blog post by Nancy Evans.

Common Disabling Automotive Injuries

Almost anyone who has been disabled in an automobile accident will tell you that it ultimately doesn’t matter how they became disabled, it only matters that they became disabled, and that their lives are forever changed. That being said, it’s still a good idea to understand the types of disabling injuries that can occur in an automobile accident to understand how the injury occurred, and the options for treatment.

It’s also a good idea to learn about these types of injuries to understand how they can be prevented in the future.

The Impact of Automotive Injuries

Whether or not the automotive injury results in a physical disability, it can still have a long-term physical and mental effect on a person’s life.

Accident survivors can often spend years, and thousands of dollars, recovering from an accident, and during that time, many people are unable to work or earn a living. If the injured party was not at fault for the accident, he might be able to get assistance from his insurance company, or even from the individual who was responsible for the accident. However, doing that often involves a lot of time and energy that someone recovering from an accident can’t necessarily afford.

For example, if someone is injured in an accident on the Dallas North Tollway, and the police find another driver at fault, that other driver's insurance could pay the medical costs. The thing is, no one is going to have the energy to deal with an insurance company while recovering from an accident. However, if the injured party hires a Dallas car wreck lawyer, the lawyer can focus on the insurance company, while the injured party focuses on getting well.

Automobile Accident Injuries

You can sustain almost any type of disabling injury in an automobile accident. However, there are certain disabling injuries that are more common to automotive accidents than others, specifically brain injuries; and neck, spinal cord and back injuries.

Brain injuries

Brain injuries are the most common type of disabling injury in automobile accidents. These injuries are usually the result of the head violently striking a solid object, such as the vehicle dashboard. Brain injuries can also happen to people outside the vehicle if they are hit by the vehicle or debris from the accident, or if they are thrown from the vehicle during the accident. Another type of brain injury occurs when the brain hits the interior of the skull, even if the exterior of the skull is undamaged. In some cases a brain injury could occur as a result of penetration – a piece of the vehicle pierces the skull.

The severity and long-term effects of head injuries can vary depending on several factors including:

•  The intensity of the impact;

•  The area of the brain or head that is injured;

•  The interval between injury and treatment, because the brain can swell, which can cause more damage than the initial impact.

Because the brain controls many different bodily functions, the type of disability caused by a brain injury depends greatly on the area of the brain that is damaged. For example, damage to the part of the brain that controls memory could result in difficulty learning or retaining new information. Damage to the motor center could result in a loss of fine motor skills in the hands or in the ability to walk. It is also possible to suffer damage in multiple areas.

Neck, spinal cord, and back injuries

The terms “neck injuries” and “back injuries” usually refers to damage to the muscles, bones and cartilage in the back and neck, with or without spinal cord damage;  the term “spinal cord injuries” refers only to damage of the spinal cord. These injuries could be the result of impact or penetration and, like brain injuries, the severity and long-term effects of the injury are determined by a variety of factors. Additionally, the type of disability depends on the location of the injury.

For example, a person who suffers broken vertebrae and bruising, or incomplete spinal cord damage, in the neck might have his neck bone surgically fused together, preventing him from turning his head, and might suffer numbness and mild loss of from the point of the spinal bruising down, but won’t be completely paralyzed.

Injuries are a major risk in any automotive accident, but there are ways to reduce your risk:

•  Always wear your seat belt, even for short trips;

•  Adjust the headrests to support your skull and prevent your head from snapping back; and,

•  Secure any loose items to prevent them from flying around during an accident.

This is a blog post by Nancy Evans.

Drug Side-Effects: When the Cure is Worse Than the Disease

Treating disease is not easy. For one thing, despite all of the advances in medical technology, there’s still so much we don’t know about the human body and the disease process. Many of the treatments that we take for granted have only been in use since the early twentieth century.  For example, the antibiotic penicillin was not discovered until 1928 and did not reach wide distribution until 1935.

When penicillin was introduced it was considered a wonder drug because it was able to prevent hospital-borne infections, and cure diseases that were previously considered terminal, like syphilis. However, there were also people who were allergic to penicillin, which made the drug dangerous for them to use. Overuse of penicillin also led to more resistant bacterial strains and the need for even stronger antibiotics.

Penicillin is not the only drug that has issues; in fact, most prescription drugs have side-effects of some sort. However, there are those with side effects so bad that it makes patients wonder if the cure is worse than the disease.

Risperdal

Risperdal is an anti-psychotic drug used primarily to treat schizophrenia, but could also be used in the treatment of bipolar disorder and irritability associated with autism. The drug is designed to make patients with these diseases more “even,” and less likely to harm themselves or others.

All of the diseases that are treated by this medication can be seriously debilitating and also difficult to treat.

For example: Schizophrenia causes delusions, visual and auditory hallucinations, and manic-like behavior. It’s not unusual for one antipsychotic drug to alleviate one symptom but have no effect on the others. Sometimes a patient has to try multiple drugs, and multiple drug combinations, before finding one that will alleviate all of the symptoms.

For many patients Risperdal, either alone or with other drugs, gives them relief from their symptoms and allows them to lead normal lives. Without it they could end up institutionalized, unable to function at all. But Risperdal also has its problems, some of which have made it the focus of a lawsuit.

The Risperdal lawsuit alleges that several patients have developed debilitating and even deadly side effects such as seizures, diabetes, breast cancer, and sudden changes in blood pressure. The issue is that many patients were unaware of these side effects when they took the drug. For some it might not have made any difference, Risperdal might have been the only medication that worked for them. But others could have opted to try a different drug to avoid the side effects. Additionally, it is alleged that drug reps were advised to suggest the drug for off-label use, such as dementia and anxiety, which would have meant thousands more people exposed to potentially deadly side effects.

Fen-Phen

Fen-Phen is a diet drug that was introduced in the 1990s. It was a combination of two drugs – fenfluramine and phentermine – and was touted as a miracle drug for weight loss. Fenfluramine was an appetite suppressant designed to make people eat less, and phentermine was an amphetamine designed to increase the heart rate and raise the metabolism. At its peak, Fen-Phen was prescribed to an estimated six million people, and many people swore by its effects. Unfortunately, like Risperdal, Fen-Phen also had its share of issues, and was the subject of a lawsuit.

The Fen-Phen lawsuit came about after the drug was taken off the market due to reports of heart valve damage in 30 percent of patients who took the drug. Heart valves are structures that prevent blood from flowing backwards inside the heart. The heart has four valves, all designed to keep blood flowing in the right direction. When a valve is damaged, blood cannnot flow properly and that can put you at greater risk for a heart attack. Damaged heart valves are incurable; once the valve is damaged the patient either needs to take medication and make lifestyle changes to prevent further damage, or they need to have the faulty valve replaced.

Fen-phen was also linked to a potentially fatal lung condition called primary pulmonary hypertension (PPH), or high blood pressure in the arteries in the lungs. The danger of PPH is that the arteries in the lungs can constrict and thicken, which means they can’t carry as much blood and the blood can’t get as much oxygen from the lungs.

Millions of people were exposed to these side effects because it was prescribed so freely, even though many health experts warned that the drug should only be prescribed to the seriously obese.

This is a post by Nancy Evans.

Water Safety at the Jersey Shore

As the summer season winds down, we’re heading away from the many beaches, and toward drier fall activities. Although we’re heading away from the water, we shouldn’t lose sight of the dangers that can lurk on the many beaches along the Jersey Shore. New Jersey has roughly 130 miles of coastline that offer everything from boardwalks and fishing to swimming and surfing, and with all those activities come the risk of drowning. This is not to say that the beaches are dangerous, but safety should always be a concern whenever you get near the water.

The CDC reports that ten people die each day from unintentional drowning, and roughly two in ten are children aged 14 and younger. Additionally, drowning is the fifth leading cause of unintentional injury and death in the US. Roughly 81 percent of water incidents are attributed to riptides – strong, narrow currents that form as waves and travel from deep to shallow water. Riptides move away from the shore and anyone getting caught in one could be easily pulled into deep water. Although many beaches have lifeguards on duty, it is important for you to understand what to do if you, or someone you know, are caught in a riptide, as well as how to administer CPR in the event of drowning.

Responding to a Riptide

For many people, the first response is to fight against the tide to remain close to shore. While this might seem like a reasonable reaction, doing so can actually make the situation worse. Riptides are so strong that even a Michael Phelps-level swimmer can be easily overcome. Fighting against the current will actually tire you out, making you unable to return to shore once you are out of the current’s grip. That exhaustion will make you more prone to drowning. The following steps can actually increase your chances of escaping the riptide safely:

1.  Remain as calm as possible. Panic can lead to poor decision making;

2.  Riptides are shaped like a funnel with a wide base at the shore that tapers to a narrow neck, then widens to a head at the deep end. Swim along the coastline, which will take you across the current instead of against it, and eventually out of the riptide. Keep your eye on the coastline to make sure you are swimming in the right direction;

3.  When you are out of the riptide, swim toward the shore.

If you are unable to swim across the riptide, remain calm and float on your back or tread water and let the tide carry you out until you either exit the tide naturally, or are able to start swimming across. Always keep your eyes on the coastline.

If you are unable to escape the tide at all, draw attention to yourself by waving your arms and yelling to shore.

If you see someone else stuck in a riptide, do not attempt to enter the water to help. Call 911 or find a lifeguard.

It’s also a good idea to be aware of the conditions that could cause riptides, such as offshore storms.

Finally, you should always take care never to swim on a beach that is deserted or does not have a lifeguard on duty.

Learning CPR

CPR, or Cardio-Pulmonary Resuscitation, is not only handy in drowning situations, but in any situation where someone might stop breathing. You can find several online CPR references for adults and children, but they won’t give you all the information you need. CPR is a delicate procedure that you can only really learn through practice and there are several CPR classes in NJ that can teach you the correct way to administer adult, child, and even infant CPR.

The great thing about these classes is that they are offered year-round, which means you can earn your CPR certification during the off-season and be prepared when you head back to the beaches in the summer.

If you do choose to get CPR certification, you will need to keep it up to date by taking refresher courses every year or so. This is because the America Red Cross is constantly updating the procedure to make it safer, more efficient, and save more lives

This is a blog post by Nancy Evans.

The Woman Who Claimed She Urinated a Bullet

While urinating a worm is physically possible as described in a recent blog post, there is an early medical report from 1668 of a woman urinating something even more incredible…a bullet. The story goes like this.

A large, pale, woman by the name of G. Eliot in Suffolk, England was tormented with intestinal problems for many years. She was persuaded by a neighbor who had similar problems to swallow two bullets.  It is not stated what the logic was behind how swallowing bullets would supposedly help. The woman claimed that she felt better initially after swallowing the bullets but that the pains returned and increased.

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After 15 years of continued symptoms, she presented to Dr. Nathan Fairfax’s pharmacy.  He prescribed her something called Lady Hollands powder that was mixed into a hot drink. She vomited over night.  When using the bathroom the next morning (which was referred to as the chamber pot), she urinated when a thwang was heard on the side of the vessel.  This reportedly surprised her and led her to wonder what it could be. So she poured the urine and saw a heavy gravelly stone that was yellow-red in color and as big as the end of a thumb. However, this is based solely on self-report.  She reportedly took a hammer, knocked off the outer crust, and found a bullet enclosed in it. She then reportedly cut it a little with a knife and found lead within it.

Dr. Fairfax asked her if she had ever urinated bullets before and she said no, including the other bullet. Recollecting back to when she swallowed the two bullets, she stated that she checked her feces slightly for days afterwards and never found the bullets and so she gave up. She stated that the bullet was smaller compared to when she originally swallowed it.  Before and since that time, she stated that she urinated an abundance of red gravel.

Ms. Eliot stated that when she voided the bullet that it felt like a kidney stone but that it lasted longer (i.e., weeks),  caused her to bow forwards, and led to vomiting.  She claimed to feel it move lower from the kidney to the bladder.  Dr. Fairfax asked her if she was sure that the bullet came from the urine and she assured him that it was and that she was not mistaken. Dr. Fairfax stated that the bullet did have a gravelly coat. Since she passed the bullet, she stated that she still had kidney stone pains but not as bad as before.

Dr. Fairfax stated the tale strengthened his belief that there must have been a passage from the stomach to the bladder but in reality, there is no such passage.  He believed that nature had found a way to finally rid the body of something it found offensive. Basically, his argument was that the body works in mysterious ways.

This story is a good lesson that highlights the problem that arises when health care professionals rely on self-report , despite claims that the self-report is definitely not mistaken. What this woman described is actually anatomically impossible. There is no known mechanism by which someone can swallow a bullet or any other foreign object and have it passed from the stomach to the kidneys. When solid objects and liquid enters the stomach from the esophagus it goes directly to the small intestines. The blood picks up excess fluid and is filtered by the kidneys but there is no way for the blood to transfer a solid object from the small intestine to the blood and into the kidneys.

Thus, either Ms. Eliot made the story up and showed the doctor a bullet that was not the one she swallowed or she or Dr. Fairfax misperceived the middle of a kidney stone as a bullet. Incidentally, there is no report in the modern medical literature of a foreign object being passed out of the body through the urine.

Fairfax, N. (1668). An Extract of a Letter, Written by Dr. Nathan. Fairfax to the Publisher, about a Bullet Voided by Urine, Philosophical Transactions, 40, 803-805.

How a Flower Can Kill a Rattlesnake: The Medical Dangers of Pennyroyal Oil

While doing some historical medical research from the 1600s, I recently came across a fascinating account of how people in Virginia used a common flower to kill rattlesnakes. The story was relayed by Captain Silas Taylor to members of the Royal Society in England, who were always interested in hearing new discoveries from places overseas.

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Captain Taylor spoke about how colonists in Virginia used a plant known as pennyroyal (pictured below) to kill rattle snakes. He noted that the leaves of this plant produced a very hot sensation when placed on the tongue.  So the colonists took some of the pennyroyal leaves, tied them to the end of a long stick, and held them by the nose of the rattlesnake.

When exposed to the pennyroyal leaves, the rattlesnakes would turn and wiggle and do whatever they could to avoid it. But the colonists were persistent and eventually the rattlesnake died in less than 30 minutes from the scent of these leaves.

How is this possible? Medical science has the answer. As it turns out, the essential oil in pennyroyal is very high (up to 90%) in pulegone. This oil is highly toxic, particularly to the liver, even at very low levels. (e.g., one ounce). The rest of the oil is made up of similar toxins. Human consumption of just a half a teaspoon of the oil can result in death.

The high toxicity of pulegone is mainly due to methofuran, an organic chemical that the body converts the oil into. Pennyroyal oil can cause seizures, fainting, failure of multiple organs, acute (sudden) kidney and/or liver failure, brain damage, hallucinations, paralysis of respiratory muscles, failure of the heart and lungs, coma, and as mentioned, death. In humans, the toxicity usually occurs a few hours after ingestion, but if one held the flower over the rattlesnake for 30 minutes, the constant exposure to the oils in the flower could explain why death occurred during that time frame.

Pennyroyal oil causes damage to organs by depleting levels of glutathione, a natural chemical in the body that prevents damage to cells. Thus, when not enough glutathione is present, cellular damage occurs quickly.
Humans need to make sure not to ingest pennyroyal oil. For example, in 1996, two infants died because they drank a tea that was made with pennyroyal.  Dogs have died after licking this oil off of their fur. A college student who drank two teaspoons of pennyroyal oil in teas died two days later in 1994. Thousands of years ago, pennyroyal oil was actually used to terminate unwanted pregnancies. It is also used as a powerful insect repellent.

Reference: 1665 (author unknown). Of A Way of Killing Rattle-Snakes. Philosophical Transactions, 3, 43.

Worms in the Urine: Strange Facts

Many people have heard of parasitic worm infections in their animals and even in humans. In those cases, people generally are familiar with worms being found in the fecal matter. However, many people are unaware that people can actually urinate worms. The reason is because some types of worms can infect the urinary tract.

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One type of worm infection is trichomoniasis, but these worms are microscopic. Another worm infection is schistosomiasis, which is caused by a worm called a fluke. This can cause severe kidney failure, blood in the urine, blockage of urine flow, and can eventually result in bladder cancer. In cases of fluke infection, worm eggs are released in the urine from the worms that live in blood vessels around the urinary bladder.

 Another parasitic worm infection is filariasis, which is threadworm infection. This can cause lymph fluid to enter the urine and a severe enlargement of tissues (elephantitis).  Yet another parasitic worm infection that can rarely present in the urine is strongyloidiasis which is caused by a type of roundworm.  Sometimes, the worms are living and swimming freely in the urine.  Identification of worms such as these in urine samples can sometimes prevent fatal health outcomes as these conditions are often treatable and reversible with medication.

Another type of roundworm infection that can rarely present in the urine is Ascaris lumbricoides (see picture above, image copyrighted by the Journal of Postgraduate Medicine).  These worms can live in the body for 12 to 18 months and can produce 240,000 eggs.

One of the earliest accounts of a worm present in the urine occurred in 1677 by a man named Matthew Milford. Mr. Milford noted that worm he passed was snake-headed and alive. He noted that it was small at the tail. He noted being very ill before hand and that since that time he had blood in the urine. He reportedly probably had urinary retention for some time. The worm presented on the second urine, leading the writer of the article to hypothesize that it descended from the kidney to the bladder initially and then out into the urine stream. The worm was then noted to be dead, dry, and a dull red color, with a thickness of 1/12th of an inch. It is unclear exactly what type of worm this was.

Reference : Ent and Milford (1677). A Relation of a Worm Voided by Urine; Communicated by Mr. Ent: to Whom It Was Sent by Mr. Matthew Milford. Philosophical Transactions, 140, 1009.