Five Ways to Evaluate Suspicious Medical Treatment Claims

There has never been a shortage of people proposing miracle medical cures for various ailments, conditions, and diseases. In the 19th century, women would line up to buy vegetable compounds to treat hormonal symptoms, people would buy swamp roots to treat kidney problems, and hippopotamus fat was used as an ingredient to treat baldness.

Medical compounds with questionable effectiveness were known as nostrums or patent medications, even though most were never actually patented. Some patent medications actually worked but had toxic/negative side effects, such as slow death from mercury poisoning when mercury was used treat syphilis or addiction from treating colicky infants with opium. After 100 people died from a drug tainted with an untested solvent in 1937 (known as the Elixir Sulfanilamide tragedy), Franklin Roosevelt signed the Food, Drug, and Cosmetic Act, which increased regulation over medication, required pre-market testing of all new drugs, and banned false therapeutic claims in drug labeling.

These days, suspicious claims of supposed miracle medical cures still exist. The people most vulnerable to trying these treatments are those who are faced with an incurable disease that modern conventional medicine cannot effectively treat or those who have not responded to curable diseases via conventional medicine.

These supposed treatments can now be easily discovered with a quick internet search, but how are consumers supposed to evaluate their effectiveness and how should healthcare providers respond to patient questions about these treatments? Below I will offer some tips on how to do this by using a modern example: the claim that Alzheimer’s disease can be effectively treated or reversed by using coconut oil. This is based on the theory that coconut oil will provide the brain with an alternative source of energy (ketones) due to an impaired ability to use its usual energy source (glucose).

STEP 1: SEARCH THE PEER-REVIEWED MEDICAL LITERATURE: The best place to search the medical literature for peer reviewed scientific research is PubMed. All searches are free, most results contain a summary of the findings, an option to read the entire article (for free or purchase), and contact information for the authors to request a copy of the article. Peer-review acts as a quality control. Articles that have not been peer-reviewed and are merely published on a blog or a website only, have less credibility because they lack peer review. There are no articles on PubMed researching coconut oil as a treatment for Alzheimer’s disease. However, there was an article published by Granholm and colleagues in 2008 showing that a diet high in hydrogenated coconut oil (which contains harmful transfats not found in organic coconut oil) in rats can profoundly impair memory and the structure of the hippocampus (the main part in the brain responsible for memory). Strike 1 against coconut oil, at least the hydrogenated type. See the articles on Lucky Strike cigarettes and Oxydendrine for another discussion of the importance of Step 1.

STEP 2: EVALUATE THE QUALITY OF PEER REVIEWED RESEARCH: Although peer reviewed research is generally higher quality than non-peer reviewed research, there are many peer reviewed articles than contain significant design flaws, limiting the conclusions that can be drawn. The best research evidence comes from studies in which patients were randomly assigned to treatment groups, in which neither the treater or patient are aware of the specific treatment (this is known as being double-blind), and in which one of the treatments was a placebo (a substance containing no actual medication). The less the study contains these features, the less confidence you should have in the results. 

STEP 3: RESEARCH WHO IS PROMOTING THE TREATMENT: It is important to evaluate the person or group of people promoting the supposed treatment to determine if there are reasons to cause suspicion about the accuracy of the claims being made. Examples can include a financial conflict of interest, desire to help a loved one with the proposed treatment, or anger towards conventional medicine. Coconut oil treatment for Alzheimer’s is mainly promoted by a single person (a physician) whose husband has Alzheimer’s disease. This doctor is selling a book based on the claim and has published comments on a website taking personal credit for outsmarting drug companies along with apparent antipathy towards those companies that make “monopoly profits.” This is not to say that family of sick loved ones cannot come up with useful treatments for uncurable conditions. In fact, Augusto and Micheala Odone did exactly that when they discovered that very long chain fatty acids from rapeseed and olive oil can treat adrenoleokodystrophy (a rare and deadly genetic metabolic disorder). The difference, though, is that there is peer reviewed research to support this treatment. Overall, strike 2 against coconut oil.

STEP 4: BE SKEPTICAL OF SUSPICIOUS CLAIMS: As a general rule, if it sounds too good to be true, it usually is. One example is a claim that you can cure obesity by allowing people to eat whatever they want, such as in this 39-Year-Old Obesity Fraud. Or, claims that the treatment can cure just about anything such as Pink Pills for Pale People, the Electric Chain Belt or The Tapeworm Diet. Another good example is a claim that an incurable disease can be cured with the proposed treatment. The fact is that Alzheimer’s disease is incurable and causes progressive degeneration of brain tissue, yet the claim is being made that coconut oil can reverse Alzheimer’s disease and totally halt brain atrophy. These claims are partly based on the doctor observing changes in her husband after using the coconut oil, which leads to a subjective investment in believing the treatment will work. This is not the standard by which medication effectiveness is judged and is very far from the randomized, double-blind, placebo controlled studies mentioned above. Strike 3 against coconut oil.  

STEP 5: RESEARCH WHAT RESPECTABLE ORGANIZATIONS DEVOTED TO THE CONDITION SAY ABOUT THE TREATMENT: If the supposed treatment is not mentioned on professional organizational websites or medical literature devoted to the condition, that is reason to be suspicious. If the treatment is mentioned and discredited, this is even further reason for suspicion. Here is some of what the Alzheimer’s Association says about coconut oil treatment: "A few people have reported that coconut oil helped the person with Alzheimer’s, but there’s never been any clinical testing of coconut oil for Alzheimer’s, and there’s no scientific evidence that it helps." Coconut oil is an ingredient in a medical food marketed for Alzheimer's disease known as Axona, but the official position of the Alzheimer’s Association is that there is no evidence that medical foods help treat this condition. Strike 4 against coconut oil.

In the end, always be cautious and skeptical and be careful about what home remedies you use to treat a loved one, because you may actually cause more harm than good.

Suggested reading: A Brief History of Bad Medicine

Attack of the Salmonella Pine Nuts

While I fully support people eating a healthy diet, people need to realize that eating traditionally healthy foods is not always risk-free and can sometimes be dangerous. In yet another story documenting the potential harms of eating traditionally healthy foods, such as bean sprouts and cantaloupes, is a story out of the Northeast that Turkish pine nuts sold in bulk at Wegman’s supermarket stores were contaminated with salmonella. Salmonella is a dangerous type of bacteria that can cause food poisoning (fever, diarrhea, stomach cramps), hospitalization, and even death (usually in the elderly and people with poor immune systems). Although 40 people have been sickened (since 8/20/11) and two have been hospitalized from these contaminated pine nuts, none have died to date and Wegman’s has recalled the pine nuts. Pine nuts are actually edible seeds from pines. They are an important ingredient in pesto.

The pine nuts story comes on the heels on another story earlier this month of 3,000 bagged salads and spinach blends from Taylor Farms Retail that were recalled due to possible salmonella contamination.

The full story on the pine nuts is presented below, which comes from Ben Dobbin at The Associated Press.

Turkish pine nuts sold in bulk at Wegmans, an upscale grocery-store chain, have been linked to a salmonella outbreak that sent two people to hospitals and sickened 40 others in five East Coast states and Arizona.

Wegmans Food Markets Inc. said Thursday it has recalled 5,000 pounds of pine nuts imported from Turkey by Sunrise Commodities of Englewood Cliffs, N.J. They were sold between July 1 and Oct. 18 at its stores in New York, Pennsylvania, New Jersey, Virginia and Maryland.

The Rochester, N.Y.-based chain said the recall applies only to Turkish pine nuts purchased in bulk. Wegmans placed automated calls to just over 13,000 customers who bought the nuts using the company's Shoppers Club discount card, spokeswoman Jo Natale said.

The Centers for Disease Control and Prevention reported that 26 people were sickened in New York, eight in Pennsylvania, four in Virginia, two in New Jersey and one person each in Arizona and Maryland. The Food and Drug Administration said it is investigating.

The CDC said people began getting sick Aug. 20 and two patients were hospitalized in undisclosed locations. No deaths have been linked to the outbreak.

Federal officials said Wegmans has cooperated in all aspects of the recall and investigation.
Salmonella bacteria can cause diarrhea, fever, and abdominal cramps. In some cases, the diarrhea may be so severe that the patient needs to be hospitalized.

Some Turkish pine nuts were eaten as an ingredient in prepared foods, such as Caprese salad or asparagus with pine nuts, according to the CDC. The median age of those who were sickened is 43 years.
Wegmans, a 96-year-old, family owned business credited with helping pioneer "one-stop shopping," has 79 supermarket stores in New York, Pennsylvania, New Jersey, Virginia, Maryland and Massachusetts.

The pine nuts were not sold at Wegmans' new store in Northborough, Mass., and possibly other stores with small bulk-food departments, Natale said. "On average, the quantity purchased by individual customers would have been somewhere between an eighth of a pound and a quarter of a pound," she said. "Not everybody who bought the nuts used a Shoppers Club card, but the vast majority are represented by those 13,000-plus people we called."

Wegmans has carried Turkish pine nuts from the same supplier since May 2010. "We are very sorry for the worry and inconvenience this (recall) may cause our customers," it said in a statement.

Little Johnny is Obese: Political Correctness Interfering with Medicine

Political correctness and “sensitivity training” are interfering with medicine and healthcare. In a recent article published in the journal, Pediatrics, a group of researchers published their findings regarding parental perceptions of the terminology that doctors use to describe childhood obesity (ages 2 to 18). The researchers found that it was undesirable to use the term “fat,” "obese" or “morbidly obese” because they were stigmatizing, blaming, and the least motivating to lead one to lose weight. What should be used instead? The term “weight” and “unhealthy weight” were rated as the most desirable. The term “overweight” fell in the middle of the pack.

When I write reports for patients and other healthcare providers, I always try to avoid use of casual terminology and stick to medical terminology. It looks more professional that way because the terms have a scientific basis. While the word “fat” is a colloquial term, the words “obese” and “obesity” are not. They have specific scientific meanings in the medical community. Don’t believe me? Grab a medical dictionary. I just looked up the terms “fat” and “obese/obesity” in the two most popular medical dictionaries: Mosby’s and Stedman’s. Mosby’s does not even have an entry for the word “fat’ as a descriptive term and Stedman’s only briefly noted that it is a common (i.e., colloquial) term for obese. However, both dictionaries contain extensively detailed scientific entries on obesity. Neither dictionary contains the term “unhealthy weight” which is vague since it can also apply to people who are underweight.

So, while I agree that we should avoid using colloquial terms that can feel degrading, we should not abandon the use of scientific terminology because someone does not like the stigma attached to it. The problem that emerges when we start to substitute euphemistic phrases for scientific terminology is that we start to de-emphasize the seriousness of the problems. For example, for people who do not like the stigma of being called “anorexic” should we just say that they are “too skinny.” Some people do not like the stigma of being a cancer patient. Should we just say they just have “really bad cells?” What about people who don’t like the stigma of major depressive disorder? Should we just say the have “the blues?” Should we tell patients they have “unhealthy sugar” instead of telling them they have diabetes mellitus? Where does it stop?

The terminology is becoming so diluted that I have even heard that some overweight people are being referred to as “persons of size.” That term means absolutely nothing since everyone is technically a person of size.

I do not doubt that the parents in the study feel the way they reported, but I would like to see some evidence that less stigmatizing terminology makes a difference in terms of the actions people take to reduce weight, as there was no such evidence of this cited in the above study. A good study would be to divide patients into two groups, call one “obese” and say that the other has “unhealthy weight” during appointments, prescribe a weight loss routine, and see who loses the most weight after controlling for other variables between the two groups that could contribute cause difference between the two groups. If the obese group loses more weight than the unhealthy weight group, then that is what really matters in the end. Sometimes, people need to feel that something bothers them in order to be motivated to really make a change.

What you NEED to know about Mesothelioma

Do you live in a house or work in a building that was built before 1990? Do your kids go to a school built before 1990? Do you or anyone you know work as an electrician, boilermaker, construction worker, pipefitter, plumber, carpenter, machinist, mechanic, or shipyard worker?. Were you or anyone you know near the 9/11 disaster in New York City? If so, you need to know about mesothelioma, which is a type of deadly cancer that is almost always caused by asbestos exposure. Asbestos is a type of mineral that is very heat resistant and is often used as an insulating material. The fibers are so small that they can easily be inhaled or ingested, causing them to penetrate tissues of the lung or other organs, triggering the onset on a deadly form of cancer that usually has a life expectancy of less than three months. This is why you need to be very careful during home remodeling projects and the type of safety precautions taken at work.

MedFriendly has just entered the most comprehensive single page entry on mesothelioma on the internet, following up on the same type of entry for asbestos that was recently posted about a month ago. Please take the time to check out these articles and/or send them to a family member or friend. Decreasing exposure to asbestos decreases the risk of mesothelioma. You do not want your lung to wind up looking like the one in the picture above.

Top 10 Ways to Lose Your Patients

As a neuropsychologist, I have the chance to talk to patients throughout the week in detail about their medical histories, supplemented by a comprehensive medical records review. Part of this involves discussing which provider the patient has seen and if the provider was changed, why. Sometimes, a provider is changed for a benign reason, such as a move or an insurance change but other times there are significant complaints. Granted, there are always two sides to every story but when I consistently hear the same or similar story from different patients year after year, the stories gain credibility. Then, when I start to notice the same problems during my own doctor visits, I know there are some serious problems that can be fixed. So, listed below are my top 10 ways for doctors to lose patients from their practice. If you have others to add to the list, please do so.

10. Not accepting lists of signs, symptoms, or timelines from patients:

If you see patients, you know they range on a continuum from poor historians who have no idea why they are there to see you and those who arrive with carefully constructed histories that they are eager to give you as soon as you walk in. Just about the worst thing you can do when this happens is to tell the patient that you don’t want the list and do not even want to look at it. That connotes a dismissive attitude to the patient and it makes them feel like all of their work was for nothing – work that was done in the hopes it would help you figure out what was wrong. You may have very good reason at the time not to look at the list such as time pressure, but at least take the list and say you will later take a look at it. It will likely provide you some useful information.

9. Asking patients choose what type of medication they want to take:

When a patient has a medical condition in need of medical treatment, the physician is looked to provide their advice as to what medication to take. They don’t want to be given a list of three possible medications, told to research them at home, and come back with a decision. From a patient’s perspective, this is why the doctor went to medical school, not me.

8. Long wait times AND no apology and/or rushing the patient once coming in

While no patients want to wait long, they will generally accept the wait time if they are pleased with the care you provide, or if it the initial visit, know that you have a good reputation. However, if the patient waits long and you then walk in and do not acknowledge the wait, explain why there was a wait, and apologize for the wait, it will significantly aggravate the patient. Rush the patient after a long wait and no apology and it will worsen the situation further.

7. Not following the Golden Rule:

This is an easy one and has been addressed extensively by others, but don’t do things such as repeatedly looking at the clock, repeatedly interrupting patients, focusing more on you than the patient, talking rudely, making poor eye contact, etc. Follow the Golden Rule and you will easily establish rapport the majority of the time.

6. Not being responsive to challenging questions

Provided that a patient is being respectful, there is no reason to become upset when a patient asks questions challenging a diagnosis or course of treatment. Most patients are generally accepting of your expertise but they may have heard or read something that has given them legitimate questions. Your answers can help reassure the patient that your diagnosis and treatment is correct. Patients are also usually more impressed when you tell them you have no problem with them seeking a second opinion rather than demanding they only accept one point of view and/or becoming overly defensive. Also, patients (or families) sometimes come up with questions that can lead you to entertain an idea you did not previously think of that can improve care. Don’t shy away from this. Embrace it.

5. Disrespectful staff

While the patient may like the care you provide, there are a host of other people they need to interact with before and after the appointment. This includes the receptionist, billing staff, nurses, and others. If these individuals are rude and disrespectful, the patient will likely switch to another provider whose friends and family say have better ancillary staff. It is like owning a restaurant with good food but a terrible hostess and waitress. Many people will just choose a different restaurant. Train your staff to treat your patients they way they would want to be treated (and teach them how to manage patients who are rude) and you will have a happy client base.

4. Drab and dreary office space

No one likes to go to the doctor. Take some time to make it a more enjoyable experience. Have comfortable seats in the waiting area and waiting room, put some nice art up on the walls (geared towards children if it is a pediatric office), have a TV on with cable (with cartoon options for children), soft music, etc. Whether right or wrong, offices that are bare, uncomfortable, and cold looking convey a message that the patient perspective is not being considered. 

3. Being unavailable when needed during routine business hours

When the answering service repeatedly picks up the phone during normal business hours, it is extremely frustrating for patients. Same with staff not returning phone calls or being absent for 1.5 hours during lunch time. Patients need to have access to staff during normal office hours to make appointments and ask questions.

2. Cancelling/rescheduling appointments too often

Patients are understanding when a doctor needs to cancel or reschedule but not if it happens too often. This was highlighted in the recent trial of Dr. Conrad Murray, whose former patient testified that after two follow-up appointments were cancelled he felt that the doctor blew him off. The patient never followed up with Dr. Murray again.

1. Making decisions that cause patient harm that were easily avoidable

While patients will sometimes give doctors a second chance, they won’t be inclined to do this if harm occurred to the patient or a family member that could have easily been avoidable. This is especially true if the harm happened to a child. As a personal example, I recall repeatedly explaining to my pediatrician that my child’s cough and wheezing was persistent and affecting her breathing, only to be repeatedly told that it was only allergies, despite the fact that she was cleared by an allergist and was not improving with allergy medications or a nebulizer. Finally, and only by pressuring the physician to do more, was a chest x-ray ordered. Diagnosis: double pneumonia and a week long hospital stay. Totally avoidable. The new pediatrician is very responsive and we have been very pleased for many years. 

Man vs Vile: Surviving a Trip to a Public Restroom

If I had a penny for every time I walked into a public bathroom and found spots of urine on the toilet bowl lid, I would be a millionaire. Men are the main culprits and I really feel bad for women who have to deal with this in unisex bathrooms that only have a toilet bowl. For guys using the toilet who only need to urinate, this is not a problem. For women though, there is really no choice but to wipe off someone else’s urine, squat above the bowl (but who wants to do that?), or try to find another bathroom (not always an option, especially in emergencies). If a man needs to defecate, he will be in the same predicament.

Sometimes, you will walk into a public bathroom and actually find one that looks relatively clean, although doing so often feels like you won the lottery after looking in a about eight consecutive stalls with urine covered toilets or bowls filled with brown water and/or feces. I don’t know if women have the same issues in their public bathrooms, but men’s public bathrooms can be absolute total nightmares to deal with.

If you do happen to come across one of those rare clean looking public toilets, don’t be fooled because germs are likely still there that can be harmful. Don’t believe me? Don’t take my word for it. Scientists at the University of Florida’s College of Medicine recently tested public bathrooms for two months and in several restrooms found that there were so many organisms present that they could not even count them all. All sorts of things are present on these toilets from salmonella to e. coli. This is not because people are rubbing raw pieces of steak and chicken meat over toilet bowl seats but because people who have these bacteria in their system defecate in the toilet, wipe (hopefully), get the bacteria on their hand and then begin transferring it wherever they touch.

That means the toilet seat, the flusher, the sink, the hands dryer, and the door handle on the way out. This is why you really should have a small hand sanitizing gel container with you so that you can clean yourself after you leave the bathroom. After all, what is the sense of washing your hands well and then getting contaminated by the door when leaving?

I also highly suggest doing things to put a barrier between yourself and other people’s disgusting bathroom habits. If you have to sit on a public toilet, put down a layer or two of toilet paper. Drop some toilet paper in the bowl before you flush it so that you create some layer of protection between yourself and public toilet water being misted upwards onto your body. Open the water spigot and the door with your sleeve if you have one. Don’t touch the inner surfaces of sinks since they contain large areas of germs. Use paper towels instead of hand dryers. Try to only touch the towels and not the box that the towels are contained in. Your immune system will ultimately help you out most of the time anyway, which is why we have one, but these extra steps can help protect you even further.

How to Find a New Doctor

These days, it is not uncommon for people to need to find a new doctor. The most common reasons include a) moving to a new city, b) dissatisfaction with your former doctor, c) your old doctor no longer accepts your new or old insurance, or d) you were diagnosed with a new medical condition and need specialized treatment. Often, people go to their insurance company website or provider book, search for a doctor, and see a list of names in their area with contact information (and perhaps a brief biographical sketch). This narrows the choices down more than the phone book would, but now what? If insurance is not a limitation, the list of doctors to choose from will be even longer.

There is an old saying that word of mouth is the best form of advertising. This is one of the best ways to find a new doctor, provided you are getting the information from a source you know and trust. While friends and family can be good sources to ask about which doctors they use and like, it is also a very good idea to ask a friend (or friend of a friend) who works in a local hospital or health care setting. Here’s why.

First, healthcare providers know who provides good healthcare in their area. They know this because they read the reports of doctors they refer patients to, hear patient feedback on their experiences with the doctor, and may work in the same setting which allows them to have inside knowledge as to whether there are any problems with the doctor that may not be more commonly known to others. When I needed to find an endodontist to perform a root canal last year, I first asked my regular dentist for a list of names. He gave me a list of endodontists who accepted my insurance and said all were good. Still, I wanted to base my choice on something more specific than using eenie-meenine-miney-mo. Problem is, I don’t have any friends or family members who are dentists. But I did know someone who had a relative who was a dentist in the area. I asked the person I knew about the names on the list, he asked the relative for me, and later he told me who I should see based on reputation in the dental community. The root canal worked out very well and I could not have been happier.

Another thing to do is look at the doctor’s credentials. First, check if the doctor is board certified since this gives you the highest probability that you will be provided competent specialized services. The best place to check is the website for the American Board of Medical Specialists (ABMS) which contains board certification status in 24 specialty areas. For psychology, see the American Board of Professional Psychology (ABPP), which contains board certification status in 14 different areas of psychology. Please note that there are good doctors who are not board certified and bad doctors who are board certified but you increase your chance of finding the former by choosing one who is board certified. Other credentials to look at are where the doctor went to school and completed training. This can be found by either calling the doctor’s office or doing an internet search.

An internet search is another good way to research a new doctor as you may discover news articles that a doctor was interviewed for, which may give you more confidence in the doctor’s expertise. Be careful, however, of doctor review websites because they tend to be skewed towards people who had a negative experience versus a positive experience and thus may not tell the entire story. Be sure to check the website for your state’s licensing board as this can tell you if there are any disciplinary complaints pending against the doctor.

One other idea some people have is to “interview” your potential doctor. Basically, this involves asking the doctor some important questions during an initial consultation such as how are emergencies handled, what are the after-hours policies, how can you get a prescription refill, do you actually see the doctor or a nurse practitioner, etc. Based on the answers to these types of questions and the personal feel you get based on interacting with the doctor, you can get a sense of the doctor is a right fit for you. While good rapport with the doctor is important, also consider how the office staff treats the patients. Are they friendly and courteous or do they seem to be rude and cut people short? Does there seem to be frequent infighting amongst the staff and is the doctor yelling at staff in front of patients. If so, these are bad signs. You need to deal with a competent office staff as well as a competent doctor to manage your health care needs.

One last point: If you get a letter from your doctor saying they will no longer be participating with your insurance as of a certain date due to a contract dispute, see this as a call to action. Contact the insurance company to complain and have others you know do the same who see the particular doctor. If enough pressure is brought to bear, you may not have to make a switch at all as the insurance company and doctor may then make a new agreement. This just happened to me recently, actually.

The Overdiagnosis of "Post Concussion Syndrome"

These days, many health providers are quick to diagnose patients with “post concussion syndrome” if persistent symptoms are reported after a known or suspected mild traumatic injury (also known as concussion). Interestingly, I have seen this diagnosis given to patients who do not meet any operational definition of concussion and/or who are less than three months post-injury. 

While diagnosing “post concussion syndrome” in patients who were never concussed or who are not yet in the persistent symptom phase is problematic, another problem is that many providers fail to realize is that there are no current consensus-based diagnostic guidelines for a condition with that exact name.
To be precise, the correct diagnostic terms are post-concussional syndrome (PCS) per the International Classification of Diseases-10th edition (ICD-10, 1992) and post-concussional disorder (PCD) per the Diagnostic and Statistical Manual of Mental Disorders-IV (APA, 1994). These criteria are listed at the end of this blog entry in Appendix A. 

While this may seem like a purely semantic argument at first, it is actually a distinction with a significant difference. To begin with, whenever a medical or psychological condition is diagnosed, one needs to know the specific criteria required to make the diagnosis. Without such criteria, diagnostic errors rise and confusion results when attempts are made to communicate about a particular condition. This is why, for example, there are clear and specific criteria for diagnosing multiple sclerosis (Polman et al., 2005). 

 Since there are many conditions that can initially present like multiple sclerosis, the use of formal diagnostic criteria helps improve diagnostic accuracy. The same holds true for all other medical and psychological conditions. That is, criteria should to be used to establish a diagnosis and the criteria should help distinguish the condition of interest from similar conditions. 

With this in mind, how can a diagnosis of “post concussion syndrome” have any real meaning if there are no current formal diagnostic criteria that anyone to refer to? The answer is that it can’t. So we then must turn to the diagnostic criteria for PCS and PCD and examine their utility. 

Serious problems with the definitions

The first question one may naturally ask is since there are two different criteria sets, how well do they agree when applied to actual patients? This question was specifically evaluated by Boake et al. (2004, 2005) who only found “limited agreement” to put it nicely. The reason for the limited agreement mainly centers around very different diagnostic thresholds. That is, after a concussion has been established, a PCS diagnosis only requires a patient to report a few symptoms to meet the diagnostic threshold. This is a very liberal diagnostic threshold since all of the symptoms are non-specific to brain injury. That is, the symptoms listed in the criteria set are often endorsed by normal controls without brain injury (e.g., college students), patients with major depressive disorder, patients with chronic pain, and personal injury claimants with no history of brain injury.
In fact, as McCrea (2008) summarized in his text, many of these groups report such symptoms at higher frequencies than patients with a history of mild traumatic brain injury (MTBI). In a fascinating study by Iverson (2006), he showed that about 90% of patients with a depressive disorder (with no recent history of brain injury) met liberal self-report criteria for postconcussional syndrome. 

Although patients may state that their symptoms began after the concussion, this is not always accurate since patients may exaggerate symptoms (particularly in compensation based claims), may unintentionally misattribute symptoms from another condition (e.g., whiplash, psychological conditions) to brain injury, or may underestimate the degree to which symptoms were present before the injury and overestimate the degree to which they were present afterwards due to expectations that people have about symptoms one should experience after a concussion (Mittenberg et al., 1992). 

Turning to DSM-IV criteria, a diagnosis of PCD requires the presence of cognitive difficulty on objective tests. Objective cognitive testing is often not feasible or practical for physicians, nurse practitioners, or other health care providers who do not have training in objective cognitive assessment. The other problem is that numerous prospective research studies consistently show that patients with a single mild TBI (and in some studies, multiple MTBIs) do not show evidence of cognitive impairment more than three months post injury (Belanger et al. 2005a, 2005b; Binder et al, 1997a, 1997b; Bleiberg et al., 2004; Dikmen et al., 1995; Frenchman et. al, 2005; Iverson, 2005; Larrabee, 1997; Pellman et al., 2004; Schretlen et al., 2003). 

Therefore, it is not all that likely that objective testing will reveal evidence of cognitive impairment more than three months post-injury, particularly when factors such as effort and motivation during testing are accounted for and when other possible etiologies are considered such as psychiatric disorders. This is important because DSM-IV requires that a diagnosis of PCD is not given if the presentation can be explained by another mental disorder.  

Since one criteria set is overly liberal (ICD-10) and another is overly conservative (DSM-IV), it should not be surprising that Boake at al. (2005) found that only 11% of TBI patients (90% mild, 10% moderate) met PCD criteria whereas 64% of patients met PCS criteria. It should be noted that the researchers used a liberal threshold to define a cognitive difficulty (one standard deviation below the mean) since the DSM-IV criteria provide no guidance in this area. This liberal threshold results in a higher degree of false positive classifications since many normal controls obtain scores one standard deviation below the mean.

Another problem is that the definitions of concussion put forth by ICD-10 and DSM-IV are inadequate. Specifically, ICD-10 requires a loss of consciousness (LOC), yet national and international definitions (including one later adapted by the World Health Organization, which is responsible for ICD-10) clearly states that LOC is not required for a concussion diagnosis. Strict adherence to the ICD-10 criteria would result in removing vast numbers of patients who were concussed (but who did not lose consciousness) from being eligible for the diagnosis. 

Although DSM-IV does not restrict concussions to those who experienced LOC, the criteria only lists a few manifestations of concussion and does not provide a precise definition. Regardless, both criteria sets make it clear that it needs to be established that a patient suffered a concussion before a diagnosis of PCS or PCD can be made. In clinical practice, however, I have seen many cases where patients who suffered head injuries (yet do not meet operational definition for MTBI) are diagnosed with “post concussion syndrome.” This would be akin to saying that you are having a post-game show without having a game first. It does not make sense.

What to do from here?

Boake et al. (2005) noted that “…further refinement of the DSM-IV and ICD-10 criteria for PCS is needed before these criteria are routinely employed.” My opinion is to avoid use of these terms entirely because the criteria by which they are based upon are too flawed and were only designed for research purposes. Using a term that has no criteria associated with it such as “post concussion syndrome” does not solve the problem either. What most people mean when they use this term is that the patient had a history of a concussion followed by numerous symptoms. However, as was noted earlier by the Iverson (2006) study and in the review by McCrea (2008) such a standard is too non-specific to brain injury and overly-inclusive. This is a significant problem because patients will interpret the term as meaning that all of their symptoms are caused by brain injury when this is likely not the case. 

While the patient may feel better initially when receiving a diagnosis of PCS because it provides medical validation he/she has been seeking, it can also make the situation far worse in the long run because other potentially treatable conditions such as posttraumatic stress disorder, major depressive disorder, personality disorders, as well as psychosocial factors may not be recognized as contributory, causing the patient to continue to suffer with symptoms far longer than is needed. 

My advice to physicians, nurse practitioners, non-neuropsychologists, and other front-line health care providers dealing with patients more than three months post-injury is to document the medical history in the note, state whether there appears to be a history of head injury or MTBI (if appropriately trained to assess this) and to then state that the patient is experiencing persistent symptoms but that the cause is unclear and needs to be further evaluated through a neuropsychological evaluation. A rule out diagnosis of cognitive disorder NOS can be listed for billing purposes. It should be explained to the patient that the cause of the symptoms are unclear and that further evaluation is needed to determine this. 

Disclaimer: The author of this entry is a board certified clinical neuropsychologist..  

REFERENCES
 

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association. 

Belanger et al. (2005a). The neuropsychological impact of sports-related concussion: A meta-analysis. Journal of the International Neuropsychological Society, 11, 345–357. 

Belanger et al. (2005b). Factors moderating neuropsychological outcomes following mild traumatic brain injury: a meta-analysis. Journal of the International Neuropsychological Society, 11, 215-27. 

Binder, L.M. et al. (1997a). A review of mild head trauma. Part I: meta-analytic review of neuropsychological studies. Journal of Clinical and Experimental Neuropsychology, 19, 421–431.

Binder, L.M. et al. (1997b). A review of mild head trauma. Part II: clinical implications. Journal of Clinical and Experimental Neuropsychology, 19, 432–457.

Bleiberg, J. Duration of cognitive impairment after sports concussion. Neurosurgery, 54, 1073-80.

Boake et al. (2004). Limited Agreement Between Criteria-Based Diagnoses of Postconcussional Syndrome. The Journal ofNeur opsychiatry and Clinical Neurosciences, 16, 493–499.

Boake et al. (2005). Diagnostic Criteria for Postconcussional Syndrome After Mild to Moderate Traumatic Brain Injury. The Journal of Neuropsychiatry and Clinical Neurosciences 2005; 17:350–356.

Dikmen, S.S. (1995). Neuropsychological outcome at one-year post head injury. Neuropsychology, 9, 80–90.

Frenchman, K.A. et al. (2005). Neuropsychological studies of mild traumatic brain injury : a meta-analytic review of research since 1995. Journal of Clinical and Experimental Neuropsychology, 27, 334-51.

Iverson, G. (2006). Misdiagnosis of the persistent postconcussion syndrome in patients with depression. Archives of Clinical Neuropsychology 21, 303–310

Iverson, G. (2005). Outcome from mild traumatic brain injury. Current Opinion in Psychiatry, 18, 301–317.

Larrabee, G. (1997). Neuropsychological outcome, post concussion symptoms, and forensic considerations in mild closed head trauma. Seminars in Clinical Neuropsychiatry, 2, 196-206.

McCrea, M. (2008). Mild traumatic brain injury and postconcussion syndrome. The new evidence base for diagnosis and treatment. New York: Oxford University Press.

Mittenberg et al. (1992). Symptoms following mild head injury: Expectation as aetiology. Journal of Neurology, Neurosurgery, and Psychiatry, 55, 200-4.

Pellman et al. (2004). Concussion in Professional Football: Neuropsychological Testing - part 6. Neurosurgery, 55, 1290-1305.

Polam et al. (2005). Diagnostic criteria for multiple sclerosis: 2005 revisions to the McDonald criteria. Ann Neurol. 58; 840-846.

Schretlen et al. (2003). A quantitative review of the effects of traumatic brain injury on cognitive functioning. International Review of Psychiatry, 15, 341–349.

World Health Organization (1992). International statistical classification of diseases and related health problems - 10th edition. Geneva, Switzerland: World Health Organization.

Appendix A

ICD-10 Definition: Post-concussional syndrome

Listed below are the diagnostic criteria for PCS from ICD-10.

“Note: The nosological status of this syndrome is uncertain, and criterion A of the introduction to this rubric is not always ascertainable. However, for those undertaking research into this condition, the following criteria are recommended: 

A. The general criteria of F07 must be met. The general criteria for F07, Personality and Behavioral Disorders Due to Brain Disease, Damage and Dysfunction, are as follows:

G1. Objective evidence (from physical and neurological examination and laboratory tests) and/or history, of cerebral disease, damage, or dysfunction.

G2. Absence of clouding of consciousness and of significant memory deficit.

G3. Absence of sufficient or suggestive evidence for an alternative causation of the personality or behavior disorder that would justify its placement in section F6 (Other Mental Disorders Due to Brain Damage and Dysfunction and to Physical Disease).

B. History of head trauma with loss of consciousness, preceding the onset of symptoms by a period of up to four weeks (objective EEG, brain imaging, or oculonystagmographic evidence for brain damage may be lacking).

C. At least three of the following:

(1) Complaints of unpleasant sensations and pains, such as headache, dizziness (usually lacking the features of true vertigo), general malaise and excessive fatigue, or noise intolerance.
(2) Emotional changes, such as irritability, emotional lability, both easily provoked or exacerbated by emotional excitement or stress, or some degree of depression and/or anxiety.
(3) Subjective complaints of difficulty in concentration and in performing mental tasks, and of memory complaints, without clear objective evidence (e.g. psychological tests) of marked impairment.
(4) Insomnia.
(5) Reduced tolerance to alcohol.
(6) Preoccupation with the above symptoms and fear of permanent brain damage, to the extent of hypochondriacal over-valued ideas and adoption of a sick role. 

DSM-IV Definition: Post-concussional disorder

 

 A. A history of head trauma that has caused a significant cerebral concussion.

Note. The manifestations of concussion include loss of consciousness, post-traumatic amnesia, and less commonly, post-traumatic onset of seizures. Specific approaches for defining this criterion need to be refined by further research.

B. Evidence from neuropsychological testing or quantified cognitive assessment of difficulty in attention (concentrating, shifting focus of attention, performing simultaneous cognitive tasks) or memory.

C. Three (or more) of the following occur shortly after the trauma and last at least 3 months.

1. becoming fatigued easily (2) disordered sleep (3) headache (4) vertigo or dizziness, (5) irritability or aggression on little or no provocation, (6) anxiety, depression, or affective liability (7) changes in personality (e.g., social or sexual inappropriateness) (8) apathy or lack of spontaneity.

D. The symptoms in criteria B or C have their onset following head trauma or else represent a substantial worsening of preexisting symptoms.

E. The disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning. In school age children, the impairment may be manifested by a significant worsening in school or academic performance dating from the trauma.

F. The symptoms do not meet criteria for Dementia due to Head Trauma and are not better accounted for by another mental disorder (e.g., Amnestic Disorder due to Head Trauma, Personality Change Due to Head Trauma.

1 of 6 Cell Phones Contaminated with Feces

You may want to think twice before biting your fingernails or picking a piece of food out of your teeth, especially if you just shook someone’s hands. In England, researchers recently found that one in six cell phones was contaminated with feces (poop). This is based on 390 samples taken across 12 cities. The study provided further evidence that people are simply not washing their hands properly after going to the bathroom…or not washing them at all.

If this is happening in England, it is most certainly happening in the U.S. And not only on cell phones, but on shopping carts too. The same shopping carts that little children rub their hands all over and try to put their mouths on. Grocery stores contain hygienic wipes to wipe down a cart when you walk into the store. Use them.

One of the main dangers of fecal contamination is becoming ill from E.coli bacteria. The illness can not only cause food poisoning but it can also kill you, as was noted in a previous blog entry on the dangers of bean sprouts.

One of the more interesting aspects of the study was that people were not honest about their hygiene practices. That is, while 95% of respondents said that they washed their hands with soap and water when possible, that 92% of phones and 82% of hands were contaminated with bacteria, 16% of which contained E. coli. In other words, people say one thing but then the evidence shows something else, a phenomenon I am well familiar with as a clinical neuropsychologist.

Reference: Article on CNN.com.

New ADHD Guidelines and the Omission of Neuropsychology

Recently, the media has reported that the American Academy of Pediatrics (AAP) has broadened its 2000-2001 guidelines for the diagnosis of and treatment of ADHD. While the prior guidelines focused on children from ages 6 to 12, the new guidelines cover ages 4 to 18. The story is being covered by the media with lead-ins such as saying that AAP is “expanding the age range for diagnosis and treatment.” This is technically not true.

The fact is that the diagnostic criteria for ADHD have already been in existence in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (Text-Revision), referred to as DSM from this point forwards. This is the book, published by the American Psychiatric Association, which mental health and medical professionals refer to for making diagnostic decisions in this particular subject area.

There is nothing in the already existing ADHD criteria in DSM that prevents a diagnosis of ADHD in a four-year-old child. While the DSM mentions that it is difficult to establish the diagnosis before age 4 or 5, there is nothing that states the diagnosis cannot be made at age 4 (or earlier). In fact, part of the DSM criteria for ADHD is that the symptoms should be present before age 7, although this has been a subject of debate and will reportedly be changed to a higher age level in the next edition of DSM due out in 2012.

What AAP is really suggesting here that is new is that pediatricians should initiate evaluations of ADHD at age 4 if the child has academic or behavioral problems and symptoms of inattention, hyperactivity, and impulsivity. The new guidelines state that “primary care clinicians” should determine if the DSM criteria are met (which means the problems need to be present in more than just one setting, not only in school or only home).

While these guidelines are laudable, I am left to wonder how primary care clinicians (e.g., pediatricians, nurse practitioners) are going to be able to do this given the combination of time-limited visits and a very busy schedule. It is important to keep in mind that according to DSM criteria, there are 9 inattention symptoms, 6 hyperactivity symptoms, and 3 impulsivity for a total of 18 possible symptoms to cover with the parent. Some parents tend to go into a lot of detail when discussing these items and so going over the criteria properly can be quite time intensive. The new AAP guidelines also say that the PCP should also interview teachers and other school and mental health clinicians involved in the child’s care to make the diagnosis. In an ideal world, this sounds great, but most PCPs simply do not have the time to do this.

Speaking of not having time to do things, the new guidelines state that the primary care clinician should rule out alternative causes besides ADHD. This is another good standard, consistent with DSM, but it is also very time intensive. Why? Because the list of possible reasons why a child can have academic, behavioral, and attention problems is very extensive. Psychological and psychosocial explanations (e.g., depression, anxiety, parental divorce, abuse) are possible explanations and the guidelines correctly state to assess these conditions as well as for developmental disorders such as learning disorders and language disorders. Physical explanation such as sleep apnea would also need to be ruled out.

While a primary care clinician can easily refer a patient for a sleep apnea study and order other tests to rule out a physical cause of ADHD-like symptoms, what primary care clinician is going to have the time to go over all 18 symptoms, interview teachers and other sources of information, evaluate for a learning disorder, and evaluate for psychological causes of the symptoms? None who I know of. For example, evaluating for a learning disability is going to require time intensive psychological testing and primary care clinicians simply do not administer IQ tests and test of academic achievement.

The AAP guidelines explicitly acknowledge the time limitations involved in these types of evaluations and the need for collaboration with mental health professionals. Who do they suggest referring such patients to for additional evaluations? Child psychiatrists, developmental behavioral pediatricians, neurodevelopmental disability physicians, child neurologists, or child or school psychologists. While I have no opposition to any of these professions playing a role in the diagnostic process, there is one major omission in these guidelines: the field of clinical neuropsychology.

Clinical neuropsychology is the field of psychology that studies the relationship between brain functioning, emotions, behaviors, and thinking. Considering that ADHD is a neurological condition affecting the brain that affects behaviors and thinking abilities, referring a patient for a neuropsychological evaluation is certainly something a primary care clinician should consider. Why? First, a neuropsychological evaluation involves the objective assessment of thinking, behaviors, and emotions. That is, the patient’s performance on tests of attention and impulse control, for example, is compared to groups of children the patient’s age with no history of neurological damage.

While some critics note that the testing results may not always generalize to real-world environments, the fact is that these tests are the only way to objectively assess the patient’s actual cognitive abilities outside of grades in the classroom on academic tests. Behavioral checklists can be used and scored but at the end of the day they are still measures dependent on subjective opinions and have their own set of limitations.

While it is true that the ADHD criteria in DSM do not require neuropsychological testing to make the diagnosis, neuropsychological evaluations are not only about testing. Neuropsychologists are able to spend far more time on a single case than a primary care clinician and thus they can do a more detailed evaluation of symptoms, perform a detailed review of medical and academic records, and perform detailed evaluation of possible co-morbid psychological disorders. Neuropsychologists are also experts in a wide variety of other neurodevelopmental conditions (such as learning disorders) that can masquerade as ADHD and thus the evaluations can rule out or rule in other possible causes that can lead to better treatment.

Admittedly, clinical neuropsychologists need to publish studies showing that diagnostic evaluations for ADHD improve outcome. Recognizing this need, the American Academy of Clinical Neuropsychology recently funded a study by Dr. Mark Mahone from Kennedy Krieger Institute and the Johns Hopkins University School of Medicine entitled “Incremental Validity of Neuropsychological Assessment in Identification and Treatment of ADHD.” We will await and see the results of this study.

In sum, families and primary clinicians should consider referring patients to clinical neuropsychologists in the development of ADHD. While neuropsychological evaluations have limitations, limitations also apply to the other professions who the AAP guidelines suggest referring patients to. The fact that not a single national neuropsychological organization was consulted in the development of these guidelines is troubling and one has to wonder whether the omission was purposeful. After all, it is not as if pediatricians and the school psychologists they consulted with have never heard of neuropsychologists. I will be contacting the AAP and request a response and will post the response if it is provided.

Disclaimer: The author of this blog entry is a board certified neuropsychologist.

Don't Worry, Be Happy

Today’s is part II of a special guest blog entry by my colleague, Dr. Christine Allen. Dr. Allen is a psychologist who is also an executive and life coach. She has over 20 years of psychotherapy experience, is past President of the Central New York Psychological Association (CNYPA), awarded the CNYPA Psychologist of the Year in 2008, serves on the governing Council of the New York State Psychological Association, and is an adjunct psychology professor at Syracuse University. She runs Chris Allen Coaching and can be followed on Twitter here.

In yesterday’s blog entry, Dr. Allen ended it with the following question: So what are some take-aways on how to increase well-being and happiness? Here are some suggestions.

• Increase savoring by focusing on the moment; enjoy healthy pleasure in the here-and now.

• Increase engagement and flow, especially through meditation and mindfulness; limit passive activities such as TV and “screen time”.

• Practice kindness; it increases your own well-being and that of others (the “pay-it forward” concept has been found in hard research to be very real).

• Practice daily gratitude or blessings.

• Identify and use your unique strengths daily and in new ways (e.g., check out

www.authentichappiness.com for a cost-free way to identify strengths).

• “WWW”: Identify concretely “what went well” today--preferably write it down and ask others, such as your children, what went well for them.

• Behavioral economists suggest that “satisficing” (which means going with “good enough”) is better than “maximizing” (always trying to get the absolute best deal) for happiness. People who research endlessly to get “the best deal” are more unhappy with their choices.

• Cultivate optimism: Seligman’s book, “Learned Optimism” can help you learn how: you don’t have to be a Pollyanna to find ways to tame those negative messages. These messages are our brain’s way of trying to protect us from disappointment and disaster, but they actually prevent us much of the time from living fully.

For more ideas and information, check out Seligman’s book, Flourish or for a more personal take, read Gretchen Rubin’s, The Happiness Project

Guest Blog Entry. The Happiness Hype: What’s All the Buzz About and Is it Worth It?

Today’s is part I of a special guest blog entry by my colleague, Dr. Christine Allen. Dr. Allen is a psychologist who is also an executive and life coach. She has over 20 years of psychotherapy experience, is past President of the Central New York Psychological Association (CNYPA), awarded the CNYPA Psychologist of the Year in 2008, serves on the governing Council of the New York State Psychological Association, and is an adjunct psychology professor at Syracuse University. She runs Chris Allen Coaching and can be followed on Twitter here.

You would have to be completely disconnected from TV, YouTube, movies, Facebook, Google and even newspapers and magazines if you have not heard about or been exposed to information about “happiness” lately. Some people are quick to dismiss this topic as another form of constantly chasing more....and always comparing ourselves to others. There were even recent articles that rate different geographical locations as being “the happiest” places to live. Is happiness competition the new way of “keeping up with the Joneses”? Or is it really something worth pursuing?

Happiness has been viewed as important throughout human history. Aristotle in

particular wrote that, “Happiness is the meaning and the purpose of life, the whole aim and end of human existence.” The language of the “pursuit of happiness” is embedded into the fabric of our society through the Declaration of Independence (although as Ben Franklin allegedly said, “The U. S. Constitution doesn't guarantee happiness, only the pursuit of it. You have to catch up with it yourself”).

But what is happiness and is it attainable? I have always liked the idea expressed by Nathaniel Hawthorne that, “Happiness is like a butterfly which, when pursued, is always beyond our grasp, but, if you will sit down quietly, may alight upon you.” Thus, happiness is not a goal in itself, but perhaps a side effect of other, meaningful, goal-directed activity.

Still I don’t completely like the idea of just sitting around and waiting, so what to do? I recently finished reading Flourish, the newest book by the prolific Dr. Martin Seligman, who is considered the “Father of Positive Psychology.” In this book, he talks about the concept of “well-being” rather than about happiness per se. He believes that just like the concept of “weather”, where we measure wind, cloud cover, humidity, temperature, etc, “well-being” involves looking at a number of measures, not just how “happy” overall we are with our lives. He uses the mnemonic called PERMA, which stands for Positivity (or positive emotion), Engagement (or “flow”), Relationships, Meaning, and Accomplishment to explain “well-being.”

When researchers assess happiness, on the other hand, they are usually looking at a unidimensional concept like positive emotion or life satisfaction only. Seligman’s idea of well-being offers us greater opportunity to consider how to design a meaningful and fulfilling life, because even the more pessimistic types of people have the opportunity to increase well-being through developing in other ways, such as improving relationships or increasing accomplishment.

To flourish according to the PERMA principle, we need to look for opportunities to increase positive emotion through savoring our pleasures and amplifying our good feelings. We also become happier when we are actively engaged... “in the zone” so to speak. Time passes without awareness when we are engaged fully in what we are doing, whether it be having a conversation, playing tennis, or cooking a meal. This means being fully present, not distracted with our smart phones, Facebook, etc. Also, the better the quality of our relationships with others and the more we build these relationships, the deeper our satisfaction with life will be. Identifying core values and living these everyday is crucial to establishing a fulfilling, “purpose-driven” life. The philosopher Nietzche was the one who said, “He who has a why to live can bear with almost any how.” So develop a sense of purpose--what you want your life to stand for.

Finally, Seligman recently added a sense of accomplishment; while endlessly pursuing achievement out of a sense of perfectionism is unhealthy, dedicating yourself to the accomplishment of important goals, whether they be personal or professional, definitely adds to a sense of well-being.

Lots of research suggests that happiness matters; it’s not just hype. A meta-analysis of 300 studies with over 275,000 people found that people with greater levels of positivity lived longer, had better health, happier marriages, and made more money. So what are some take-aways on how to increase well-being and happiness? Stay tuned tomorrow to find out, in part II on this special guest blog entry.

Attack of the killer bean sprouts

Many people are well aware that undercooked meat is dangerous because it contains harmful bacteria such as salmonella and E. coli. To counter this, you are supposed to cook meat thoroughly, and use common sense food preparation methods such as hand washing, and avoiding cross contamination when preparing raw meat.

What many people do not realize, however, is that bean sprouts can be just as dangerous as raw meat. Yes, bean sprouts. Why? Because the sprout seeds can easily become contaminated in the fields where they are grown. Bean sprouts need to be grown in a warm and moist environment. Such environments are the ideal setting for bacteria to grow, including salmonella and E. coli. Some of the sprout seeds can also become contaminated by animal manure where they are grown.

In Germany, contaminated bean sprouts killed 42 people and caused about 4,000 food-born illnesses. In fact, in June 2011, bean sprouts were the source of a major E. coli outbreak in that country. There have been 40 worldwide food outbreaks linked to bean sprouts since 1973. The largest outbreak was in Japan, which killed 17 people in 1996 and affected 6,000 people. Outbreaks have also occurred in the United States.

In the United States, the Food and Drug Administration has done a good job promoting safe manufacturing practices. Nevertheless, if you eat raw bean sprouts, you are putting yourself at risk for developing a foodborne illness from harmful bacteria. The risk is greatest on young people, senior citizens, and people with weak immune systems.

To be safe, it is best to avoid bean sprouts at restaurants because you have no way of knowing how well they were cooked, unlike meat, which you can inspect. If you want to eat bean sprouts at home, health officials suggest immersing the sprouts in boiling water and cooking them thoroughly to kill harmful bacteria.

Lastly, keep in mind that bean sprouts can actually contain toxins and that to reduce risk, people should not eat large quantities of bean sprouts on a regular basis. 

The Chinese Elephant Man

You’ve all heard of the Elephant Man and have perhaps seen the famous movie of the same name. His real name was Joseph Merrick and he lived in the 1800s. His body was grossly deformed due to the presence of disfiguring tumors.

RECOMMENDED BOOK: The Elephant Man

He was mentally and physically tortured by his disease and was keenly aware of how his appearance affected others. He ultimately died when trying to sleep like a normal person but the weight of the tumors in his head, crushed his trachea and caused him to suffocate. An autopsy revealed a broken neck. Here is a picture of Mr. Merrick when he was alive.

I remember watching The Elephant Man movie as a teenager in my basement one evening and being profoundly affected by sadness that someone would ever have to go through such a terrible experience. It has always made me reflect on my life and deal with life stressors much easier by putting things in perspective. There is not much in life we can go through that would be worse than such an experience.

In doing some reading on the Elephant Man, I came across the name Huang Chuncai, also known as the Chinese Elephant Man. The picture at the top of this blog entry was taken after he had 33 pounds of a tumor removed from his face in 2007. He had another 4.5 pounds removed in January 2008 and another 10 pounds removed in late 2008. Despite this, the rare genetic condition known as neurofibromatosis, which causes nerve tissue growth, was expressed in such an extreme from in Mr. Chuncai that he can never look normal and the goals of the surgeries are to make him recognizably human.

Below is a video of how he appeared before and after surgery, but it is obviously disturbing so be warned before viewing. The case is remarkable, sad, and inspiring all at the same time. If Mr. Chuncai can get through his days and find some positives (see the video) there is no reason that any of us cannot either, even when we hit rock bottom.