Why Neuropsychological Testing Is Helpful in Dementia Evaluations

If you or a loved one is concerned that dementia may be present, a neuropsychological evaluation can be critical to confirming this, specifying the exact type, and guiding treatment. Dementia is a general term referring to a significant loss of intellectual and cognitive (thinking) abilities without impairment of perception or consciousness. There are many different types of dementia, with Alzheimer’s disease being the most common. Most forms of dementia are progressive and irreversible (such as Alzheimer’s disease and fronto-temporal dementia) although some forms are non-progressive (static) and reversible. An example of a static form of dementia is dementia due to severe traumatic brain injury. An example of reversible dementia is dementia due to unrecognized thyroid disease or vitamin deficiency.

Most forms of dementia begin with memory loss but other cognitive difficulties (naming problems, getting lost) can also serve as the initial symptoms. Sometimes, behavioral symptoms are the initial prominent symptom such as the decline in personal and social conduct that is typical of fronto-temporal dementia. Usually, a person with these symptoms will initially be evaluated by a primary care physician. This typically results in sending the patient for blood tests and a brain MRI (magnetic resonance imaging) to search for reversible causes of dementia and determine if there are any visible abnormalities in the brain. The MRI may show tissue loss (atrophy), abnormal areas of tissue (known as lesions), a mass such as a brain tumor, or other types of abnormalities.

The person may also be sent to a neurologist, which is a type of physician specializing in the neurological system. The neurological exam will typically consist of a brief interview and a physical exam focusing on the cranial nerves, reflex testing, and sensory-motor functioning. There will usually be some brief testing of thinking skills. This could merely involve asking the date and/or memory for a few words but can involve the use of a brief formal screening test of thinking such as the Mini-Mental State Examination. These screening measures are broad tests of thinking skills that are designed to pick up on red flags that may prompt a referral for more detailed cognitive testing. While screening measures may detect some difficulties that support a diagnosis of dementia, these tests are fairly easy, are not meant to replace a comprehensive neuropsychological evaluation, and are not good at differentiating between types of dementia.

There are several advantages to a neuropsychological evaluation. First, a neuropsychologist specializes in understanding the relationship between brain functioning, thinking, emotions, and behaviors. This is important because there are psychological conditions that are common in the elderly (e.g., major depressive disorder) that can mimic a neurologically progressive dementia (e.g., Alzheimer’s disease). Thus, an expert in how psychological and neurological conditions present is very important and neuropsychology offers that level of expertise.

Second, neuropsychologists spend hours upon hours with their patients to understand the history, obtain and thoroughly review relevant medical records, perform a detailed clinical interview (with the patient and a close informant[if possible]) and detailed testing. This degree of detail cannot be obtained in a physician’s office due to significant time constraints.

Third, neuropsychologists apply specialized procedures to formally estimate the estimated intellectual status before a suspected dementing condition began. Additional specialized tests include measures of memory, learning new information, attention/concentration, expressive and receptive language (e.g., naming, vocabulary, command following), IQ, visual-spatial and visual constructional skills, motor and sensory functioning, information processing speed, and executive functioning. Executive functioning refers to higher-level thinking skills such as abstract thinking, multi-tasking, planning, judgment, problem-solving, and organizational skills. Test performance is compared to groups of people who are in the same age group as the patient with have no history of brain damage. Some tests are also compared to groups of normal controls with the same/similar educational backgrounds and also for gender. Some tests of personality and emotional functioning can also be administered.

Neuropsychologists review the objective information from the testing and look for areas of impairment, the degree (level) of impairment, and patterns of performance. Specific thinking and sensori-motor skills are controlled by  different areas of the brain. The neuropsychologist then integrates this information with the information obtained from the clinical interview, medical records review, behavioral observations, and knowledge of how various neurological and psychological conditions present. These results can help determine the specific diagnosis, which leads to specific treatment recommendations as not all dementias are treated identically. These recommendations not only may include medication suggestions but also include practical suggestions to improve daily functioning. Treatment is drastically different if dementia is due to Alzheimer’s disease, a reversible thyroid condition, malnutrition, or a severe psychological disorder.

It is also worth noting that neuropsychological testing may not reveal dementia but instead show Mild Cognitive Impairment, which is stage between normal aging and dementia. This is important to know as it also effects treatment and not all of these cases convert to dementia.

One needs to be careful in selecting a neuropsychologist and some guidance on how to do so is offered here.

Living to 106 by Eating Pizza and French Fries

As I pointed out in a prior blog entry entitled "Exercise & Eat Fruits & Veggies All You Want: You're Still Going to Die," the belief that you are going to be able to eat your way to a long wife with healthy foods and that you will die early for eating unhealthy foods does not always hold true. This is likely because genetics plays a major role in determining whether certain abnormal health conditions will develop that can lead to death.  This does not mean that the types of food you consume play no role in your health. But food choices likely interact with genetics to determine risk. If your genetics are strong enough, traditional health guidelines regarding food selection may not apply to you. Also, if your genetics are poor, what you eat may not matter much at all.

In the blog entry noted above, I discussed the death of fitness guru Jack LaLane, who lived to 96 after a life filled with exercise and healthy food. Many cite that lifestyle as the reason for his long life but as I pointed out, there was likely a genetic component to this since his mother lived to age 89. To be fair, if people are going to use Jack LaLane as a model  for how lifestyle choices can lead to a long life, they need to account for another case as well…that of Margaret Moores.

Who is Margaret Moores you ask? Well, she outlived Jack LaLane by 10 years, living to age 106 based on a diet consisting largely of pizza, French fries, sweets, salt beef, and very little water. Apparently, the only medication she takes is Tylenol for arthritis. Other favorite and preferred foods of people known to live over age 100 includes bacon, coffee, red wine, dumplings, chocolate, and honey. To read more, see this article at The Huffington Post. I’m not saying to go out and have a diet consisting largely of these foods, but the point is that traditional health guidelines regarding food clearly do not apply to everyone equally.

The Absurdity of Using Facebook to Send Real Illnesses via Mail

It’s one thing to have concerns about the possible harmful effect of vaccines and/or not vaccinate one’s children due to these fears. While the anti-vaccine community will vigorously defend their concerns and choices, other will strongly criticize the need for these fears and the decision not to vaccinate with standard vaccines.

Regardless of what side you come down on, the decision not to vaccinate is not illegal if the parent(s) cites a religious objection or health reason that contra-indicates the need for a vaccine. But it is quite another thing for parents to take vaccination fears to such an extreme that they purchase lollipops, saliva, Q-tips, or other items over the internet that are infected with chicken pox and other bacteria in an attempt to vaccinate their children against the disease.

Although this may sound unbelievable, it is true. There is a Facebook page entitled “Find a Pox Party in Your Area” that allows people to connect who want to share viruses through the mail to naturally vaccinate their children. Here is what one of the messages on the page says from the administrator of the page: "Warning. The mailing of infectious items, such as lollipops, rags, etc, is a federal offense. This page is not private and can been seen by members and non members alike. You may post on the page that you have the pox and are willing to share but please keep your specifics in private messages between members.”

I’m not a lawyer, but it seems to me that the administrator is readily acknowledging that mailing these viruses are a federal crime but endorses people using the page to find others to carry out a crime. Some of the posters are charging $50.00 for infected materials. The page is not limited to people seeking natural immunity to chicken pox, however, as some posters have actively sought items tainted with measles. This is more concerning because measles is a more serious disease as it is more deadly and has more complications.

Regardless of the bacteria (or virus), no one should be sending these materials through the mail. The infected materials could contain other serious diseases that the parent is unaware of, such as hepatitis. How effectively these diseases can be transmitted is questionable, but it is possible, particularly when one proposed method is drinking another child’s saliva sent through the mail.

While social media has so many positive benefits to offer patients and healthcare providers, this is one of the negative sides. Healthcare providers need to be aware of this issue and dissuade parents from taking this route. For parents caught doing this, regardless of how correct they believe their views to be, they will likely find themselves facing serious federal charges in addition to the health hazards potentially inflicted on innocent people.

When I wrote this entry on 11/6/11, the Facebook page mentioned above was still open to the public. Later that night, it was gone, perhaps due to fears the administrators and participants had about federal prosecution.

The SHOCKING Ingredients in a McRib Sandwich

The older I get, the more likely I am to just eat at home so I have greater control over the ingredients that go into my food. These days, the ingredients that go into some foods are downright shocking.

Just so people do not think I am only picking on vegetables, take McDonald’s McRib sandwich, which is recently making its way onto menus nationwide again and has gained a lot of media attention. I remember this sandwich many years ago and bought one. It tasted good but when I ate it, I had no idea what the ingredients were besides assuming it was rub meat. So, before buying one this time around, I looked into the ingredients posted on the McDonald’s website and report my finding below.

First, let’s start with the meat. Technically it is made of pork, but it is a "restructured meat product." This means you are not getting a pure cut of meat. You are getting a bunch of different parts mixed together, which reportedly includes pig heart and pig stomach. The meat also contains water, salt, dextrose (a type of sugar), citric acid (a natural preservative), and…

1. Butylated hydroxyanisole (BHA): This is a preservative in food, but is also used as a preservative for food packaging, animal feed, rubber, cosmetics, and petroleum products. The National Institute of Health has listed it as a likely carcinogen, meaning that it likely causes cancer, especially in high doses with some experimental animals. In mice, it is not known to cause cancer and may even protect against cancer from other chemicals. In humans, it is not known to cause cancer when consumed in low levels. Nevertheless, California considers it a recognized carcinogen and a suspected toxin to the endocrine system, gastrointenstinal system, liver, immune system, nervous system, respiratory system, skin, and sense organs.

2. Propyl gallate: A food preservative also used in cosmetics, adhesives (glues), lubricants, and hair products. Some rat studies have found that it may cause cancer. It can irritate the stomach and skin, cause allergic reactions that affect breathing, and cause liver and kidney problems. Some countries have banned it or only allow limited use of it.

II. The bun actually has the most ingredients. Of these, the most concerning are:

1.   Azodicarbonamide: A synthetic chemical, which is used as a food additive to flour to improving baking functionality. However, its main use is actually as an additive to make foamed plastics. It is banned as a food additive in Australia and Europe as a precaution due to unknown health effects in humans.

2. Ammonium sulfate: This is a type of salt that is most commonly used as a soil fertilizer, explosives, and as a flame retardant.

3. Calcium propionate: This is used to inhibit mold growth. When infused directly into rats, it causes reversible neurological changes in behavior and brain functioning.

III. The sauce contains mostly natural ingredients but does contain:

1. Sodium benzoate: A food preservative that has been inconsistently associated with hyperactivity and is theorized to cause cell malfunction. In response to health concerns, the Coca Cola company is phasing it out of Diet Coke and some of its other beverages.

IV: The pickles contain natural ingredients but also contain:

1. Polysorbate 80: This is an emulsifier, which is a substance that allows foods to mix together. It is often used in ice cream but is also used in eye drops, to dilute flu vaccines, to stabilize for certain liquid medications, in tuberculosis cultures, and as an emulsifier for a cardiac medication (i.e., amiodarone) that stabilizes the heart beat.

My basic rule is that if I can’t pronounce the ingredients in my food, I try to stay away from it. I’m not perfect yet at applying that rule, but I’m paying more and more attention. However, if I want ribs, I definitely go to a genuine rib joint.

Suggested reading: McDonald's: Behind The Arches

Related blog entry: The SHOCKING Ingredients in a Mountain Dew.

How Exercise Can Kill You

While exercise is generally a good part of balanced healthy life style, many people do not realize that it can also be a risky and deadly activity. This is generally by taking unnecessary risks while exercising. As an example, I continue to be surprised at how many people are willing to jog on the shoulder of a road with cars speeding by at 55 to 70 mph with absolutely no physical barrier separating them from the vehicle. All it takes is one carless mistake on the part of the driver or jogger and serious injury or death can occur.  Unfortunately, I have seen many patients with severe brain injuries and/or paralysis as a result of these types of accidents.

As a recent example in the news, a man in North Carolina was recently killed while jogging along a roadway after an SUV lost control and crashed into him. A group of five joggers were recently killed when a drunk driver of a Mercedez Benz crashed into them. Sometimes, joggers make the mistake of deciding to dash across a street, are not paying attention (e.g., listening to music), and get killed by a car that crashes into them. This is exactly what happened to a young woman in Texas this month. This is why when I go for a jog, I stick to parks, residential areas where cars are going slow, and treadmills.

Another problem I see is that far too many people are pushing their body to extreme limits and trying to participate in triathalons. The result is premature death for some people. For example, a few months ago two people died after suffering cardiac arrest during triathalons. One was from the city I grew up in – Freehold, New Jersey. The ages were 40 and 64. Both died during the swimming event. The risk of dying from these extreme exercise activities is less if you are young and healthy, but the older you are, the more you risk a catastrophe like this from happening, particularly if you do these activities in extreme weather conditions such as 90 degree heat. A 2009, Minneapolis Heart Institute study that found that athletes participating in triathlons have twice the risk of sudden death.

Overall, it is important that people use common sense when exercising and not put themselves at unnecessary risk of serious injury or death. This involves avoiding exercising near 4,000 pounds of steel traveling towards you at high speeds, avoiding exercise in extreme temperatures, not jogging in the dark with dark clothes on, wearing a helmet when riding a bike, and avoiding extreme physical activity particularly if you are older. Some days, it’s better to just stay inside, relax in the recliner chair, eat some buttered popcorn, and watch a movie.

Update: See How Jogging Can Kill You.

How Fruits and Vegetables Killed Steve Jobs

One of the themes of the MedFriendly Blog has been to combat the notion that a diet filled with fruits and vegetables and frequent exercise automatically guarantees a long, healthy life. This was explored in detail in a thought-provoking blog entry

The blog entry was entitled, “Exercise & Eat Fruits & Veggies All You Want: You’re Still Going toDie.” While all of this may seem like common sense to some people, it does not seem apparent to everyone, including people who are geniuses in other aspects of life such as Steve Jobs.

A new book on Steve Jobs by Walter Isaacson details some strange health habits he had which were clearly guided by false beliefs. To begin with, Jobs would consume a diet consisting only of a certain fruit or vegetable for weeks at a time, such as apples and carrots. The only reason I can think of that Jobs would do this is because he was told that apples and carrots were good for him and so he decided that if this was all he ate for a long period of time, that would be even better. However, while these foods have some positive qualities, they are not supposed to be the sole source of a diet.

For example, while apples are a good source of vitamin C, vitamin A, and fiber, they barely contain any protein or fat and most of the calories come from sugar. No fat is a good thing you say. Not true if you have a diet that completely excludes fat because your body needs to use fat for energy storage. Not having enough protein is a major problem as well because proteins also provide energy, supports the growth of muscles and body tissue.

Jobs reportedly also believed that his fruit, vegetable, nut, seed, and grain diet rid his body of toxins that would cause body odor. Thus, he felt there was no need to shower or wear deodorant regularly. Coworkers strongly disagreed. The irony of all of this is that the lack of certain proteins in a diet can interfere with detoxification and cause more bodily odor.

No one can ever say for sure whether this type of extreme dieting contributed to Jobs developing pancreatic cancer but once he did develop pancreatic cancer, he again turned to diet and other alternative medicine techniques to treat the condition rather than conventional surgery that can offer a cure. These alternative techniques included the same type of diet noted above, acupuncture, online herbal treatments, and psychic consultations.

Once the tumor grew, Jobs finally gave in and decided to have the surgery 9-months later. But it was too late. After consuming hundreds and thousands of carrots, fruits, nuts, and seeds, Steve Jobs is dead…at only 56-years-of age. According to Harvard medical doctor, Ramzi Amri: “'Given the circumstances, it seems sound to assume that Mr. Jobs' choice for alternative medicine has eventually led to an unnecessarily early death.'

The moral of the story is not to be extreme with your diet, eat sensibly, treat yourself once in a while, and if diagnosed with a serious medical illness, use common sense and mainstream science to guide treatment not unproven methods (such as treating Alzheimer’s disease with coconut oil) that lack peer-reviewed scientific support.

Reference: MSNBC article by Melisa Dahl.

Related Blog Entries:

1. When Fruits and Vegetables Kill
2. Michael Clarke Duncan Turns Vegetarian, Loses Weight, and Dies of a Heart Attack

Even More and More EXTREME Body Images: Part 3

Back by popular demand, I am happy to bring back one of the most popular features of the MedFriendly Blog…EXTREME BODY PARTS. This is the third installment of this feature. For other extreme body parts, see the original article here and part 2 here. And now, without further ado, here is the…

WORLD’S LARGEST EYES: This is Kim Goodman. It’s not how she normally looks, but she contains an amazing ability to pop her eyes out about half of an inch. 

2. LONGEST EAR HAIR: This is Radhakant Bajpai of India, who has 5.19 inches of ear hair. Looks like he actually styles it. 

3. STRETCHIEST SKIN: This is Garry Turner of England, who can stretch his skin 6.25 inches. This is due to a rare condition of the connective tissues, known as Elhers-Danlos syndrome.

4. WORLD’S HAIRIEST CHILD: This is Supatra “Nat” Sasuphan. Seeing is believing.

5. WORLD’S MOST FLEXIBLE MAN: This is Daniel Browning Smith who hold many world records for incredibly flexible poses like this one:

6. WORLD’S LARGEST BICEPS: This is Gregg Valentino, who had 28 inch arms.

7. WORLD’S LARGEST PALMS: This is the palm of Leonid Ivanovych Stadnyk, believed to be the largest in the world.

8. LARGEST COLLECTION OF BELLY BUTTON LINT: This is the only one that actually gave me chills for some reason, probably because it is just so bizarre. This is a 26 year collection of belly-button lint! The collection is from Graham Barker of Australia. 

Trick or Treat! Dentists say its better to Gorge on Halloween Candy

From a strictly oral health perspective, dentists are reported to be advising people that it is better to gorge on Halloween candy rather than eating a little bit each day. The reason is that frequent intermittent candy snacking keeps the teeth covered acid that wears down the enamel of the teeth. The acid is produced after bacteria feed off of the sugar and carbohydrates in the mouth. Wear down the enamel enough and cavities result. Dentists also say it is better to eat a lot of candy at once because people are more likely to brush their teeth at this point than if they are frequently eating sugary snacks.

While this advice is interesting, gorging on Halloween candy is not exactly good for your weight or cardiovascular health. In my opinion, the best solution is not to gorge on Halloween candy or eat a bunch of candy throughout the day but to eat a little bit of Halloween candy here and there and keep the teeth clean regardless of what is eaten.

I remember about 10 years ago when I moved to a different state and the dentist told me I had a lot of cavities. I had drank soda throughout the day and figured that was the likely culprit. After getting the cavities filled, I began carrying a bottle of water with me almost everywhere I went, so I was frequently cleansing my mouth and washing away a lot of the sugar throughout the day. I have rarely had a cavity in nearly 10 years of using this approach. So, enjoy Halloween, enjoy the candy, but eat it in moderation, keep your teeth clean, and encourage your kids to do the same.

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.