Albert Provocateur

Countdown

2011-06-13T07:07:00.002-06:00

The count to “down” has begun, and we’re all strapped in to take that power surge to lethargy, hopelessness, and feelings of worthless. No one is immune, in these times of economic hardship, when selling a mother-in-law for a tank of gas becomes not such a bad idea. How did it all start? Where did it come from? Why are the air waves and magazine ads so full of the trance-like visages and the artificial smiles of mental zombies hawking the wares of pharmaceutical leviathans bent on addicting us all to powdered sunshine, in the form of pills, capsules, and tablets, to the tune of greenback or euro billions in treasure trove earnings?

Down for the count, or count as we go down. Let’s face it, life is no picnic, and it’s getting no easier, as our worries mount and our life’s savings go the way of the horse and buggy. Sending our troops to war to keep them employed and off our streets has created an enormous financial shortfall and an army of the homeless and destitute middle class back home, who have no jobs, no health insurance, and no viable nest eggs to cover mortgage payments, spiraling gasoline costs, and the high price of sending junior to college. It’s no wonder that depression has become a best friend and bed partner, as we pray in Chinese to puppet masters across the Pacific, who produce everything today but our children. So, let’s do the math, as countdown numbers decrease, and our anticipatory downward trajectory begins.

Ten. Let it be known that depression affects 1 in 6 Americans, with women bearing the brunt of its weight. Diabetics are particularly vulnerable, although no one is sure what actually causes the illness. A sudden life event, a serious illness, or simple everyday chronic stress may trigger depression-causing biochemical changes in the brain, and then that’s all she wrote. In addition, the association of depression with diabetes, heart disease, stroke, HIV/AIDS, cancer, and Parkinson’s disease leaves the door open to a wealth of exotic theories on its origins.

Nine. The definition of depression has been hashed and rehashed ad nauseam. While we know that its signs and symptoms must last at least two weeks to fit the paradigm, we are often caught off guard when the former are atypical and run the gamut from irritability, restlessness, and anger to physical symptoms such as headaches, digestive problems, and a worsening of chronic pain symptoms.

Eight. While depression is often a subtle companion whose talons don’t draw blood, its toll on the ability to work, develop and maintain friendships, establish intimate relationships, raise families, and engage in self-improvement is undeniable. Swallowing a barrel and pulling the trigger is extreme in most cases; eating too much and cutting out physical activity to the point of obesity is not. When blood sugar goes up, depressive symptoms worsen, to the joy of cavity-drilling dentists caught in an economic slump, and the chagrin of those of us who cast daily headlong stares into our bathroom and dressing room mirrors.

Unlucky seven. Teaching a depressed person to think or behave differently, in order to shut down negative thoughts and actions, is not as easy as it sounds. Sad, sleep-deprived, emotionally exhausted patients with chronic aches and pains are fertile terrains for failure of behavioral modification. It’s not that they don’t want to improve and feel better. They just don’t have the bag of tricks at their disposal to be successful.

Six, and we’re halfway there. So, when teaching fails, it becomes necessary to call in the big guns, namely, the antidepressants. They come in all shapes and sizes, and one size does not fit all. Trial and error is the name of the game here, as only 6 out of 10 people feel better after following the treatment regimen with their first antidepressant. The most common and widely used antidepressants are selective serotonin reuptake inhibitors (SSRIs), which all of us have seen advertised between segments of our favorite morning news programs or at Sunday half-inning, quarter, or film intermission. Household names like Prozac (fluoxetine) and Zoloft (sertraline) work by increasing available serotonin in the brain, whose shortage is postulated to cause depression.

Five. Antidepressants do not kick into high gear immediately. In fact, they are downright slow, and can take up to several weeks to elicit their desired effects. Their ultimate success may come at a price, however, as weak and depressed patients may then find the force to carry out their suicidal ideations, or, at the least, fall victim to the potpourri of side effects inherent in the antidepressant beast. The latter encompass a daytime plethora of unfriendly fellas such as constipation, daytime sleepiness, diarrhea, dizziness, dry mouth, headache, nausea, sexual problems, shakiness (with exotic names such as tardive dyskinesia and others), lip smacking, trouble sleeping, and weight gain. While side effects may disappear in a few weeks, there is no guarantee that they will not last until discontinuation of the medication.

Four, and we’re getting there. We’ve heard the horror stories, and we decide to go the herbal route. So, we mount our trusty, gas-guzzling SUVs, and go down to our local neighborhood Walgreens or Wal-Mart pharmacies to pick up the newest installment of St. John’s wort or some such other herbal magic bullet in the good fight against depression. What we fail to recognize is the fact that such over-the-counter herbal supplements, which require no prescription or authorized professional supervision, can be dangerous if used with certain drugs.

As the countdown reaches three, we make one last stand, before lowering our colors and hoisting the white flag. We begin an exercise program to alleviate the symptoms of depression. Many studies have linked physical activity to improved mood. Not only does exercise boost spirits, but it takes no Oprah, Doctor Phil, or Doctor Oz to attest to the innumerable ways in which it can improve general health.

Two. Almost there. Our engines begin to rumble, and we try to reign in stress. Actually, taking on too much stress, whether that be in the workplace, at home, or in our day-to-day relationships, can make us vulnerable to depression. Carefully monitoring our stress levels, whether that be via timeouts, vacations, yoga, or an “unplugging” at the same time everyday, can go a long way to aborting the count.

Finally, one. Sometimes God helps those who cannot help themselves. A simple distress call to the Almighty or to our friends and family will set the wheels in motion on the road to recovery. We can’t solve the problem unless we acknowledge its full ramifications, admit our inability to go it alone, and call in the necessary players to act in our behalf and in concert with us.

If we permit the countdown to reach zero, blast-off will take us to new heights. Unfortunately, they will not be of this world!

Sugar Plum Fairies

2011-06-11T19:01:00.000-06:00

Ask any layman what diabetes is, and chances are that he or she can give you a somewhat accurate answer. Not so for the connection between type 2 diabetes and sleep, as the sugar plum fairies of Tom, Dick, or Harry are anything but innocuous. With 35 percent of Americans reporting less than the recommended seven to nine hours of sleep each night, the gate has been flung open to a horde of health problems on the morning’s horizon, ranging from sleep apnea and compromised immunity to high blood pressure and diabetes mellitus. This wasn’t always the case, however, as Americans used to sleep more in the good old days. Between 1959 and 2002, as the story goes, with the good life becoming ever so much more difficult to attain, and with a shift in the collective psyche toward a workaholic paradigm, the percentage of people sleeping fewer than seven hours a night on a regular basis more than doubled. At the same time, the number of cases of diabetes grew precipitously, and almost overnight the young at heart went from dreaming sugar plum fairies to becoming plump, highly sugared, diabetic patients. Recent studies bear this out.
In a 1999 study published in The Lancet, when a group of healthy young people was restricted to just four hours sleep for six nights in a row, its collective ability to use sugar shifted dramatically to that of old men, demonstrating that adequate sleep promotes not only sound minds but also healthy bodies. Then came a study published in the 2008 Proceedings of the National Academy of Sciences demonstrating the influence of deep, or slow-wave, sleep on the risk of developing diabetes. When deep sleep was restricted, metabolic changes increasing the risk of diabetes occurred. Voilà! It became clear that not only the amount but also the quantity of sleep were key to diabetes prevention. Now, while these and other studies show that sleep can affect sugar metabolism, there has been no definitive proof to date that inadequate sleep causes diabetes. To assert anything else would be tantamount to laying claim to being an eyewitness to unicorns, fairies, or the Loch Ness monster. The jury is still out, however, and the evidence is mounting. For example, a 2010 study in Diabetes Care found that people with sleep problems or some form of chronic insomnia are more likely to develop type 2 diabetes than sound sleepers. So, the next time the boss at work catches you taking a snooze or an afternoon siesta, just claim you’re increasing your productivity by preventing type 2 diabetes.
Now, this is all well and good, but let’s not place the cart before the horse in all cases. What about those unfortunate souls that are already prey to diabetes? How does sleep affect their conditions? The relationship between adequate sleep and enhanced immunity has been shown time and time again, but what about the connection between sleep and hemoglobin A1C (or average blood sugar over two to three months)? The reader knows where this is going. Otherwise, the author would have never brought it up. A 2006 study published in the Archives of Internal Medicine, in fact, found that diabetics reporting poor quality sleep were victim to higher A1Cs. Not only that, but a chain of events is set in motion that leads to high blood pressure also, and we have all heard in our favorite televised news programs that lack of sleep makes dieting that much more difficult.
The brain has an internal clock, or circadian rhythm, as it is commonly known, that is closely linked to sugar metabolism and other bodily functions. When the clock is out of synch, due to too little sleep, sleep at the wrong times, or unnatural sleep, as well as a high-fat diet, the normal harmony between the clock and behavior is disrupted. Instead of the pancreas producing more insulin by day and more glucagon, an additional hormone to keep the body fueled, at night, chaos ensues. So, once again, sleep becomes a major protagonist, center stage, in the drama of diabetes. The question remains, however, does better sleep in habitually poor sleepers prevent or improve diabetes? Can something as simple as sleep be a magic bullet in the arsenal amassed against this chronic malady? While it is still too early to tell, studies have shown that treatment of obstructive sleep apnea (OSA) improves both sleep and blood sugar levels. There may be a direct connection, indeed!
To ensure that sugar plum fairies are the food of our dreams, and not the result of our dreams of food, we can make a concerted effort to get more and better sleep by scheduling bed and wake-up times at the same times each day, avoiding nicotine, caffeine, and alcohol, exercising early, not late, in the day, removing the television from the bedroom, not going to bed on a full or empty stomach, and, when all else fails, seeking professional help for prescription or over-the-counter sleep medications. Being a dreamer has had a bad connotation for far too long now!

© 2011, Albert M. Balesh, M.D. All rights reserved.

Glue Factory

2011-03-30T14:56:00.001-06:00

I come to you, my readers, in my 100th piece for the West Texas County Courier Newspaper, a broken man. Life has not been what I or many of us envisioned for ourselves, in this age of medical miracles, information super highways, quick-draw plastic, and the burning of Stars and Stripes and Mom’s apple pie. As unbridled imagination seeks to establish a beachhead and the complexions of kindergartens become an experience in the color spectrum, niches become harder than ever to carve in the human collectivity. With laptops plugged into walls, earphones into any orifice that will take them, and cellular phones into our privacy, something as simple as reading a good book on a lazy Sunday afternoon becomes tantamount to SAT calisthenics for disenfranchised youths bred on a healthy diet of white noise versus productive brain waves. Whoever said the meek will inherit the earth? That primacy will rest with the unqualified of stellar résumé legions of under-thirty stamp, whose English is heavily accented, intelligible only in the darkest recesses of remedial ESL classrooms, and written correctly only to the rattle, hum, and glow of spellcheck and Google Search. And all the while Baby Boomers are looked upon with disdain, called “old” and “bald,” and readied for 21st century furnaces, “soylent green,” or the glue factory.

Nothing new. It has always been that way, you say. Well, I say, “Enough!” Sometime, someone, somewhere must draw a line in the sand, and with the world currently on a downward rollercoaster spiral toward Sodom and Gomorrah, perhaps it is time to roll out the old and reign in the new. Unrealistic, you protest. Well, so was $5.00 a gallon gasoline several years ago. And while a cure for cancer goes the way of the horse and buggy, we continue to be held hostage by a generation whose only claim to fame is a resting on forefathers’ laurels and a relentless conviction that “honor student” bumper stickers are a true sign of worth and gauge of future success. Bah, humbug! My dog is smarter than your honor student! Then, again, maybe the 78 million Baby Boomers, born between 1945 and 1964, don’t have what it takes to compete with the current trade school or college-age population, as they are prepared for entry onto or continued longevity on U.S. employment scrolls.

God help us, and God help this country of ours! It is a sad commentary on life and times when chronological age is equated more with a readiness for the glue factory, than with experience to not only be passed on to others but also to increase productivity in the workplace. While 50- and 60-year-olds continue to be discarded from the job market, in favor of twenty- or thirty-somethings whose nimble fingers make laptops, iPods, iPads, smart phones, and every imaginable (and, most often, totally useless) electronic gadget dance, literacy, math, and science skills, and the ability to read and write clearly and coherently, continue to be outsourced to China, India, and Pakistan. America, shame on you! The worth of a nation is not measured by how it values the new, but by how it treasures the old. The Japanese would most certainly attest to that assertion, while at the same time having done away with the traditions and inner nobility of the Samurai. The American Indian admonishment should be chiseled in the stone of the Washington Monument, that “That which you take will always be taken from you.” Fast forward to twenty or thirty years from now, and I’ll be gone, leaving the so-called “young and able” to write the follow-up piece, in God only knows what language and with how much incorrect syntax.

When young and playing fast-pitch on a brick wall with only enough money in the pocket for a soda pop, one longs for the day when adulthood brings riches and the American Dream. That shiny red sports car that zooms by is not seen as an object of envy to be coveted, but rather a goal to be reached with hard work at the coming of age. No longer true today, however, as financial solvency walks a tightrope between soup kitchen and fast-food restaurant, as prescription medications are cut in half by the sick and indigent to make them go farther, as families must decide between winter heating oil and sending junior to college, and as a missed paycheck marks the beginning of the yellow brick road to invasion of privacy by collection agencies, as the number of unemployed workers 55 and over continues to swell to 2.2 million and beyond. That is triple the 2005 figure, with half the vagrants, unemployed, homeless, jobless, migrants, old bags, welfare cons, hand-out abusers, or whatever else one chooses to call the innocent out of work for more than six months. All the while, establishment big-wigs tell the rest, “You should be grateful to have a job in these times.” Translation: be miserable, earn a minimum wage not commensurate with your educational level, pay off those expensive student and high interest credit card loans, and with the change in your pocket be glad you’re alive. After all, you brought this on yourselves.

Is “recareering” the answer for laid off auto workers, engineers, bankers, builders, and doctors, like myself? Not in a long shot, especially in the current economic climate of heartless foreclosures, devastating tsunamis, readily available iodine pills to forestall the immediate effects of fallout particles on the thyroid while placing the subsequent leukemias twenty years down the road on the backburner, and a bloated and ravenous military fighting losing battles on three fronts in order to keep its uneducated masses gainfully employed and out of sight, out of mind of job recruiters and Ivy League-trained economists in a sputtering civilian job market. The latter echoes the “Let’s make war, not love” mentality that has made American great in times of economic downturn.

In 1905, world-renowned physician William Osler stated in no uncertain terms that ages 25-40 were the golden years of productivity, with workers aged 60 and above being basically useless. The fight for survival, lack of food, and scarce resources made Darwinian logic a mantra during the subsequent Great Depression, with older Americans refusing to retire and causing great unemployment among younger workers. After that, it became all too evident that the only way to get old people to stop working was to pay them enough to stop working. Now, however, you cannot either pay them enough to stop working or work them enough to start paying. The “glue” will just continue to flow.

The history lesson and venting are over. I guess I’ll just make my way down to the factory.

Hospital-ity

2011-02-08T05:39:00.001-07:00

There you have it! Go in with something, come out with something else, or not at all. The game of Russian roulette has begun, in a casino called a hospital, with dealers dressed in white, all in the name of “hospital-ity.” This game is different, however. Lives are at stake, and you, the crap shooter, not the house, are in control of your own destiny. With 98,000 people dying each year in hospitals due to medical mistakes, the stakes are quite high. The cards are stacked against you, and unless you play with something up your sleeve, namely, the trump card of information, you are destined to see your pile of chips dwindle, as the lack of hospital electronic medical records, the longer working hours of physicians and nurses, and the lack of simple precautionary measures like handwashing all contribute to a nasty stay or your ultimate demise. Even in a best case scenario and in topnotch hospitals, hospital-ity is at a premium, with 18 percent of patients hurt as a result of a medical procedure, medication, infection, or other cause, a euphemism for “blunder.” While counting cards is prohibited, some numbers simply cannot be overlooked. The lion’s share of hospital harm, over 63 percent by some estimates, can be prevented, and the name of the game, pure and simple, to do this is getting educated. Whether a patient is hospitalized for diabetes or surgery, the rules for maximum patient satisfaction and pay-out are similar, as are the consequences for failure to abide by them. How many times have we heard horror stories about wrong limbs being amputated, wrong operations being performed, patients going into hypoglycemic shock, and antibiotic-resistant strains of bacteria having free reign in hospital wards? In most cases, a throw of the dice is just that, when an ounce of prevention would have most certainly yielded a seven or eleven. And you say you’re not a gambler?

So, what can be done to turn the tide on the house, and stack the deck in favor of the bird to be plucked, namely, the patient? First of all, stay informed. Don’t be intimidated by your surroundings or by the air of importance generated by your health dealers in white. They are there to serve you, and not vice versa. The more questions you ask and the more informed you are, the smoother your treatment will be. You can take that to the bank! Secondly, don’t hide cards up your sleeve, when it comes to allergies, alcohol use, sexual activity, medications and supplements, and any other piece of relevant medical information that you consider too personal or too embarrassing to reveal. Remember, anything your doctor or nurse doesn’t know can kill you! Another bit of information to carry with you to the cash-out cage or discharge desk is a full understanding of any prescription your physician has written for you. Doctor’s scrawl is akin to hieroglyphics, and don’t expect your friendly neighborhood pharmacist to possess the Rosetta Stone or read your physician’s mind. Whether it be the name of a drug, the dose, its frequency, side effects, the availability of a generic version over a brand name, or any special instructions, make sure you cut the cards openly and cut your losses, too, by holding both your doctor and your pharmacist to the letter of the label. Pills, capsules, and tablets are like colored poker chips. Sometimes they get lost in the heat of the shuffle or the intensity of play. So, be sure on that score.

It goes without saying that you should move around the hospital as if it were a casino, and as if you were looking for just the right slot machine. Bedsores, blood clots, and infections have a tendency to make losers of the immobile. It is a no-brainer, therefore, to at least take that walk down the hall once a day. Don’t be afraid to speak up either, if you happen to run into your doctor or nurse, and wish to ask a question, get something off your chest, or obtain clarification on some aspect of your care. That’s what they’re there for, and the worst they can do is ban you from the casino for life, in which case you’ll choose a future hospital with better health care providers, management teams, educators, dietitians, and ancillary staff. You hold the four aces as a consumer, and it is up to the pit boss and hospital administration to retain your health care dollar and your health care business. Something as apparently inconsequential as a caregiver failing to wash his or her hands, and then subsequently not complying with your gentle germophobic reproach and reminder to them to do so, is a serious matter and grounds for changing the table you are playing at.

Taking your personal health matters into your own hands will not only cut down on iatrogenic errors and unintentional cheating by the “whitecoats,” but will guarantee a pay-out measured in numerous disease-free years and improved quality of life. Don’t get taken to the cleaners by failing to do so!

Articular Attack

2011-02-02T06:27:00.001-07:00

Like a toy in the attic, collecting dust until polished and thrown back into the mainstream of the temple’s hallowed halls, rheumatoid arthritis (RA) subtracts luster and adds exquisite pain to muscles and joints long ignored in a restful and tranquil hibernation. Dormancy breeds contentment, especially in the fairer sex, until some as yet unknown trigger unleashes a symmetric articular maelstrom that rivals a perfect storm and leaves its hapless wayfarers cursing the day they were born. In short, RA is no fun, and its countless victims, currently estimated at 0.8% of the U.S. population with three times more women than men suffering its ravages, to second that attestation. Most cases, 80% in fact, develop between the ages of 35 and 50 years of age, with the onslaught attributed to a possible infectious agent such as the measles virus or the virus causing infectious mononucleosis. Whoever or whatever the culprit initiating the skirmish, the ebb and flow of battle results in devastation of joint linings and their associated blood vessels, along with an unhealthy dose of inflammatory cell invasion and edema. The latter cells release a barrage of activated substances and destructive enzymes that are up to no good, degrading the joints even further. If that were not enough, reserves are called up from the rear to discharge a battery of antibodies, which attack self-proteins called antigens that have no other fault than being in the right articular zone of combat at the wrong time.

Hostilities begin with vague symptoms of fatigue, loss of appetite, and muscle, bone, and joint pain, that gradually progress over the course of weeks or months to a more specific chain of cataclysmic events. Several joints, especially those of the hands, wrists, knees, and feet become involved symmetrically, with no prisoners taken in that 10% of the combatants who wage an acute and losing battle against fever, enlarged lymph nodes, and a spleen that roars its resentment to its increased girth. Pain in affected joints, aggravated by movement, is the alarm sounded and call to arms, with morning stiffness of greater than an hour duration interdicting immediate obedience to the bugle’s blare. Inflamed joints are held in a flexed posture, resembling a “Z,” the neck of a swan, or a buttonhole, in order to maximize their volumes and consequently minimize the hurt. Laboratory surveillance, counterintelligence, and a sending in of skirmishers to scout the terrain and lay of the land do little to extend the beachhead, as 5% of healthy recruits demonstrate rheumatoid factor, an autoantibody whose presence is not necessarily specific enough to warrant capitulation. In fact, RA may be mimicked or camouflaged by any number of conditions harboring rheumatoid factor; those being lupus, hepatitis B, tuberculosis, leprosy, syphilis, chronic liver disease, malaria, infectious mononucleosis, bacterial endocarditis, and a host of others all to ready to swing into action.

So, what to do? What weaponry in the possession of a modern-day bombardier or rheumatologist can slow the progression of disease, while at the same time lessening its cost in blood and treasure? Obviously, exercise directed at maintaining muscle strength and joint mobility is the first line of defense and stopgap measure to halt RA invasion. When lines are overrun, bigger guns are called to bear on troop movements of autoantibodies that if left to rape, pillage, plunder, and otherwise wreak havoc on the articular landscape, will inevitably result in disabilities so grave as to compromise daily activities and quality of life. Enter the fray, low-dose anti-inflammatory steroids, and, if need be, disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate and sulfasalazine, to temper RA destructive capacity. Symptom mitigation and pain relief via nonsteroidal anti-inflammatory drugs (NSAIDs), simple analgesics, and cycloogenase (COX) inhibitors (or Coxibs) may additionally be drafted into service. Finally, when all else fails, a resort to nukes, in the form of potent biologics, is authorized to control signs and symptoms of RA, slow damage to joints, and limit disability, all at the expense of a crippled defense budget.

Make no bones about it. When the dogs of war are unleashed by RA on unsuspecting joints, their bites are inevitable, at the cost of sometimes muted barks.

Brickfish Social Media: Rome Wasn't Built in a Day

2010-12-08T07:49:00.001-07:00

Brickfish Social Media: Rome Wasn't Built in a Day My entry to the Centers for Disease Control (CDC) "The Flu Ends With U" poster contest. Please take a look at my poster via its link, and, if you like it and its message, vote for it. First prize is $2,000, a part of which I will give to charity and the rest of which I will use to throw one heck of a party for all my Blogger and Facebook friends who get vaccinated. Many thanks for your support. Remember, the flu is a serious illness, which can lead to death in some cases. So, GET VACCINATED!

White Man Speak with Forked Tongue

2010-12-05T12:10:00.001-07:00

The United States has long prided itself on being a guiding light and the bastion of democracy in an ever-hostile and tyrannical world. The founding fathers conceived of a government “…by the people and for the people” with “…freedom and justice for all.” Wonderful words and beautiful thoughts, but are they still applicable in a changing world in which it is sometimes felt that a circling of the wagons and a ducking of heads behind Fort America is the best course of action. Should a government’s leaders, indeed, provide full disclosure of facts to the public, when, in fact, such “coming clean” might compromise a country’s defense, a population’s safety, a nation’s intelligence services, industry, infrastructure, and agriculture, not to mention popular opinion and faith in one’s political leadership? This is a question that has either dominated or occupied the wings of the U.S. stage since its inception, over 200 years ago. The U.S. continues to wrestle with the issue, in the face of world terrorism, a burgeoning China and a loss of manufacturing jobs to that juggernaut that continues unabated, disillusionment on the home front due to a failing economy and rampant unemployment, and a higher education system floated on false hopes and staggering student loans.

Yes, the world has become extremely complicated, but Americans like to think that certain unalienable rights, principles, and doctrines remain immutable in the face of cultural, technological, religious, social, and moral upheaval. The “holier than thou” attitude cultivated by America and Americans is perhaps based on a myth and on the hope that things really aren’t as bad as they appear. After all, this is America, the “…land of the free and the home of the brave,” as well as of Ma’s apple pie. Those terrible things that happen in other countries couldn’t possibly occur on home soil. After all, U.S. politicians and leaders come from the same stock as the populace, and they would never lie to the people. Little white lies, perhaps, but never those black “ops,” shady dealings, and dark innuendos that threaten to shake the foundations of democracy and the moral backbone of the American people. Think again! Further fresh revelations on the John F. Kennedy assassination, which occurred almost 50 years ago, are, in fact, just coming to light today, and that is just the tip of the iceberg; lest we forget the mysterious circumstances surrounding the attack on Pearl Harbor, the assassinations of Robert F. Kennedy and Martin Luther King, the U.S. involvement in Vietnam, the Oklahoma City bombing, the “9-11” terrorist attack on New York’s World Trade Center, and the rush to judgment and rush to action in the first and second Gulf Wars.

Psychiatrists and psychologists tell us that lying is socially expedient. Many feel that we are all natural-born liars, and that an innocuous fib or a “little white lie” here and there not only helps our day-to-day conversations flow more smoothly, but keeps them from stalling, sputtering along, or just plain boring our listeners. It has been estimated that in an average 10-minute conversation with a stranger or a new acquaintance, approximately 60 percent of us lie three or more times. Men and women are equally prone to stretch the truth, with the former fibbing to make themselves look better, and the latter to make another person feel good. Lies, for better or worse, just slip out of us, and we simply don’t realize how dishonest we are until we make a conscious effort to analyze our motives or stop.

On a grand and national scale, there is a growing suspicion and permeating mentality among scientists, political thinkers, philosophers, religious leaders, and the citizenry that the U.S. Government is “holding back,” so to speak, from the general public. National defense concerns are often quoted as justified or unjustified motives for reticence on the part of those who have taken a solemn oath to protect the U.S. Constitution, while at the same time giving the people what they want and not pulling the wool over their eyes. The price tag of the subterfuge involved in cover-ups and national defense excuses is not only backbreaking and heartbreaking, however, but also bank-breaking, as countless years, dollars, and human productive capacity is wasted, trying to unravel mysteries as diverse as Area 51, the Roswell landing, the Watergate debacle, and any number of other national concerns, past and present, that drain precious resources better devoted to finding solutions to problems that threaten to severely damage any legacy left to American children. Wouldn’t time, money, and manpower be better spent finding solutions to the energy problem, the continuing destruction of the environment, and the growing religious and social intolerance between peoples of different race, creed, and national origins?

If the answer to the question of whether U.S. and world politicians and leaders should come clean in all cases is to be in the affirmative and free of all shades of gray, then not only the U.S., but also her partners and enemies, must band together to create a kinder, gentler world. It has often been said that, “The truth will set you free,” and nowhere is this more true than on the political scene. So, if you ask me in no uncertain terms whether U.S. and world leaders can and should always tell the truth to their people, my answer is a resounding “Yes!” Not only will the truth free up monies better used to solve far more pressing national and world problems, but a spirit of trust among the people of a single nation and between peoples of diverse nations will go far to increasing the cost-effectiveness of those remedial measures; in other words, our money will go farther, if we spend more on solving the problems themselves, rather than putting accompanying safeguards in place to protect the actions and measures we deem necessary. While national borders and the idea of countries themselves may be fading away, as technology breaches territorial beachheads, no one would argue that truth, and nothing but the truth, from the mouths of political leaders would go far to making the process as painless and productive as possible. Not only is the pen, but also the “un-forked” tongue, mightier than the sword!

Editorial Edict or Evict?

2010-11-15T05:46:00.001-07:00

The argument made by marketing directors to the editorial departments of television news programs, that editorials presented at the end of newscasts cost the programs both viewers and substantial revenues, in terms of sponsors and advertisers, is a particularly cogent one. Marketing directors base their assertions on statistics that viewers either switch stations or turn televisions off entirely, when end-program editorials are presented. They are very much convinced of their opinions, and make it clear that news programs and television stations are in the business not only of presenting news, but also of making money to stay on the air. After all, no program can afford to stay on the air without both a viewer base and committed, enthusiastic sponsors who are confident that their wares can be peddled, so to speak, to the former. News programs, and the news stations and networks to which they answer, can only charge top dollar to advertisers, if the latter feel that their products receive adequate exposure to a wide and informed audience willing to pay a fair price for their services and/or products. Although marketing directors do not usually come out and say this in no uncertain terms, they imply it, along with bottom lines. They usually keep their statements to a minimum and to the point, and oftentimes convince editorial departments already cautioned by management to keep editorials brief, easy to comprehend, interesting, informative, and, most importantly, entertaining, if that is possible, in order to retain viewers long enough to the view commercials and advertising spots of the program’s sponsors.

There are some flaws in the marketing directors’ logic, however. While their statistics may and often do demonstrate a loss in viewership during the editorial portion of news programs, that might be due to other contributing factors, which they fail to investigate sufficiently. The final portion of news programs, for example, usually herald the dinner time of most households, and coincide with mass migrations to the dinner table, at the expense of editorials that are many times lackluster in their breadth, scope, and subject matter. Furthermore, editorials are usually read or recited verbatim by newscasters who are dry in demeanor, perhaps not stylish in presentation, and who the viewers feel are not relevant to personal taste due to language, dress, mannerisms, culture, past points of view, or any number of critical, unconscious cues that make us love to love or love to hate someone, and, yet, for those reasons, keep us glued or unglued to the television screen.

Were that not enough, enter the playing field and the mindset of the viewing public of what is commonly known as “information fatigue syndrome.” In fact, the barrage of information to which we are constantly exposed carries a cost, both mentally and physically. The spotty memories, short attention spans, and drawn out, tired feelings to which many of us are subject are fertile terrain for the syndrome and its host of symptoms. The latter run the gamut from increased cardiovascular stress, due to a rise in blood pressure, weakened vision and the Japanese prediction of nearly universal nearsightedness in the future, confusion and frustration, impaired judgement, and decreased benevolence to others due to an environmental input glut.

What marketing directors fail to realize, even though they constantly research and statistically analyze viewer numbers, is that most people today get their news from news programs and the Internet, not from traditional news media sources such as newspapers and magazines. Were they to think about that for a moment, they would come to the conclusion that news programs have captive audiences, and that all that might be required to stop the hemorrhage of viewers at the end of news programs is a simple tweaking of formats, perhaps with the addition of those audiovisuals that we are all so very fond of. Also, a simplification of the form and content of the news would go far in the quest to ease information fatigue syndrome. After all, we have become a visual society that reads less, and both editorial departments and marketing directors need to come to terms with that. Both are in the business of informing the public and getting the news out. They just approach that end-result from a different perspective. Both need one another, like a right hand needs the left, and both cannot remain in business without financially solvent, viewer-friendly news enterprises based on mutually symbiotic and beneficial relationships.

Now, while all this is well and true, and while the moral high ground of editorial staffs often trumps the bread-and-butter of marketing departments, it must be reiterated that the news is a business in and of itself. Programs cannot survive, even with the best of intentions, if the revenues are just not there to buttress continued sustainability. Failed and failing newspapers throughout the country will attest to that fact, as every day we read or hear about decreased newspaper circulations, bankruptcies, and prestigious news and editorial staffs that have gone the way of the horse. If news programs are to fight the good fight, and if news journalists are to continue to present unbiased, informative news to a public starved to be informed but overloaded by the superfluous, then bottom lines need to be met, and that in itself is what marketing directors continue to insinuate, if not come right out and say. While we would all like to be moral and ethical in our choices, oftentimes that becomes the birthright of the rich. Without sufficient profit margins, marketing directors teach us, not only does capitalism on a wide scale suffer, but the right to inform becomes dangerously monopolized by the business “haves,” at the expense of easily manipulated news consumer bases of “have nots,” who have no real choice in their selection of news outlets or networks. End of case. End of unbiased journalism and consumer choice. End of this news story.

Odd Job

2010-10-31T10:05:00.000-06:00

It is the job of outside efficiency experts to measure productivity in the workplace, and employers are increasingly turning to them to gauge employee competency, in the form of increased or decreased productivity, with a subsequent eye to improvement. In these times of increased technology and computer literacy, and with the transformation of the majority of American workers into providers of services rather than skilled laborers and manufacturers, employers have witnessed a tendency for worker productivity to decline, because of both the sedentary nature of most jobs and the hours spent before computer monitors emailing, surfing the World Wide Web, playing online games, and interacting remotely with distant friends and colleagues via Facebook, Twitter, MySpace, and a host of other Internet web sites and portals. While outside efficiency experts have been summoned in many cases to determine why employee efficiency has declined, it has sometimes been difficult for them to put a finger on the reasons for decreased employee productivity. The reasons behind increased productivity have also been difficult to measure in some cases, when the experts called in have not been familiar with the service or industry being examined. Landmark legal cases brought by disgruntled employees against industry giants, and immortalized by popular news media anchors, the press, and the tabloids, for consumption by the public to the tune of higher ratings, bear this out.

While outside efficiency experts continue to believe, in no uncertain terms, that employee work-related behaviors and productivity improve when the workers themselves knowingly come under direct observation and scrutiny, and while that may contain an element of some truth, it in no way illustrates the entire picture. Improvement in employee productivity may be due to any number of reasons in the workplace. To assume that worker conscientiousness is directly related to a Big Brother mentality is not only nearsighted, but also counterproductive to open-mindedness and a sense of fair play. It places the workforce in the position of spoiled little children, not only ill-equipped and reluctant to perform the job-related duties for which they were hired, but also requiring a mother, a mother superior, a mother hen, or some such other disciplinarian to guarantee compliance with the stated goals, duties, performance tasks, and productivity stated implicitly and mandated by individual job descriptions.

Rather, outside efficiency experts would better spend their time understanding the workers themselves, their needs, the specific company and what it requires of its employees, the points of view of management, union, and employees on the reasons for the decline or failed improvement in productivity, the mental status of the workers, the work environment, and a plethora of other motivators for and detractors from healthy increases in productivity over time. Now, granted, human nature being what it is, employees will tend to stray a bit if they are not held to account for their performance. No one argues that. A Big Brother in the workplace, however, can only serve to have a detrimental effect on productivity, leading to employee resentment of management and a further decline in company productivity and profit margins. Passive aggression between employees and between employees and management is a terrible thing in the workplace, and “spying” by management and/or outside efficiency experts can only make an already tense situation unbearable, to say the least, leading to frayed nerves, absenteeism, lack of motivation, and a host of occupational-related maladies that put money in the pockets of labor attorneys, occupational medicine physicians, and those psychologists and counselors that no company would be complete without.

On the other hand, a vested interest in the company demonstrated and sincerely felt by employees who sense fair and equitable treatment by management, makes for a healthy symbiosis that can only be beneficial to the company. Diverse corporations such as Microsoft, IBM, Starbucks, Samuel Adams Brewing, Humana, and numerous others have successfully instituted and obtained outstanding results with employee-management models in which workers are treated more as partners than as servants. They have found that workers are not lazy, and that they will, indeed, increase their efforts and productivity when they feel that they are being treated honestly, being cared for by upper management, believe in the product or service they represent, and have open lines of communication, and perhaps even an open-door policy, with their supervisors, managers, and upper level management. Outside efficiency experts, who should know better and who are privy to the company success stories mentioned above, need to examine all the possibilities mentioned earlier for possible employee malcontent and decreased productivity. Playing the “easy” surveillance card, for whatever reason, and attributing past, suboptimal performance to a lack of observation, surveillance, and disciplinary control begs the question and misses the mark entirely.

In this age of new cultural awareness and social correctness, outside efficiency experts would find their time better spent examining the actual, multifaceted causes for employee and management malcontent, instead of hiding behind past stereotyped generalities for declining motivation and subsequent productivity shortfalls.

Good for the Goose

2010-10-31T10:00:00.000-06:00

Today’s society is in a constant state of flux. We move faster today than ever before, what with new advances in communication and society’s incessant need for instant gratification. Laws, too, must change with the times, being constantly adapted to new contingencies, while at the same time maintaining certain unalienable principles. Indeed, life has become complex, and perhaps laws should be enacted to keep pace with those complexities. It is obvious that any statute or law enacted cannot possibly be applicable to a multivariate playing field, but nonetheless must maintain a certain degree of malleability in both application and interpretation, in order to provide for a modicum of simple justice in a world tinted by shades of gray. Some examples will serve to bear out this point.

Let’s take, for example, the case of handgun laws and registration. While states in the Midwest and Northeast of the United States have adopted a particular negative posture in their regard, said point of view is not applicable to other areas of our great nation, where handguns and rifles are viewed as a necessary quotidian tool, in much the same manner as an automobile jack is to the trunk of our cars. While a jack is not something we think about on a daily basis, we are grateful for its place in our vehicles, when the time comes for that unexpected change of the “rubber guard.” Perhaps handgun laws should be viewed in the same light, providing a certain lenience and understanding in their application to those instances, individuals, and areas of the country where a certain degree of deterrence on the part of the common citizenry is warranted. While it is certain that the closed living spaces of the Midwest and Northeast, with their higher populations and greater numbers and visibility of law enforcement personnel, demand a stricter code of application and enforcement of handgun laws, areas of the West, Southwest, and Northwest of our great nation require perhaps a looser interpretation, if not an all together different codification of those laws. The matter is complicated, but adapting handgun laws not only to a changing society but also to changing demographics, geography, and population migrations just makes good sense.

On the other hand, lest we forget their potential to rain on parades, it goes without saying that handguns are an all but necessary evil. In 2007, for example, a total of 12,632 people in the United States were murdered with firearms, and it is estimated that 48,676 were treated in hospitals for gunshot wounds received in assaults. Now, we must ask ourselves, how many of our troops placed in harm’s way have succumbed to the power of the black powder? It appears that our civilian casualties far outweigh their body bag count. Physicians, in particular, are well aware that gun violence is a major public health concern, and one that hits home not only in the torso, but also in the pocketbook. It has been estimated that society bears the brunt of annual gunplay to the tune of over $100 billion.

Cries of “self-defense” echo throughout the land, and the great State of Texas holds some preeminence in that regard. For years now, we have seen Texans raise their collective fists in outrage and heard their collective cry, if not roar, of defiance, when Northern politicians have only alluded to the possibility of stricter control of their handguns. The argument of the Lone Star State’s vast gun-toting population has been that every man and woman has the right to bear arms and defend his or her homestead against possible invasion from without. Laws have been enacted to guarantee this right to the homeowner, and jurisprudence teaches us that test cases in Texas have always favored the defender’s use of force to protect family. In fact, there is a running joke in Texas that if someone violates your property and trespasses, you are to shoot first, ask questions later, and be sure to drag the body into your home, in order to cut your losses. Should an ambitious prosecuting attorney decide to make an example of your rush to judgment and violence, hold firm, as the National Rifle Association (NRA) will most certainly come to the rescue. Now, while that explanation of Texas law may be slightly exaggerated, statistics show that retail sales of firearms appear to corroborate the cultural wisdom of a large-scale Texas vigilante movement. Cross-border violence, with Mexican neighbors to the south of the Texas border, has also fueled the flames of the local and national gun lobby.

The two instances and laws mentioned above appear to confirm a tendency to adapt laws to current societal and cultural trends, in their enactment, applicability, interpretation, and enforcement. It nonetheless should be realized, however, that there are dangers inherent in a body of laws that is dynamic and in a constant state of interpretive flux. Referring back to our previous examples, without a uniform legislative standard of handgun availability, purchase, registration, transport, use, and storage, we run the risk of “returning to the future” and transforming ourselves into trigger-happy patriots with sophisticated weaponry that our forefathers could not have imagined in their wildest dreams. Also, who speaks for the “little people,” in other words, those innocent bystanders who are wounded, maimed, and killed by stray bullets that false pride and fear coerced us into firing at the sound of a creak, crack, or scratch in some far off place in our homes in the middle of the day or night. Many an innocent bystander out on the sidewalk or street has paid the ultimate price for devil-may-care interpretation, implementation, and justification of a Bill of Rights that perhaps is too antiquated to be applied in its letter to a 21^st century population of descendants who face challenges all together different from those of their forefathers.

So, it must be said that laws that are too strict in their vision do as much damage as those too loose for their and society’s own good. Society and even culture changes on a continual basis, and perhaps laws themselves, if not in their immediate substance, at least in their interpretation and application, must be constantly molded and adapted to meet the ever-changing social challenges of melting-pot population dynamics. While the backbone of a federal law must be as straight in Nevada as it is in New York, the lengths and breadths of its limbs can be as diverse as a population’s body shapes and sizes. When it comes to law and white shirts or blouses, one size does not fit all. A slight modification or a trip to the tailor, however, can make us all presentable, and then we can truly say that what’s good for the goose is, indeed, good for the gander.

Beguiling Guilt

2010-09-05T09:02:00.000-06:00

It accompanies us throughout life, taking its seat at our right hand from an early age, and leaving us not, even in sleep. We come to cherish it as a best friend, not because of any particular attribute it might possess, but because we’ve grown so accustomed to its presence, that we would be utterly lost if it got up and walked out on us one day. Plainly speaking, guilt is just no good, but if we can learn to bury the hatchet and place it on an unconscious backburner, then our lives can proceed on an even keel. After all, the conventional wisdom and a host of psychiatrists, psychologists, social workers, ministers, shamans, and new-age gurus tell us that we were not placed on this earth to punish ourselves. The trite ring in the confessional that we cannot begin to love others until we love ourselves may take on new luster and dynamism, if applied to everyday guilty pleasures that paralyze the mind, in much the same manner as the obsessions and compulsions of he who would like to cast the first stone but is wont to find a suitable geologic specimen. Rid the mind of guilt in the quotidian, and quality of life can only improve. In short, bad can achieve that end, and bad can, indeed, be good. Perhaps a few examples will convince you, the reader, of the wisdom of those words. After all, sages are not born. They are constructed on the foundations of years and years of trial and error.

Let’s look at something as simple as cursing or swearing. We all do it, but whoever thought that it might be good for us? A volley of f-words can be as therapeutic as a stream of consciousness on a shrink’s couch. Cursing has been found to minimize physical and emotional pain by stepping up our inherent physiological fight-or-flight mechanism and releasing natural pain relievers. Researchers in England have found that people who immerse their hands in ice water tolerate it longer when they swear up and down. Damn those ice cubes!

We often turn to alcohol, or worse, when our coping mechanisms short circuit. Guilt has driven many a good man or woman into the arms of Johnny Walker, Jack Daniels, or Jim Beam, and many of us have pursued or been pursued by a Wild Turkey. Whoever thought, however, that a bartender’s poison might lift the Sword of Damocles from our hearts, if not from our minds? In fact, moderate alcohol intake, while remaining guilty as charged for increasing detox and rehabilitation center reservations and DWI dockets, nonetheless reduces the risk for cardiovascular disease, the leading cause of death in the United States. The challenge comes from building both a salubrious psyche and a tamed ticker, preferably at the expense of no more than one drink a day in women and two in men.

Smartphones and multitasking have taken their toll on dog days and downtime. The rat race we run in has become ever more frenetic, as we juggle appointments, sprint errands, and rush to the finish line, all in the name of keeping up with the Joneses and putting away that nest egg for our golden years. While we do more and more each day, we learn less and less, as our long-term memories have been sacrificed for a semblance of betterment in the here and now. Our minds no longer wander, with the daily so goal-directed, and that simple game of Monopoly on a back porch, so popular just yesterday, is disparaged as an utter waste of time today. Lo and behold, we couldn’t be further from the truth! Researchers at New York University, in fact, have found that relaxing not only helps the memory but also aids the brain in processing prior experiences during periods of awake rest. So, the next time someone guilt trips you for laying around and doing nothing, be sure to declare in no uncertain terms that your brain made you do it. Who knows, being a little lazy might even be fun!

Leaving our beds unmade provides instant gratification in the short term, only to engender self-recrimination and feelings of worthlessness, indolence, and filthiness in ourselves hours or days later. But what if we could justify those unmade beds? Researchers across the great pond in England appear to have heard our collective call. They have found that the average bed houses 1.5 million dust mites, and, abracadabra, leaving the sheets turned down is a potent weapon against them, as mites can’t survive in the dry conditions of an unmade bed. Children, the next time your mothers scold you for not making you beds, just stand your ground and tell them you are doing your fair share in the good fight against dust mites.

While we’re having so much fun debunking fallacious assertions and simultaneously ridding ourselves of pent-up guilt, let’s throw a few more logs on the therapeutic, soul-searching fire set to consume the dry branches and cobwebs of mythical “do’s and don’ts.” Whoever thought that actions as bad or deleterious as chewing gum, venting, fidgeting, or eating fat at every meal could be good for what ails us? Nonetheless, sugar-free chewing gum is relaxing and can help us eat less; venting our anger can lower our blood pressures; fidgeting and moving around can aid circulation and burn extra calories; and a tablespoon of “good” fat, such as nuts or avocados, at every meal can help our bodies absorb nutrients and vitamins.

Finally, and perhaps the most important means of combating and eradicating guilt, if the latter is indeed possible, is catharsis. While women may be from Venus and men from Mars, they can find common ground here on Earth in the sanctimonious confines of a religious retreat methodology and surroundings. The Catholic Church, for example, has exorcised the guilt of many of its followers through a retreat called ACTS, the acronym standing for “adoration, community, theology, and service.” Without going into the details of ACTS, for both lack of space and the sincere desire on the part of the author for the readers to discover the same peace he found last month on his retreat, suffice it to say that we are all broken toys, and whether it takes a retreat or a witchdoctor to repair that damage, the important thing is to begin the work of beguiling guilt. Becoming one’s own best friend is the lion’s share of a good start.

Bad can be good, but only if guilt has seen better days.

Stuck Up

2010-09-05T09:01:00.000-06:00

Stuck, prodded, poked, and goaded! Is there no limit to the invasion perpetrated by modern medicine in the name of good health, clinical, and preventive medicine? And now it’s the turn of alternative and new-age remedies, with an old, but not so old, friend bringing up the rear. You know his name, and growing numbers are feeling the pinch of his bite, as acupuncture holds sway on a field of both unabated enthusiasm and spined skepticism. The poster child of more than a decade ago has again come to the fore in informed enclaves of the United States, in the wake of dissatisfaction with the pills, potions, procedures, and pronouncements from on-high of allopathic medicine. Perhaps the Chinese got it right the first time. After all, there is strength in numbers, and 1.3 billion of them can’t be wrong. With an estimated 70 percent of people in Western industrialized countries having low back pain, the descendants of Chairman Mao have had their work cut out for them up to now, and are finally starting to receive the credit and a handsome profit, to boot, for technologies developed eons ago.

In 1997, 6.8 million U.S. adults either lamented or demonstrated physical disability associated with back pain, which was nonspecific low back pain in most cases. The financial shortfall resulting, and bringing smiles to the pusses of those affectionately called “orthopods,” in the jargon of the trade, was more than $90 billion annually in health care expenses. Of that amount, $26 billion was directly attributable to the treatment of back pain. Enter, from stage left, the new protagonist and darling of the grimace-in-pain set, namely, acupuncture, which had been heretofore mysterious in its ramifications, therapeutic results obtained, and modality of use. Might the reader, at this point, provide some elucidation on the subject? Probably not, unless, of course, belonging to the growing legion of converts.

Actually, a licensed practitioner will advise a patient to relax and leave the probing to him or her, with the acupuncture needles left in place after insertion for 15 to 30 minutes. During that brief period of time, which may seem like ages for some, the practitioner may stimulate the needles manually, with electrical current, by burning an herb on the ends of the needles, or with heat. All of these methodologies elicit a dull, localized, aching sensation in the patient, and a tugging sensation perceived by the acupuncturist, as mechanical interaction occurs between the needles and connective tissue of the “pin-cushioned” guinea pig, hapless victim, or satisfied customer, whichever term is preferred. One treatment is considered inadequate by most practitioners, and a series of 12 sessions of acupuncture, starting with 2 sessions a week and tapering off after 4 weeks to once weekly, is just what the doctor ordered. Booster treatments, monthly or every other month may follow.

Silver linings are never 100 percent, and the cost of acupuncture is not negligible, ranging from $65 to $125 per session. To make matters worse, Medicare and Medicaid do not cover acupuncture. On the positive side of the ledger, however, the proportion of third-party health insurance plans providing coverage for the procedure has increased from 32 percent in 2002 to 47 percent in 2004. Major adverse effects of acupuncture are close to nil also, and significant minor adverse events occur in less than 0.1 percent of cases. The latter include needle-site pain, nausea and vomiting, and dizziness or fainting. So, the end may, indeed, justify the means, when impalement on small needles terminates that nagging, sinking feeling, lumbar stiffness, or aching that heralds the new morn or accompanies the setting sun of a day lived badly.

The American College of Physicians and the American Pain Society have also put in their two cents, recommending acupuncture for refractory low back pain not responding to self-care and conventional treatment modalities. The U.K. National Health Service has even taken the matter one step further, providing a maximum of 10 acupuncture sessions over a period of 12 weeks for people with low back pain that has persisted for more than 6 weeks.

When chronic back pain does not respond to reassurance on the part of the health care provider, physical activity, and a number of conventional medical treatments, then being “stuck up” takes on an all together entirely different connotation from that immortalized by yesteryear’s prom queen. A course of 10 to 12 acupuncture treatments over a period of 8 weeks from a licensed medical professional can take the sting out of being “on one’s back,” and make it pleasurable again.

Transylvanian Tango

2010-08-15T08:51:00.002-06:00

"I did the mash. I did the monster mash. I did the mash. It was a graveyard smash!"
Count Drabalesh

For Fear of Porphyria

2010-08-15T08:34:00.000-06:00

Carpathian Mountain ice chills the bones, but something far more sinister curdles the blood. It is a name that must not be spoken, even when exhumation of the “undead” reveals scalp and facial hair grown longer, fingernails fit for a wolf’s paw, and an unholy glean to the skin.

Premature burial, you say. Oh, yes, it happens. No freak accident, however, or erred pronouncement of death can exculpate the sawbones, tame peasant superstition, or ground flights of fancy.

The Count has risen, and the dawn’s solar flares are no match for another force of nature, one that bides time in the crypts of body cells while bedtime stories, ornate crucifixes, and silver bullets promulgate a myth. He walks among us, and, for those unknowing and hapless victims whose blood has been tainted by Count Porphyria, the quotidian suddenly becomes a race against the disfigurement, skin blistering, swelling, forehead hair growth, and utter havoc wrought by his growing legions.

How could this have happened? If God exists, how could He have given full sway to a creature ingenuously entombed in a permeable, protective vault? Why have Professor Van Helsing and his modern-day counterparts been powerless to halt the scourge?

Perhaps protoplasm and her offspring, ectoplasm and endoplasm, like native soil and a coffin’s nurturing bosom, shield the beast in some way. We can only surmise that the story must go something like this. Be forewarned, reader. It is not pretty!

Back in 1985, when cool wits and steady nerves did not prevail, a biochemist and fearless vampire hunter, named David Dolphin, theorized a connection between the physical appearance of patients suffering from porphyria and the traits of folkloric creatures of the night. He postulated that porphyria, a group of rare, largely hereditary blood diseases, may have afflicted the so-called vampires of yesteryear, in other words, ordinary people whose resulting facial scarring, mutilated noses and fingers, receding lips and gums, and subsequent elongated canines could be directly attributed to the malady. While holy water and a bell’s toll did little to halt the death march of these hapless hordes, an extraordinary sensitivity to sunlight became their constant adversary, forcing them underground and restricting activity to nightly jaunts.

If that were not enough, other characteristics inherent to porphyria provided further food for thought, or perhaps for fertile imaginations. For example, garlic was found to worsen the symptoms of porphyria, and, while injections of blood products treat the illness today, centuries ago its victims may have sought relief drinking blood.

A link to stress has also been expounded. We know that porphyria is inherited, but perhaps a stress of some sort may have been required to unleash its symptomatology. Just imagine, in ages gone by, a stricken sibling or other family member biting you to quench a thirst for blood. Suddenly, that stress would jumpstart your own latent porphyria, and, lo and behold, you would grow your own set of matching fangs.

Nonsense, you say! Let’s debunk the myth and shed light on the argument, no pun intended. Porphyria comprises a series of seven disorders, only the rarest of which, called congenital erythropoietic porphyria, causes skin blistering, itching, swelling, and disfigurement. Just 200 cases have been documented, far too few to account for the widespread belief in vampires. Enter the imaginative element of human nature. Furthermore, porphyria victims do not crave blood, and even if they were to drink blood, digestion in the stomach would render it useless. And garlic, an ally in the fight against the unholy host? That has never been proven.

So, what are we left with, scientifically speaking and keeping medical jargon to a minimum? In congenital or acquired porphyria, body cells lack the basic enzymes required to process porphyrins, which are components of heme, in turn a component of blood hemoglobin. Because they are neither degraded nor biosynthetically processed, porphyrins accumulate in the body and are toxic to tissue in high concentrations. Throw alcohol, antibiotics, certain foods, sunlight, and fasting into the recipe, and you have concocted a surefire way to trigger an attack and befriend the night.

It does not end there, however. Count Porphyria’s little brother, Prince Catalepsy, may have a hand in the matter. Catalepsy affects the central nervous system of epilepsy patients, freezing muscles, slowing heart rate and respiration, and giving new meaning to the term “living dead,” for those of us who inadvertently stumble upon a cataleptic “corpse.”

We must stake a conclusion here. When the horrors of everyday living take their toll, when we seek scapegoats to cover our own evil tendencies, and when choosing between right and wrong is tempered by shades of gray and the color of money, we must find the courage of those prematurely buried. A return to consciousness, a brush of dirt from our clothes, and a return home demonstrate, to the surprise of our adversaries, that we are not down for the count. Unless, of course, long hair and fingernails, reddish mouths and teeth, receding skin, expanding and engorged abdomens, and the pungent smell of decomposition indicate broken springs in our biological time clocks. At that point we can expect a knock on the door from our parish priests or a new generation of Van Helsings.

T-Time

2010-07-05T08:27:00.001-06:00

Erections, ejections, elections, infections, all make life a bit more complicated, and all, at the least, can be annoying, when they appear or disappear without notice. Problems with the first of the list, however, strike terror in the hearts and minds of once virile, middle-aged men, confronted today with a potpourri of blatant and subliminal signals that decapitate former breadwinners and break links at the top of the food chain. When all else fails and when significant others earn more and enter more socially laudable professions, well-serviced “plumbing” and a functional set of pipes provide safe haven and a level playing field in the minds of the economically, educationally, and emotionally castrated.

Dethroned heads of households currently have to contend with an adversary that threatens to undermine the very essence of masculinity. It’s now “t-time” for testosterone, as its gradual, age-related loss is about 1 to 1.5% per year beginning at age 40, leaving the former dominant sex less energetic, less self-assured, and, in short, less manly. The progressive transformation from sexual tyrannosaurus to puppy dog is quite telling, not only on the performance side of the coin, but also on the long and unexpected road to other health problems. It has been shown, in fact, that low testosterone (low-T) decreases bone density leading to osteoporosis, affects the ability to concentrate, as well as mood, resulting in bouts of irritability and depression, and increases mid-section abdominal fat and the consequent risk of type 2 diabetes, heart disease, and certain cancers. So, whenever “whatever” doesn’t go up, the general health of Homo sapiens goes down.

There has been a great deal of misinformation and bad press on the attributes and functionality of testosterone. The latter, indeed, can be compared to a fuel that keeps a man’s motor running. In that regard, the record needs to be set straight. As stated above, when a man’s machine is running on empty, mental drive, clarity, and motivation all suffer. In short, a run-down feeling prevails that can take its toll on significant others and marital bliss. Why is testosterone so important? What can a hormone so neglected in the past and below radar screens possibly do in the sacristy of a man’s body? Frankly speaking, there is nothing mysterious here, as it has been known for decades, if not centuries, that testosterone is responsible for puberty. It deepens a man’s voice, helps muscles develop, grows pubic hair, regulates those mustaches and beards that go in and out of fashion, controls sperm production, and makes the “hot-blooded” boil, increasing the appetite for sex. No testosterone, no fun, and therein lies the beginning of the long road to infidelity, low self-esteem, and long hours in front of the television instead of engaged in bedroom calisthenics contributing to sound mind, body, and spouse.

While low-T may be a normal part of aging and quite common, something sinister may lurk beneath its apparent expiration date. Sometimes just getting old is not sufficient to explain its decline, and professional eyes must be turned to the possibility of testicular cancer, the chemo and radiation therapy used to treat it, injury to the testes, pituitary maladies, and thyroid diseases. Once those harbingers of gloom are excluded, remedies to raise testosterone back to normal levels of 300 to 500 nanograms per deciliter (ng/dl) can be implemented. T-boosters should be discussed with the physician, and run the gamut from painful and expensive deep muscle injections every three weeks and daily skin patches and gels to slow-release, 12-hour buccal tablets placed between the gums and upper lip and subcutaneous implants that work continuously for six months. The latter are the latest in a procession of treatments, but don’t come without a price, as infections, bleeding, and bruising can occur at the implant insertion point. Furthermore, long-term use of testosterone boosters may increase blood cell count, thicken blood, increase risk of blood clots, and accelerate age-related enlargement of the prostate, but not prostate cancer. Other potential adverse effects of low-T remedies include acne, reduced sperm count, worsening of sleep apnea, and breast tenderness in some cases. So, as usual, shades of gray prevail, and damnation may win the day whether action to correct low-T is taken or not. Consultation with a health care provider is, again, of paramount importance.

Finally, staying fit goes a long way to enhancing the treatment of low testosterone, as fat increases the speed with which the hormone is metabolized. Exercise, eating right, and keeping weight in check will help get the most mileage out of the fuel running manly engines.

While tea time conjures up memories of a shedding of the shackles and oppression of our cousins across the great sea, this 4^th of July Independence Day can also signal the start of an American “t-time.”

Cocky Cocci

2010-05-27T08:54:00.001-06:00

There’s a plague brewing in the salty southern desert lands of Arizona, along the Mexican border, that goes beyond politics, national origins, or the color of one’s skin. While not communicable from beast to human or human to human, it is no less dangerous because carried on the winds of all-too-common dust and sandstorms. Its calling card of profound fatigue, cough, shortness of breath, fever, and night sweats leaves one prostrate at best, and, when it instigates nodules, cavities, and pneumonia in the lungs, or dissemination to other organs far and wide, its hapless victim can be down for the count for anywhere from 4 months to over a year. The alarm and call to arms has been sounded in south-central Arizona, the southern San Joaquin Valley in California, the southwestern Rio Grande Valley of Texas, and northern Mexico where the scourge is endemic, and perhaps it is none too soon for El Paso, Juárez, and Las Cruces to heed indicators pointing to a possible spread of this cocky adversary, otherwise known as Coccidioidomycosis, “Cocci,” or Valley Fever, to the unsuspecting bosom of virgin territory.
Coccidioidomycosis, unaffectionately known as Cocci, is a soil-dwelling fungus as hard to isolate from dry southwestern dirt as the elusive gold of the old prospecting days. It is there, though, just waiting to be borne into the channels and hidden pockets of elderly lungs by a sudden gust of wind. While it is asymptomatic in 60% of its predominant prey, elderly male retirees spending their golden years in new homestead and construction development sites in the more populated central and southern regions of Arizona, other groups such as HIV and immunocompromised patients, transplant patients and those taking immunosuppressors and glucocorticoids, those placed on tumor necrosis factor alpha therapy by their physicians for a score of maladies, and pregnant women in their second and third trimesters are also fertile terrains for the finicky fungus. The nodules and cavities it produces in the lungs may produce no signs or symptoms, but may become evident on a chest x-ray or CT scan performed for another reason, and therefore require no medical or surgical intervention. Potential spread to distant organs like the skin, bones, joints, soft tissues, and meninges, however, can become a nightmare for 1% of the unlucky souls whose path and airways the arthroconidial (barrel-shaped) adversary has crossed. Even though dissemination to recesses far and wide of the human body and possible subsequent downward spiral into the abyss of fatal meningitis are so rare as to make choking to death on a fast-food French fry more common, the acute pneumonia and chronic symptomatology of the mangy microbe are by no means trouble free. In fact, a 2-3-month history, with no signs of improvement, of night sweats, extreme fatigue, cough, and a fever that may or may not be present, should trigger a closer look. As some clinicians like to put it, a low threshold for suspicion of Cocci should be in the front, not back, of the mind when a patient states that those symptoms have not improved over time. Couple that with increased eosinophils (a type of white blood cell alarm) on blood work, enlarged lymph nodes known as hilar or mediastinal lymphadenopathy in the center of the chest between the lungs on chest x-ray, and positive, if not dubious and unreliable, serologic tests performed on the sputum, and both the most experienced stalwart doubter and the most inexperienced, off-the-beaten-track, rural, bumpkin physician reach the same forgone conclusion that Cocky Cocci cometh.
Were that not all! Asymptomatic Cocci presents an additional series of problems, not the least of which are the emotional concerns it engenders in those who fall victim to its innocuous lung nodules, that just so happen to resemble and cannot be easily distinguishable on chest x-ray from pulmonary malignancies. The verdict is still out on treatment, too. Most would agree that primary pulmonary Cocci usually requires no therapy, with signs and symptoms gradually disappearing over a 2-4-month period. Extensive, disseminated disease with no signs of improvement, local pulmonary disease provoking fatigue and night sweats that just don’t seem to get better over time, and dreaded meningitis, on the other hand, require medical treatment of sometimes up to and over one year, as well as surgical intervention when the sky starts falling. While oral triazole antifungal drugs, such as fluconazole, itraconazole, and newer formulations, are the name of the game, they can cause birth defects in the offspring of pregnant women taking them. The primitive big gun, intravenous Amphotericin B, when used in more serious and resistant cases of cantankerous Cocci, is not without its problems either for the kidneys. So, damned if one has to treat 1% of the time, and fingers crossed 99% of the time that Cocky Cocci will fade into the sunset on its own, the clinician is left with some hard decisions.
Cocci and its distant, yet all-too-common cousin, the athlete’s foot fungus, are as different as night and day in their ramifications. Yet they both need to be stepped on!

© 2010, Albert M. Balesh, M.D. All rights reserved.

Screen Saver?

2010-04-18T15:19:00.000-06:00

For years now, doctors, nurses, health educators, and patients have sung the praises of screening and subsequent early detection, aggressive therapy, and increased longevity for breast and prostate cancers. They may have gotten it all wrong, however! In fact, recent retrospective studies done at the University of California at San Francisco (UCSF) and the University of Texas Health Science Center in San Antonio, and published in the October 21, 2009 issue of the Journal of the American Medical Association (JAMA), have demonstrated the ineffectiveness of 20 years worth of screening for breast and prostate cancers, which currently account for over 25 percent of annual cancer diagnoses in the United States, in significantly reducing the death rates from those maladies. So, perhaps doctors should refrain from teaching their patients how to perform breast self-exams, until their efficacy can be proven. If that were not all, in November 2009, a federally appointed panel of experts, known as the U.S. Preventive Services Task Force, all but panned baseline mammograms at age 40 in women with neither risk factors nor family history of breast cancer. The rationale behind the task force’s pronouncement from on high was an end not justifying a means, with the risks of mammograms before age 50 outweighing the benefits of early detection of breast cancer. New recommendations, that women aged 50-74 years without symptoms or risk factors of breast cancer undergo mammography every other year, instead of annually, have unleashed a wave of accusations, criticisms, finger-pointing, and protests that the federal government is now rationing health care, to the detriment of its citizens. Nonetheless, evidence continues to mount that screenings are neither savers nor saviors, and even the American Cancer Society (ACS), one of the staunchest supporters of cancer testing, has had to reevaluate its position and scale back support of mass breast and prostate cancer screenings.

The change in position of the ACS and other former supporters of early, regular, and frequent screening stems from the increased detection of small, slow-growing breast tumors that may never cause harm, at the expense of aggressive tumors that arise and grow rapidly between screenings. Were that not all, repeated exposures to screening radiation, false-positive diagnoses of breast cancer, and overtreatment and extensive procedures for slow-growing tumors that may never cause problems place women and their families in the precarious positions of being “damned if they do” and “damned if they don’t.” On the prostate side, controversy is no less evident, with neither the ACS nor the Preventive Services Task Force recommending or justifying routine screening for prostate cancer via prostate-specific antigen (PSA) blood tests, in the face of the most common cancer in men presiding over an increased mortality risk of only 3 percent. So, satisfactory answers are not immediately forthcoming, and each patient must rely on introspection and personal health philosophy to guide judgment on the wisdom and benefits of detecting small, slow-growing, non-aggressive, and/or only remotely lethal tumors, in exchange for peace of mind that may not outweigh the burden of knowledge, the potential complications and drawbacks of overtreatment, and the financial hardships imposed. It makes no sense to inflate unnecessary screenings in these times of shrinking health care dollars.

This medical piece would not be complete, without some final affirmations and a bit of advice to the readers. While regular breast cancer screening is warranted in patients over 50 years of age with no risk factors, it does not mean annual mammograms. Women aged 50-80 with low or average risk may be screened by mammography every other year, with those over 80 perhaps no longer requiring mammograms. Worrisome are the patients who go five or more years without a mammogram, not those screened every one or two years. Self-discovery of a lump or abnormality in a breast, however, no matter how recent the mammogram, mandates immediate visit to a physician.

In the “non-fairer” sex, on the other hand, the jury is still out on routine annual PSA testing to screen for prostate cancer. For every man who avoids prostate cancer, 50 will be treated unnecessarily with subsequent incontinence and impotence resulting, due to a test that fails to distinguish slow-growing cancers that will never cause problems from the aggressive kind.

A screen saver works just fine in the inanimate, but when it comes to the living and breathing, too much of the scientific community’s best of intentions does not always make for a happy ending. In fact, quite the contrary!

The Devil Made Me Do It!

2010-04-07T08:08:00.001-06:00

Don’t step on a crack or you’ll have to recite one hundred Our Fathers and Hail Marys, wash your hands ten times or until the skin peels off to prevent contamination, go back five times to make sure you’ve turned off the stove’s gas and locked the front door, and, most importantly, blame the devil for the daily rituals and hell on earth suffered by your psyche in order to guarantee some semblance of a normal life. You’ve got to be kidding, you say. No, if you’re one of the more than three million lost souls in the U.S. wrestling with the anxiety disorder known as obsessive-compulsive disorder (OCD), you know that the description above is not far removed from your quotidian reality. In fact, the series of episodes described might even be a best-case scenario, with severe cases bordering on science fiction or the ludicrous, and veterans of the OCD wars resorting to behaviors and idiosyncrasies that only half a century ago would have landed them in state insane asylums or worse. Victims in some cases, for example, have been known to go for extended periods of months without taking a shower, or the opposite extreme of washing so often that they’ve actually denuded their skin and left little time in the day to do other things, in order to compensate for misgivings, perceived errors, or murmured instructions of sulfurous origins exacting penance for sins as innocuous as touching a doorknob or shaking a hand.
But how does this all start? Where in the world do those recurrent, unwanted thoughts and repetitive or ritualistic behaviors come from? The answers to those questions are not immediately forthcoming, in the wake countless lost hours every day, a great deal of distress, and hurdles thrown in the paths of those who just want to get through a simple day in one piece. Without therapy, medication, and the love and support of those most dear, however, that is as unlikely as putting the square peg of one’s sanity into the round hole of what is generally regarded as normal for the human race.
Frankly speaking, diagnosis of OCD brings some relief. When one realizes that checking a locked door repeatedly to assure its closure is a disease, ever bit as real as heart disease or diabetes, then solutions can be sought for one’s fear of uncleanliness and germs, known as mysophobia, or the utter paralysis brought on by that fear. Those suffering from the ravages of OCD are not alone, and television personalities such as Howie Mandel, afflicted since childhood, have done much to increase awareness and outreach on that score. Destigmatizing OCD, mysophobia, and other mental illnesses, and urging people to get professional help, is nonetheless a full-time job, especially in a society that prides itself on looking good, showing no signs of weakness, and keeping up with the Joneses.
So, just how do we tackle the problem? First, you must realize that there are some definitions to be digested, with obsessions being uncontrollable thoughts associated with various fears, and compulsions being the uncontrollable repetitive actions or attempts to ease anxiety. Enormous periods of time can be lost every day by those afflicted with OCD, as they are drawn onto a merry-go-round or endless loop of obsessive and compulsive behaviors. Fear of contamination, fear of harm or danger, fear of discarding objects, fear of imperfection, and fear of disorder and superstitions are just a few of the obsessions that inundate fragile minds ill-equipped to break the chain. Fear of contamination seeks its champion in repeated handwashing, excessive cleaning, and avoidance behaviors that border on going out of one’s way to bypass the imaginary. When checking a door or gas or electric burner becomes a full-time job, then we know that OCD has won the day. Hoarding behavior, or a fear of discarding objects ranging from newspapers and canned foods to sales receipts and plastic containers, is a sign that all is not well in Oz, and that something bad will happen in the Emerald City if those objects are thrown away. Near and dear to many of us, if not to our teenagers who leave their homework undone, their beds unmade, and their appearance unkempt, is a fear of imperfection that drains hours from our day, as we strive to make the perfect bed, groom ourselves as if to walk the “red carpet,” or print notes, lists, or diaries so impeccably that we leave calluses and blisters on our fingers and a disdain for all that requires transcription of the written or spoken word. In OCD, a perceived failure to be perfect inevitably results in our punishment or catastrophe, and, while we are cognizant of the irrationality of our obsessions and compulsions, we are absolutely powerless to halt their onslaught. If that were not all, order and symmetry, the perfect number, and colors, if not pleasing to the mind, at least tacitly accepted by it, round out our, or perhaps only your, foray into the realm of OCD. How many times have you aligned those cans in your cupboard or those books on your shelf? Once or twice? Ok. More than that? Then perhaps a reality check is in order, as you batten down the hatches and prepare for the OCD storm that is sure to follow.
What can you do when disaster strikes? As always, seek professional help. The weaponry in the armamentarium of the latter ranges from psychotherapy, and, specifically, cognitive behavior therapy (CBT), or retraining thought patterns and routines so that compulsive behaviors to “correct” obsessions are no longer necessary, to medications, with antidepressants that increase serotonin in the brain at the fore. Antidepressants should be prescribed at the lowest possible dosages to control the signs and symptoms of OCD. There are no guarantees, however, and if psychotherapy and drugs don’t work, then the “big guns,” like electroconvulsive therapy (ECT), may need to be called in, to quash an unruly devil.

© 2010, Albert M. Balesh, M.D. All rights reserved.

Obsessing on Ovaries

2010-03-22T14:08:00.001-06:00

We obsess about so many things today. What the weather is going to be like, will we have enough money for retirement, should we purchase big screen televisions today or wait for the next technological marvels, will our children be safe in school this week, is the IRS going to audit us, will there be enough money in Social Security for our golden years, will war in Iraq and Afghanistan ever end, and a host of other concerns dominate our waking hours. Now, that is all well and good, when we are being civically minded, concerned citizens, hoping to make a difference. We must ask ourselves, however, what benefit is to be derived from solving the woes of the world, when we may not be around to see such resolution? Our health, and we’ve heard it all before, is first and foremost. One has nothing without health, and obsessions, if they are, indeed, necessary, should be directed at “silent killers,” like ovarian cancer, which, if we are not vigilant like Paul Revere and his “oneth by land, and twoeth by sea,” can devastate families and the ones we love, as we contemplate that new car in our driveways. We don’t know the exact cause of ovarian cancer, nor can we fathom why some women are marked for it, while others lead relatively tranquil lives. What we do know are the numbers, and they certainly are not encouraging. Only about 20 percent of ovarian cancers are detected before tumor growth has spread beyond the ovaries, and the Grim Reaper is advised. How disheartening, when studies have shown that 93 percent of women diagnosed in the early stages of the malady survive at least five years. The lesson to be learned from this is early detection is the name of the game, and, what was once considered a silent enemy that wreaked havoc before discovery, has now been found to cause symptoms even at onset.
There are three basic types of ovarian tumors, “coming out of nowhere” in healthy women in many cases, and perhaps triggered by a wide variety of risk factors ranging from inherited gene mutations, family history, age over 50, history of breast cancer, infertility, and being childless to hormone replacement therapy (HRT) with estrogen, obesity, and male hormones given to women to treat painful conditions such as endometriosis. It becomes obvious that risk factors abound, but with no threshold to trigger vigilance or obsession with ovaries, they simply pass, like the box scores of a Major League Baseball game a couple of days later. Symptoms? Perhaps we should concentrate on the minor aches and pains that might drive us to seek professional consultation. One small problem, however, is the fact that ovarian cancer is quite nonspecific in its symptomatology, and may mimic a vast assortment of bladder and digestive disorders, such as irritable bowel syndrome, for example, as well as stress and depression. What we do know is that women with ovarian cancer consistently experience abdominal pressure, fullness, swelling, or bloating, urinary urgency or an incessant sensation to urinate, and pelvic discomfort or pain. While there may be other signs and symptoms, when those key players are persistent or worsen, we become cognizant of our own mortality and the need to see a physician.
Before performing a pelvic examination, an ultrasound, and a CA 125 blood test, a health care provider will most likely ask a series of questions dealing with the initiation, continuity, severity, improvement, worsening, and family history of the symptoms experienced, as well as the existence of ovarian, breast, and other cancers in the immediate family and first-degree relatives. No standardized screening tests for ovarian cancer currently exist, and it should not come as a surprise that doctors don’t recommend screening for this type of cancer in most patients. It must be pointed out here that many medical papers have been published on the conventional wisdom of employing a blood test called the CA 125 blood test as a screening procedure for ovarian cancer. There has been a great deal of confusion in its regard, and we must state categorically that CA 125 is a protein made by the body in response to many conditions, that many women with ovarian cancer have abnormally high levels of CA 125 in their blood, that a number of noncancerous conditions also cause elevated CA 125 levels, and that many women with early-stage ovarian cancer have normal CA 125 levels. Therefore, to rely on a nonspecific CA 125 blood test to screen for the malady can only cause more harm and grief than good. When, on the other hand, the battery of exams listed above, as well as other diagnostic tests such as computed tomography (CT), magnetic resonance imaging (MRI), or even chest x-ray (to detect cancer spread to the lungs), suggest ovarian cancer, then a surgical procedure called a laparotomy or a less invasive surgical procedure called a laparoscopy will be required to explore the abdominal cavity, collect abdominal fluid and tissue samples, and perhaps remove an ovary for pathologic examination. If ovarian cancer is detected, surgeon and pathologist will team up to identify the type of tumor and whether it has spread.
Now that we know the problem, what are our treatment options? It doesn’t take a Nobel Prize laureate or gynecologic oncologist to point to surgery and chemotherapy, with radiation therapy in some cases to treat the symptoms of advanced cancer, as the mainstays of treatment. Without going into the detail of those modalities for lack of space and time constraints, our time might be better spent discussing lifestyle and home remedies to provide that “ounce of prevention” that we have heard so much about recently, especially in these times of Medicare, Medicaid, and private health insurance cutbacks. Staying physically active and managing stress, by knowing what to expect, becoming proactive, maintaining a strong support system, letting family and friends help, and setting reasonable employment goals that allow sufficient time for yourself, go a long way to stemming the physical and mental onslaught of ovarian cancer and prolonging survival. In younger women, oral contraception (birth control pills), pregnancy and breast-feeding, and eventual tubal ligation or hysterectomy can also reduce the risk of ovarian cancer. But haven’t we forgotten a substantial part of the equation? What about diet? Eating protein-rich foods that help build and repair body tissues, such as beans, cottage cheese, eggs, fish, lean meat, lentils, peanut butter, poultry, and yogurt, and packing calories into the foods eaten, as well as eating smaller amounts of food more frequently, boost immunity and help our bodies ward off the deleterious effects of serious illnesses when we just don’t feel well. Ovarian cancer is no exception to these rules. Far from being a death sentence, cancer provides a new lease on life and an excellent opportunity to put into practice a lifetime’s worth of preaching.
Obsessed? You bet we are, and with good reason!

© 2010, Albert M. Balesh, M.D. All rights reserved.

Malign Neglect

2010-03-08T11:17:00.001-07:00

You’ve put the kids through college and then saved for decades, putting away a nest egg for those Golden Years when retirement would dictate trips to Europe, extended play on the golf course, more time for what matters most, and a new devil-may-care lease on life. Everything is rosy, and it’s good to be alive. Then it strikes you or your significant other, chipping away steadily at financial resources that were originally set aside to see you both through the rest of your journey on earth, until the Almighty beckoned. Currently, millions of people, 5.5 million in the United States, to be exact, and 35 million worldwide, and those who care for them, have been grimly awakened by a malady created by a medical science that has given us longevity. Alzheimer’s disease reigns, bringing minds to a halt immediately and hearts subsequently, within 3 to 9 years after diagnosis. To make matters worse, we should beware of what we wish for, namely, a ripe old age, as the incidence of the disease doubles every 5 years after 65 years of age. The good news is that studies on centenarians have shown that Alzheimer’s disease is not necessarily the outcome of aging. The bad news is that as the aging population increases, the prevalence of the disease will approach 13 to 16 million cases in the United States by mid-century. With medical costs continuing to spiral out of control, the bitter pill we will need to swallow is the malign neglect that will be afforded to those and their families who wander the physical world, in complete sensorineural oblivion, without the creature comforts and medical care that a life’s worth of savings was earmarked to provide but fell hastily into the red.

So, as is usually the case today, we are left with many questions and very few answers. Alzheimer’s disease is a strange one, at best, and we haven’t even scratched the surface of its causes, let alone therapies to cure, correct, or reverse its devastating effects. While ignorant bliss is perhaps the coin of the realm for those afflicted, it is the spouses and children of Alzheimer’s victims who bear the brunt of the financial and emotional pain surrounding the disease. There is no end in sight either, as unlike other chronic illnesses such as diabetes and heart disease, the biochemical and physiologic mechanisms of the malady have as yet to be elucidated. Yet, although we know neither the causes nor how to stop the devastation of dementia, we learn more each year about combating the small losses in brainpower that often occur after age 50. There are even some brain benefits of getting older.

Speed is the name of the game, when it comes to nerve impulses, which can travel as slow as a tricycle or faster than a NASCAR racecar. Reaction time often slows with age, but, with practice, the elderly can improve their mental speed by more than 50 percent. Scientists have been stunned to find full-blown Alzheimer’s disease on brain scans of people in their 70s who continue to get top scores on memory and IQ tests. In fact, in some studies, up to 20 percent of people autopsied who had no major memory problems were found to have had Alzheimer’s. So, what is going on? What dictates damnation or relative impunity to the long arm of the disease? Why does the brain continue to function efficiently in some cases, despite changes that should cause severe disability? Perhaps the answer lies in what is called “cognitive reserve,” which is the sum total of a person’s innate abilities plus the additional brainpower that comes from challenging one’s mind. No malign neglect there! Studies have shown mentally stimulating tasks increase brain cells, improve connections between those cells, and help bypass age- or disease-related trouble spots in the brain. In short, the more we work our minds, the greater our cognitive reserve; and the greater our cognitive reserve, the greater our ability to mitigate the inevitable challenges of aging.

Despite a youth-oriented culture that wants to bury us before our time, we can take comfort in a body of scientific knowledge indicating that accumulated knowledge, expert skills, wisdom, and emotional savvy all increase with age. Furthermore, higher-order decision making, such as choosing the best investments, and learned skills, such as driving, usually do not decline with age, unless, of course, one is afflicted with Alzheimer’s. Not all silver linings are 100 percent, however, and memory for events, short-term memory, and brain speed all suffer with age. The most likely explanations for such deficits are loss of neural connections, blockages of blood supply, and decreases in nerve transmission chemicals.

With no answers forthcoming on the causes and cures of Alzheimer’s, and with no stopping the march of time, what can we do to stop, or at least slow, malign neglect? The rule of ten applies here, as we make the best of what doesn’t have to be a losing hand, and, namely, boost our brain health by finding stimulating walking partners, varying our daily routines, becoming lifelong learners, playing games with several levels of difficulty, de-stressing with meditation or exercise, getting enough sleep, increasing creativity through new hobbies, socializing and making new friends, following healthy diets rich in fruit, vegetables, whole grains, and fish, and, finally, watching our blood pressure, weight, blood sugar, and cholesterol numbers.

Ignorance is bliss only for the ignorant and those too far gone to care or notice. For the rest of us, it is downright dangerous!

My Review of Bones 2 Bike

2010-02-22T13:15:00.001-07:00

Originally submitted at saris.com

Performance. Art.

Injection-molded arms and legs are the strongest on the market.
Built with 100% recyclable,non-rusting materials.
Ratcheting anti-sway straps secure and stabilize bikes.
Arc-based design fits over most spoilers,and separates bikes on diff...

Bones 2 is not perfect, but close!

By Albert the Mad Doctor from El Paso, Texas on 2/22/2010

Pros: Lightweight, Easy To Install, Attractive Design, Durable

Cons: Straps need reinforcing

Best Uses: Casual Riding, Road Biking

Describe Yourself: Casual/ Recreational

I love my Bones 2, but I wish it could hold 3, instead of 2, bicycles and the installation straps were more rugged and reinforced. Thank you.

(legalese)

Murphy's Melodrama

2010-02-21T08:14:00.001-07:00

Are we masters of our fates, or is Murphy’s Law, that everything than can go wrong will go wrong, set in stone and beyond our mere mortal minds to break? How many times in our lives have we heard or pronounced, “If only I had…”? Many of us feel jinxed, doomed, or otherwise fated to fail. We drink and smoke to excess, eat like there’s no tomorrow, burn the midnight oil for no good reason, and abuse the physiologic machinery lent to us by the Divine with the justification that we are failures anyway, so we might as well buckle up for the ride and enjoy ourselves. Some of us remember our fathers saying, “You will never amount to anything,” and that verbal flaying has remained with us for our entire lives. If only we could think positively and place our minds over matter, we might reap dividends for both our health and wealth, not to mention a good dose of inner tranquility. Positive thinking can not only help us to reverse and write off Murphy’s Law as an old witch’s tale, but also avoid missteps like traveling up snowy slopes in Ruidoso, New Mexico without snow tires, four-wheel drive, or chains, driving all night to Dallas, Texas without sleeping the day or night before (as practiced by the author of this piece), and other forms of personal lunacy that have become the gold standard for those of us who feel destined to fail anyway, good for nothing, or shackled by Murphy’s legacy.

Never underestimate the power of positive thinking on one’s health. Studies have shown that optimistic coronary artery bypass surgery patients not only recover more quickly, but also have fewer complications after surgery than those with a gloomier outlook on life. Optimism is a healing resource every bit as powerful as the myriad of capsules, tablets, injections, potions, and elixirs promulgated by pill pushers in white, the pharmaceutical industry’s juggernaut, and your friendly neighborhood pharmacists, often more concerned with the ring of cash registers than renewing old acquaintances to the tune of, “Hello, I’m not here to buy anything.” Let’s face it, medical outcomes can, indeed, be influenced by mental and emotional expectations. It doesn’t take an advanced degree to figure that one out. Just think of the placebo effect, or the fact that some drugs or treatments with no proven medical benefits, except for a patient’s belief that they will help, have been found to provide satisfactory relief for any number of medical problems. That is not to say that placebos are medical marvels, magic bullets, or gold standards. When we are really sick, we need real medicines and procedures, but positive thinking is an important adjunct that should not be left out of medicine cabinets and little black bags. While no one really understands why a positive attitude can go far to speeding up recovery from surgery or helping to cope with serious illnesses such as cancer, diabetes, heart disease, or AIDS, the answer may lie in the mind’s power over the immune system. Studies of healthy first-year law students have found that those who are optimistic about the upcoming year and maintain such optimism through mid-semester, not only have more immune cells but better functioning immune cells than their pessimistic counterparts. So, an organic basis for positive thinking actually does exist. Pessimism, on the other hand, has been found to boost levels of destructive stress hormones in the bloodstream.

While we can’t change the circumstances of our lives, we can certainly change our attitudes toward them. Pain can be used for good. Life-threatening and incapacitating illnesses such as AIDS, cancer, emphysema, heart attack, or liver cirrhosis, to name a few, can be thought of as “gifts,” with very little stretching of the imagination. Those conditions can even empower us, by removing the blinders that hinder us from valuing each day, appreciating moments, getting priorities straight, and successfully reaching goals we never thought possible. The loss of a breast to breast cancer, the loss of a high-powered job due to a disabling illness, or the loss of mobility and perceived freedom due to age or a crippling disorder can be looked upon with despair and fatalism, as we cry in our beer, conclude that we are no good and have been singled out for suffering, fail to see a silver lining, or abandon all hope. On the other hand, “being sick” can be viewed as an opportunity to reach out and grab for all that is distinctly human, and all those missed possibilities we have swept under life’s carpet because we were simply too busy or too tired to view them in the light of reason. So, while the exchange of a breast for less energy devoted to cultivating the perfect body, the exchange of a job for free reign to pursue interests and hobbies, or the exchange of mobility for the freedom to pursue deeper passions may hardly seem fair at the moment of immediate impact, a step backward and pause for reflection will most assuredly convince us of the contrary.

The philosophy of making the best of what we’ve got might not have saved Air Force Capt. Edward A. Murphy, an aerospace engineer at Edwards Air Force Base in California in 1949 for whom the law was named, and who died one dark evening in 1990, while hitchhiking to a gas station, when his car ran out of gas and he was struck from behind by a British tourist who was driving on the wrong side of the road. Even though he was facing traffic and wearing white, Capt. Murphy’s fate was sealed. Not so, however, for the men participating in a 2008 study conducted at the University of Rochester Medical Center, in whom it was found that their belief that they were at lower-than-average risk for cardiovascular disease actually resulted in their experiencing a three times lower incidence of death from heart attacks and strokes.

So, as Murphy rests in peace, those of us still around may do so also.

From the Heart

2010-02-21T08:13:00.000-07:00

You’ve eaten too much. You’ve promised to never do it again. This year is going to be different. You’ve made your New Year’s resolution. You think you are indestructible, that life will go on whatever your excesses, and then, “Wam, bam, thank you, Ma’am,” a sinking feeling from the heart tells you that even the best laid plans have expiration dates. That pressure on the chest, pain in the jaw radiating down the left arm, or air hunger spells “I told you so,” as you hover above your body and make that journey toward the white light. If only you’d listened, if only bran muffins had trumped jelly rolls, if only that primordial spark and DNA imprint in your genes had coded for an unconscious “Forbidden” sign to modify dangerous behavior, you’d still be around to give away the bride, watch the Super Bowl, or engage in that harmless mischief that puts smiles on faces and separates homo sapiens from a vast evolutionary assortment of biped, quadruped, finned, and slithering creatures who, while knowing no better, perhaps live fuller lives. Gut a lowly lizard on the evolutionary scale, and you’ll find cardiac machinery similar to your own, minus the plaqued arteries, scarred endocardium, and enlarged cardiac chambers. Plumbers in white may be able to intervene on your cracked chest, but wouldn’t an ounce of prevention have preempted painful coronary bypass surgery, polyethylene tubes running into places you never thought existed, an apothecary’s delight as you fork out the thousands of dollars necessary to keep a sinking heart afloat, and the charade attached to the “I feel better than ever,” when the grim realization sets in that your thoracic “little engine that could,” cannot?

You’ve heard the drill before, that keeping your weight down, increasing physical activity, banning those nightly excursions to the neighborhood Seven Eleven for smokes, and taming your high blood pressure and cholesterol will assuredly add years and quality to your life. Now, however, come the scare tactics. Each year about 1.1 million Americans suffer heart attacks, and, sadly to say, 500,000 do not survive them. Let’s keep this train of thought going. While twenty-five percent of Americans over age 50 have at least two risk factors for heart attack, such as high blood pressure, increased cholesterol, or elevated blood sugar, only 10 percent of all Americans have all risk factors under control. The stark mismatch, reality of the matter, and increasing body count have not bred behavior modification. This is especially troubling when the medical literature has provided a “silver lining,” and, namely, that while a 50-year-old man with no risk factors has only a 5 percent chance over the next 45 years of ever having a heart attack, just one risk factor increases the likelihood of a family visit to the undertaker to 50 percent. Women should not be left out of the equation either, as their chances of having a heart attack over the same time period increase from 8 to 38 percent, depending on the presence of none or just one risk factor, respectively. Numbers are numbers, however, and human nature precludes teaching “an old dog new tricks.” It takes a leap of faith to practice what is preached here.

So, what are you going to do about it? Are you going to finally heed a message that you know to be true, or are you going to continue to play dumb? The platitude that, “I know this is bad for me, but I don’t want to live forever,” just doesn’t cut it here, especially when the Grim Reaper may not come for you, but instead leave you physically maimed and a financial and emotional burden to your family. You need to shoot for still more, easy to remember and attain, numbers, instead of shooting yourself in the foot, or worse. So-called bad cholesterol, or LDL cholesterol, should be kept under 100, blood pressure below 120/80, and blood sugar after fasting between 70 and 130. Then, again, you knew that! Losing weight will make those numbers more “palatable,” and kicking the “cancer stick” or cigarette habit will undoubtedly lower your blood pressure, raise the level of HDL (good) cholesterol, and reverse or halt the damage already done to your blood vessels. Even if you’ve been smoking for years, kicking cigarettes to the curb will help your heart. Studies have shown that smoking cessation not only cuts heart attack risk by half within one year, but also nearly reduces it to the level of a nonsmoker within 15 years. Add 30 minutes of moderate exercise, such as brisk walking, most days of the week to the mix, and you have a prescription for a new lease on life that will promote healthy heart function, while at the same time cutting those high financial costs of blood protein CRP tests, heart scans, and drugs to drive down cholesterol. Laboratories, drug companies, and morticians will hate you for it, but they certainly won’t go hungry without your business.

Taking to heart this message from the heart may mend a broken heart in more ways than one!

Green Teen

2009-12-13T17:19:00.000-07:00

Teens will be teens! While parents seem to understand this, the motivation behind adolescent action is dubious. In fact, it is not the raging hormones that make teenagers do what they do, but rather the teen brain itself. The issue becomes of paramount importance when focus is directed at teen driving and the influence of alcohol, substance abuse, and cellular telephone usage on its performance and dangers. Biology and physiology don’t lie, and brain scans indicate that the adolescent brain undergoes a thinning of the gray matter or thinking part of the brain around puberty. While motor and sensory areas of the teen brain, as well as reward centers, mature early, the areas of a teenager’s brain controlling plans, decision-making, and impulses and emotions remain immature until the middle 20s. Voilà, parents, educators, and the general public at large are faced with a potential recipe for disaster when the immaturity of the teenage brain, a propensity for high-risk behaviors and potential substance abuse, and the inexperience of adolescent drivers are all combined. So, how does this all translate? The KISS (“Keep it simple, Stupid!”) principle, in this particular case, leaves no room for misinterpretation when it states that teen brain changes can result in high-risk behaviors, substance abuse, and mental illness, that control over high-risk behaviors is still maturing during the teenage years, and that over 2.7 million children and adolescents suffer from behavioral or emotional ills.

The statistics are sobering! Each year 5,000 teens die in automobile accidents, and 400,000 are seriously injured. Teenagers are only 10% of the U.S. population, but account for 12% of all fatal car crashes. It is as if Russian roulette is being played on our roads, with 16-19-year-olds four times more likely than others to “crash and burn,” and with risk of a car crash highest during the first year of driving. Teenagers cost society 30% or $26 billion in annual automobile costs. This fact must be impressed upon them, and the only way to do so and put the financial downside in perspective is by comparison with something teens know and love dearly, namely the cost of a Microsoft Xbox® or a Sony PlayStation®.

Machismo and machines don’t mix, but try telling that to a teenager. If he or she gives you the time of day, you can explain that teenage drivers are more likely to speed, tailgate, and drive hazardously. Will teens listen, however? There seems to be a gender difference also, with teen male drivers 1.5 times more likely than teen females to die in automobile accidents. In these days of “super-sizing” and everything being bigger in Texas, teens are as likely to run into the jaws of life as they are to jaw a quarter-pounder in a fast-food joint. It is a well-known fact that adolescents have the lowest rate of seatbelt use. Statistics demonstrate that of 15-20-year-old male drivers killed in auto accidents, 38% were speeding and 24% were drinking and driving. Male teen “co-pilots” who egg the young driver on make matters no easier!

We are faced with what might be called the “booze blues,” although this is no light matter, by any means. The numbers bear this out. Seventy percent of high school seniors have been found to use alcohol in the previous year. Twenty-three percent of 15-20-year-old drivers who die in car crashes have blood alcohol contents greater than or equal to 0.08, which is comparable to four drinks. Of teen drivers killed in auto crashes after drinking and driving, 74% did not wear seatbelts. And if all this were not bad enough, 33% of teenagers report riding with teen drivers who drink, and 10% drive themselves while drinking. That will certainly give mothers and fathers out there something to think about!

We’ve all heard the expression that a brain is a terrible thing to waste, and nowhere is this idiom more applicable than in consideration of the wasted potential of the teenage brain. Studies show that the adolescent brain is particularly vulnerable to the negative effects of alcohol and other drugs and to addiction later in life, and more so than the brains of people not using such substances before age 21. We can only say “holey smoke” at this, as we learn that large amounts of alcohol close up blood vessels in the brain, causing brain cells to die in decision-making areas and resulting in “dead spots,” craters, or holes. Future shock is a terrible thing, and getting an early jump on the future is not always a good idea, especially when it comes to the devastating effects of alcohol consumption. Teenage binge drinking causes the brain to become inflamed and lose cells, with massive brain shrinkage and behavioral problems arising later in life, as a result. Even the gladiators and charioteers of Ancient Rome knew better than to drink “vino” before battle or high-speed races, which is more than can be said for their modern-day counterparts!

And lest we forget the “green, green grass of home” and the almighty cellular, we are once again confronted with a brick wall. Cars are the second most popular place for smoking marijuana, and more than 2.9 million driving-age teens have reported lifetime use of marijuana. In 2005, more than 750,000 16-17-year-olds reported driving under the influence of illicit drugs, with 1 in 6 teens (15%) reporting driving under the influence of marijuana, and 16% under the influence of alcohol. Driving and talking on a cell phone is still another major distraction and possible cause of car crashes, no less serious than substance abuse. Drivers who use a wireless telephone while driving can lose situational awareness and experience inattention blindness. Parents who give their teens cellulars and teenagers themselves must come to grips with the fact that automobile accidents are the leading cause of death in 15-20-year-olds. Drastic steps, measures, and laws are, indeed, warranted!

If parents and teenagers cannot police themselves, then local, state, and federal authorities must intervene to administer acute and chronic remedies that go far beyond provision of a symbolic Band-Aid®. Current proposals have run the gamut from graduated driver licensing laws and nighttime restrictions, comprehensive underage drinking and driving laws, and restrictions on the number of teen passengers traveling with young novice drivers to restrictions on the use of cell phones, education of parents on the impairment of concentration, coordination, perception, and reaction time for up to 24 hours with marijuana, and national anti-drug media campaigns referring specifically to drugged driving.

Teens are “green,” but the brutal reality of the matter is that we’d rather have them green with envy than green and six feet under!

Bleep Sleep

2009-12-13T14:21:00.000-07:00

I have a problem, a problem that is probably going to take years off my life, as well as contribute to my descent into what is called the “grouchy old man” syndrome. I don’t sleep at night. The years of stress, trials and tribulations, utter rancor and dissatisfaction with my station in life, and bitter taste in the mouth from one too many battles lost have taken their toll on my sleep-wake cycle. I have been known to literally pass out in the middle of a conversation, fall sound asleep after eating an average-sized meal in the early evening, nod off at the wheel of my car on the highway on my daily drive home from work, and start to full wakefulness at 2:00 a.m. when average Joes and Josephines are at rest under warm blankets, souls of the departed find repose and sustenance in communal camaraderie, and not a creature is stirring, not even a mouse. In short, I have “bleeped sleep,” and do what I will, I cannot reverse the tide of chronic fatigue I feel and the vicious circle I have created. Simple daily survival has become my mantra, as I no longer take pleasure in the little things in life, and I subsist solely on the caffeine or battery of other stimulants that buttress a circadian rhythm gone awry. I find myself thinking that if I can only get from the “vampire hours” to the early evening, then my day is complete, and I can surrender completely to the narcolepsy and little brother catalepsy that medical science, in all its infinite wisdom, is just now beginning to understand.

I think time would be well spent here explaining and understanding the simple workings of normal sleep, in order to arrive at a solution to my, and possibly your, problem. It is a well-known fact that insomnia, whether it be trouble falling asleep or staying asleep, affects one third of American adults. Wow! To make matters worse, insomnia can result in excessive daytime sleeping, increased appetite, reduced mental abilities, a diminished immune system, growing frustration, and a decline in daytime productivity. Now, while the amount of sleep a person requires is relative, there is a general consensus that seven to eight hours a night is needed to feel fully alert during the day. No one in this life is without worries, and an occasional bout with sleeplessness is normal. When sleep problems persist, however, beyond a few weeks, it becomes necessary to call in the heavy artillery, namely, one’s family doctor. The latter, if a lack of drowsiness on one’s part permits an understanding of the knowledge imparted, can explain the difference between the two states of a normal sleep cycle, and that is that REM (rapid eye movement) sleep is the period in which dreams occur, as opposed to deeper non-REM sleep. The number 65 is something to remember, for at that age the sleep-wake cycle begins to function inefficiently, sleeping for long periods of time occurs less frequently, and illness, pain, medicines, or a frequent urge to urinate take their toll on ZZZZs and prolong the counting of sheep.

While I understand the problem at hand, there must be some reason why I find it hard to sleep. I refuse to believe that the motive is hidden and mysterious. Whatever the latter may be, there are things I can do to combat the utter desolation of tossing and turning, as the rest of the world regenerates its corporeal fuel cells for the coming day. An attempt at inner calmness on my part breeds a game plan from which I must deviate little. First and foremost, a bedtime routine is called for, in which I do the same thing every night before going to sleep. A quiet and dark bedroom helps and, if my inner demons don’t allow my repose in a reasonable amount of time, say 30 minutes, then a brief trip to another room before returning to bed may help. A light snack, such as warm milk or some crackers, before going to bed may be just what the doctor ordered, but knowing myself and my tendency to do everything in excess, I must remain vigilant against eating too much. A “worry wart” I am, so if I can just leave my problems outside the bedroom, and use the latter for sleeping and sex (and a lot of that!), not eating, talking on the phone, or watching television in bed, then I can become a worthy adversary to insomnia. That’s not all, however. Exercising a little each day, at the expense of daytime naps longer than 30 minutes, and avoiding alcohol, caffeine, and nicotine in the evening can’t hurt. Finally, and perhaps most importantly, I must learn to retrain my body to sleep at night. What does that mean? It means that if I can go to bed and wake up at the same time every day, then maybe this Count Dracula can transform himself into an innocuous Rip Van Winkle.

If none of the above measures bring somniferous satisfaction, then “oneth by land and twoeth by sea” sleep studies are warranted to discriminate between periodic limb movement disorder (PLMD) in which legs are kicked many times during sleep, sleep apnea with repeated breathing cessation during sleep, and narcolepsy with its sudden “sleep attacks” without warning, as well as to determine the source of insomnia, snoring, or teeth grinding. I’ve been told that thorough sleep clinic monitoring of my brain activity, body temperature, breathing rates, and muscle movements during sleep can help get to the bottom of this mess I find myself in.

I’ll keep you posted as to my daily daytime quest to uncensor my “bleep sleep,” that is, if I can stay awake long enough.

Weight-less

2009-12-13T11:22:00.000-07:00

Why do we hate fat people? Why do we look at them with disdain, with holier than thou attitudes? We are all guilty of their perceived sin, and, to boot, when blinds are drawn and monitor screens glow, we are the first to type “diet” into search engines of choice. Food companies spend millions of annual dollars hawking the latest miracle aliments promising to lower LDL (“bad”) cholesterol, raise HDL (“good”) cholesterol, and increase energy, libido, and everything short of our bank accounts. The high-fat, high-protein, low-carbohydrate (HPLC) diet of yesteryear has been touted from its throne on high for years, until recent research demonstrated its hand in promoting plaque buildup in the highways and byways of our bodies, otherwise known as arteries. While it is obvious that becoming “weight-less” is difficult at best, it certainly isn’t brain surgery. If the solution to the obesity epidemic, however, is as simple as eating more healthily and being more active, then how do we explain the plethora of unsuccessful fad diets and even crash dives into unnatural decreased calorie intake that can leave our bodies in physiologic starvation modes, eat away at healthy muscle, burden our minds with fatigue, grouchiness, and irritability, and disfigure waistlines with that all-too-common B-word, “binge” eating?

We all know the problem. We’ve been victims of it time and time again. What can we do about it? In this case, we are not talking about an ounce of prevention. Pounds are the name of the game, with a new lease on life coming at as simple a cost as a change in eating habits, albeit a small change at first. Let this short piece serve as both a primer to our initial foray into the realms of salubrious diet and healthy weight, and as a rematch between ourselves and past New Years’ resolutions kicked to the curb. While any good change in diet and eating habits begins with our family doctor, we must realize that the men and women in white simply do not have the time to completely overhaul our current lifestyles. They are underpaid, overworked, and, in many cases, more concerned with drugs and “pharmacologic surgery” of the problem than preventive medicine and patient education. We must become creative ourselves, and look to our own proactivity.

First and foremost, we must examine the good, the bad, and the downright ugly. In other words, we must make a concerted effort to assess our own dietary strong and weak points. Are we eating five to seven servings of fruits and vegetables every single day? Is calcium part of our diet and a plan to preempt brittle bones? Do regular whole-grain, high-fiber foods bring up the rear (no pun intended!), contributing to our regularity and preventing unwelcome house guests such as colon cancer, diverticulosis, and something as inconsequential, yet troublesome, as chronic constipation? Will we never learn that too much sugar, salt, and saturated fat is just plain no good? We’ve heard ad nauseam that fatty meats, cakes, cookies, potato chips, biscuits, and sweets not only increase calorie counts, obesity, and weight, but also lead to high cholesterol and heart disease. Nonetheless, we desist from limiting them in our diets and making those small changes, such as adding fresh fruit or vegetables to every meal, or getting more fiber in our diets, that would make hospital emergency rooms, cardiologists, and funeral directors quite unhappy. While keeping food diaries to that end is an exercise in persistence and healthy obsession that many of us do not possess, something as simple as a kindly reminding refrigerator magnet can reap untold economic and quality of life-preserving windfalls.

Lest we forget portion size and the gentle admonishments of our parents who cajoled the benefits of cleaning one’s plate, we may have taken this too far. Current statistics bear this out, and they’re not pretty. The American Institute for Cancer Research has reminded us of what we already know to be true, and that being that more Americans than ever are making Jack Sprat proud, by “licking their platters clean.” Were that not enough, the public is grossly unaware that we unconsciously consume 56% more calories when we are served larger portions, and that more than 78% of Americans are deluded into thinking that the specific food they eat is more important in losing weight than the amount they ingest. God help us!

With Christmas and New Year’s Eve on the horizon, and a change in waistline in the cards unless we act now, here are some “no-brainers” and food swaps that may not trim food expenses in the short term, but will most certainly balance the future medical budget, both personally and nationally speaking. Substituting low-fat, whole breads for white breads, English muffins for doughnuts, baked potatoes for French fries, turkey dogs for regular hot dogs, low-fat cheese for Cheddar, and non-fat for regular mayonnaise may not entirely please the palate, but will certainly keep us around long enough to see our loved ones grow and prosper. And we’ve saved the best for last, as we urge blind obedience to the eight commandments of clever food choice, and those being: have a healthy side dish with meals; go easy on the butter or margarine; avoid high-fat sauces and gravies; serve fresh fruit with the skin on; eat more fresh fish than beef or chicken; consume five or more portions of fruit and vegetables daily; bake, broil, roast, or steam instead of frying; and, finally, substitute dry beans, peas, or lentils as often as possible for red meat in favorite recipes. Impossible, you say! Start slowly, and build up to a crescendo.

Do as we say, and not as we’ve done in the past, and we can liberate the term “weight-less” from the exclusive lexicon of NASA.

Turkey Trot - Home Alone for the Holidays

2009-11-29T10:28:00.001-07:00

You’ve lost your last friend, you’re down in the dumps, the planets are not aligned correctly, the holidays are fast approaching, and you’re home alone. There is nothing more depressing than the sense of utter helplessness one feels at the hands of a perceived abandonment forcibly endured during the festivities of Thanksgiving and Christmas. This is especially true when financial figures dip into the red, when family members are far away, when loved ones are no longer with us, and when television, magazines, the Internet, and other forms of mass communication show us those cozy fireplaces, warm and loving households, and smiling faces that we’d just love to punch in. While it can be normal to feel somewhat subdued and sad during the holidays, when those feelings become tantamount to downright depression, then we have problems. It is usually the elderly that bear the brunt of those “Thanksgiving turnarounds” or “Christmas crises,” due to a plethora of real or imagined factors ranging from financial limitations and being home alone to a loss of independence, eyesight, or mobility. No one is immune, however, and even the young can feel blue, as chestnuts roast on an open fire and mistletoe catalyzes self-embrace, for lack of a suitable partner to share a touching of lips. We know the problem, or do we? We have all felt it at one time or another, what with parties, shopping, baking, cleaning, and entertaining during the holidays taking their toll on sleep, exercise, and self-love. So, I guess my gift to you this holiday season is to come up with a primer or set of instructions for halting, or at least making bearable, that annual mad dash or stampede that leaves us feeling drained and devoid of healthy cheer between that last Thursday of November and the first of the New Year.

Our so-called quest to tame the turkey trot could not begin if we were unable to state categorically that before a cure can be prescribed, an accurate diagnosis must be made. What is it that actually causes us to wallow in self-pity during the most joyous time of the year? Are doldrums a normal sign of aging or are the social obligations, mad hatter shopping, financial difficulties, work-related angst, and sleeplessness of the holidays something greater than the sum of their parts but much less than incurable? Three things are certain at this crossroads of the year, that family can be a burden as well as a blessing, that overspending can mean financial worries for months to come, and that exhaustion, lack of sleep, and exercise deprivation increase stress in a vicious cycle from which it is difficult to extricate oneself. And let’s not forget those vodka spiked eggnogs, peppermint hot chocolates, or Christmas martinis that do little to raise low spirits, rather they have an opposite effect. Adding alcohol to imposed social obligations is a recipe for self-flagellation, when saying “no” to liquid amenities or social outings without pangs of guilt or a need to explain becomes an exercise in willpower that many of us are ill-equipped to muster.

While we have accurately presented this annual rite of remorse, which is new to no one and further complicated by “selection psychosis,” with incapacity to choose the right gifts for family and friends, and “tradition tampering,” with failure to duplicate the conscious and unconscious holiday ceremonies of a happier past, we have done nothing to solve the problem. The good doctor will now make amends, and give you his take on the remedies, which, by the way, are free of charge. The premise here is that we have all gone through this, and, rather than reinventing the wheel, we must adopt what is tried and true. While we cannot force ourselves to be happy during the holiday season, we can certainly reach out to the individuals and community organizations around us. The holidays don’t have to be perfect to be enjoyed, and new friends and traditions can provide an excitement lacking from the usual seasonal rigamarrow. Now, the name of the game is to also set aside family grievances for peace of mind, stick to a realistic shopping budget for obvious reasons, and plan ahead. Running around like chickens without heads was not something envisioned by the inhabitants of Bethlehem many moons ago, and, what was good for the founders, is most certainly good for the rest of us. Learning to say “no” to social activities that can leave us resentful and overwhelmed follows suit, or perhaps attending them only briefly to make an appearance or a surgical “hit-and-run.” Sound realizable? Then let’s put the finishing touches on this work in progress. Don’t forget to get plenty of sleep and physical activity during this holiest time of the year, as well as direct greater attention to stuffing the turkey instead of oneself. Alcohol, sweets, and cheese are fine, but everything in moderation, and, remember, “breathers,” in the form of moonlit walks, stargazing, or soothing music are good. Finally, when all else fails, irritability, hopelessness, and insomnia may warrant a trip to your doctor or mental health professional. There is no shame in asking for help. A perceived loss of face in no way compares with a loss of mind.

Cheers! Things could be worse. I could have mentioned that turkey not only contains more cholesterol than ham, but that it has also been known on occasion to give one the “trots.”

Funeral Fandango

2009-11-29T10:26:00.001-07:00

While my medical pieces have heretofore addressed a slew of maladies ranging from acne to zoster, as well as the collective human spirit to preserve life and fight any incursion into our bodies’ inner sanctum, sometimes a final number is called in destiny’s 50-90-year-old bingo game. When taxes no longer disturb the slumber of a hapless victim, the deceased’s family and friends are often left with a reminder of the high cost of dying, in the form of an average funeral bill of $7,323. Then, as the band engages in a badly timed “funeral fandango,” especially in these times of high unemployment, rising medical costs, dashed retirement savings, and freefalling home values, we are left to wrestle with the dilemma of where to find the money to bury loved ones. The Grim Reaper knows no black ink, and the 700 bodies lying unclaimed in the Los Angeles County morgue last July attest to the unsettling reality of sticker shock of the numerous families who can ill-afford to pay runaway funeral costs.

With the price of an average funeral outstripping the cost of living and with funeral directors nonetheless claiming their services a bargain, some good old-fashioned truth is warranted when false prophets, vacillating editorial points of view, and general disbelief in the printed page envisioned by Gutenberg to honestly inform reign. So, let’s call a spade a spade. Here are the facts. In 1984, the Federal Trade Commission (FTC) issued the so-called “funeral rule,” requiring all funeral homes to provide a general price list of all goods and services and permitting consumers to choose individual items instead of a complete package. Notwithstanding this mandate, in 2004 funeral directors continued to argue that the intensive services they provide accounted for their misunderstood prices, and that most people pay far more for weddings, cars, or one year’s college tuition than the average funeral. Obviously, they were steadfast in their convictions when, in 2008, FTC undercover investigators found that a fourth of the funeral homes they visited significantly violated the funeral rule. Hello! We can’t even rest in peace. We feel the pinch even in death!

Aside from a basic services fee, charged by all funeral homes and which there is no getting around, price negotiations can be conducted on a vast assortment of related items ranging from the funeral service and public viewing to embalming and the casket itself. The name of the game is to neither be pressured nor “guilt tripped” by funeral directors who prey on frayed emotions by referring, for example, to less expensive coffins as “welfare caskets” or “morgue boxes.” A little homework goes a long way, and the Funeral Consumers Alliance, which many of us would be hesitant to join as regular card-carrying members (due to the unpleasantness of its connotation), advises family discussion of funeral plans in advance, in much the same way that weddings, vacations, home purchases, and college tuition are hashed and rehashed in the living room or around the dinner table. Who knows, perhaps participants can arrive at alternatives to the traditional funeral home experience.

Unpleasant, you say, and how dare that man broach such melancholia at this joyous time of Thanksgiving and Christmas merriment! Perhaps you’re right, but death is a constant companion that gets no vacation time or annual leave for the holidays. Death of a loved one, while never acceptable, can at least be defused financially if cremation and services at $1,350, do-it-yourself home funerals at $250, or “green” funerals are opted for, instead of the simplest of funeral rites at $5,000 and a grave marker of $3,000, not to mention the cost of a funeral plot. The facts bear this out. While fifty years ago, cremation accounted for only about 4 percent of funerals, that figure rose to 35 percent in 2007 and is projected to increase to 59 percent in 2025, if we live that long to see it.

No one is implying that family members of the deceased, with the help of a death midwife, should bathe, dress, lay out the body, and preserve it with dry ice in the home for three days, in order to save a few bucks and defray the costs of chemical embalming and a traditional funeral service. That possibility does exist, however. Nor is anyone advocating “green” funerals, with burials in open fields, grave markers made from local rock, and even employment of GPS coordinates instead of the markers themselves. Nevertheless, a failure to reel in funeral costs can turn a funeral fandango into a dance with the devil.

Al Capone was a Capricorn

2009-11-29T10:24:00.001-07:00

For some time now, animated and often hostile debate has raged over a proposed connection between astrology and medicine, or what is called astro-medicine. Even Al Capone weighed in on the subject, and there were those, critics and curiosity seekers alike, who linked his fateful demise in prison from neurosyphilis to a not-so-casual alignment of his stars in Capricorn. Going back still further, it has come to light that the ancient Babylonians and Egyptians, who were far from ignorant and who gave the world horticultural marvels, a magnificent library, monuments in stone that still stand and awe today, recorded history in the form of hieroglyphics, and willow bark, or aspirin, for rheumatism and pain, were students of medicinal astrology and a perceived influence of stars and planets on health. Their “captive audience” of Jews also kept a knowledge of astrology among their confidential doctrines. It didn’t end there, either. The Middle Ages was a particularly florid period for “star power,” with faculties of astrology springing up in such diverse Spanish cities as Cordoba and Toledo, and with kings, Popes, aristocrats like Catherine de’ Medici, and even a famous doctor-astrologer and bubonic plague authority or two such as Michel Nostredame, better known today as Nostradamus, plying their wares in the heavenly-body arena of the early and middle 1500s. It was thought that a star disharmony between physician and patient would lead inevitably to incomplete recovery from physical malady or no recovery at all. Physician promulgators of astral alignment familiarized themselves with the horoscopes of their patients, and, when that was not the case, patients took it upon themselves to investigate those of their healers. Furthermore, a common conception, or misconception, whichever you prefer, arose that the way the planets were arranged at the moment of a child’s birth dictated a later predisposition to disease.

So, that is all well and dandy, but where does the field of astro-medicine stand today, if it can be considered a field at all? Before that question is answered, some startling revelations bear denouement to incredulous minds. One of them is the fact that two-thirds of the world’s population seek health care from sources other than conventional biomedicine, otherwise known as allopathy. Closer to home, 42% of American households have tried complementary and alternative medicine in recent years, and the staid and somber National Institutes of Health (NIH) has supported no less than 50 investigations into the usefulness of various alternative therapies, of which astro-medicine is no stranger. Demand for attractive, affordable, alternative medicine approaches to chronic disease has grown exponentially, especially on the preventive and public health care stage. In mysterious India, where truths are often hidden and minds open, allopathy rides shotgun to yoga, massage, prayers, spiritual healing, tantra/mantra, gem therapy, hypnosis, acupuncture, magnet therapy, and that old acquaintance, astro-medicine. Can we dismiss the swelling legions of astro-medical warriors and a hungering public so lightly?

Perhaps there is more to the story than mere superstitious invention of a medical system that renders various parts of the body, diseases, and drugs subservient to the influence of the sun, moon, and planets. Perhaps the celestial-corporeal association is real, and the instrumentation and investigative methods currently available are too primitive to prove validity beyond allopathic doubt. Can so many people be wrong? Are the purveyors of allopathy so presumptuous as to think that their medical dominion and carte blanche of the last 400 years trumps the collective wisdom of the prior 60 centuries?

Medical astrologers study the anatomical-astrological birth charts of their clients or patients, in order to give advice about the areas of the body most likely to experience trouble. Farfetched and outlandish, you say? Perhaps, but condemning astro-medicine does not mitigate the fact that scores of patients with chronic diseases such as cancer, AIDS, arthritis, asthma, diabetes, and epilepsy, to name a few, have derived solace, comfort, and a measure of symptom control, if not out-and-out cure, from other alternative medical methods. Those remarkable gains, with survival of up to five years in some cancer patients, warrant a closer look at the “attractive nuisance” posed by complementary therapies so easily discarded by undiscerning allopathic eyes. As Shakespeare put it, in Julius Caesar, “The fault, Dear Brutus, is not in our stars, but in ourselves, that we are underlings.” He might have said, instead, to paraphrase, “Open minds breed sound bodies.”

In astrology, there is a dictum that states, “Stars assume, but do not force,” meaning that the influence of the stars and planets on the health of a person can always be weakened by self-discipline, a healthy diet, and benevolent thoughts. Nowhere is this more evident than in the case of Al Capone. The stars reveal that as a Capricorn his knees, joints, and skeletal system should have done him in. As it was, another “bone” brought about his demise, for he lived, loved, and died by the sword.

Sorcerer's Soup

2009-11-29T10:20:00.001-07:00

As ghouls and goblins descend upon us in this Halloween season, the annual question of whether one can be scared to death, or “scared stiff,” whichever you prefer, must once again be posed. The sorcerer’s cauldron froths and boils over, rendering its soup no more toxic than the so-called brain-heart connection. In fact, there is a physiologic basis for strong emotions causing death, when the nervous system becomes so jump-started by serious threat that it can cause heart attack and consequent exitus. Animal studies bear this out. There are also historical precedents to the lethal brain-heart connection, with a Roman emperor, a 13^th century pontiff, and American patriots all succumbing to the mortal blows of anger, grief, and elation, respectively.

Both disruptive life events and the chills of Bela Lugosi, Christopher Lee, or Freddie Kruger movie house madness can lead to an inevitable downward spiral in life’s course. The palpitations, heartache, and anxiety wrought by Hollywood make believe can easily parallel similar repercussions of real-life calamities such as the death of someone dear, the threat of death to someone close, the anticipation of a difficult examination, the embarrassing loss of self-respect or self-esteem, the unpleasant memories exhumed during an anniversary memorial service, or the threat of imminent harm or injury in battle. Even the jolt of a happy ending can end miserably, with the strength of the emotions elicited weighing heavily on an “animus et corpus” worn down by neuronal, hormonal, and psychic bombardment.

We have all experienced anxiety at some point in our lives. The adolescent on a first date with an unsightly pimple that just sprang up, the college student about to take a first set of final examinations after pulling an “all-nighter,” the hapless groom about to say “I do,” the postmenopausal woman awaiting biopsy results after a suspicious mammogram, the second-string athlete about to get his chance in the big game, the employee suddenly called in to the boss’s office after rampant rumors of pink slips and company lay-offs, and the list goes on and on, indicating that being human entails a certain amount of heart palpitations, taut nerves, queasy stomachs, cold hands, and downright urges to roll up into the fetal position until the all-clear has been sounded. Until now, however, the latter had been considered nonlethal, par for the course, and attributed to simply living life. Now we know that they can kill you! A study of 3,015 70-79-year-olds, in fact, has demonstrated that not only “the good die young,” as the saying goes, but the anxious also. The more anxious one is, the more he or she is likely to die, with the added twist that anxiety is a greater predictor of death in blacks than in whites.

And what of the million-dollar shrink’s term, “catatonia,” theme of horror movies and idle cocktail chatter? Catatonia is a paralysis that has no apparent physical cause and little physiologically concrete to refer to, except that it may be provoked by fear. On any given day, any one of us can become its victim with no advanced notice, and a study conducted in 2004 suggests that it was originally rooted in our collective DNA to protect our species from being eaten by other animals. Unfortunately, we now know that other kinds of fear, anxiety, or feelings of imminent doom, real or imagined, can lead to catatonia.

Passing from a sorcerer’s soufflé of Ouija boards, tarot cards, horoscopes, pinned effigies, amulets, potions, elixirs, bloodied chicken corpses, and Santeria, we subsequently navigate the singularly turbid waters of Cupid’s domain, where we pose the question of whether one can, indeed, die of a broken heart. Been there, done that, and lived to tell the tale, you say. Perhaps. But consider yourselves fortunate, as failed romance may be just stressful and acute enough to cause heart failure. While people under stress may already have heart disease, who’s to say that the stress of unrequited love is insufficient to cause fatal heart failure? After all, acute stress cardiomyopathy, which resembles a heart attack without actually being one, occurs in non-cardiac patients hospitalized after acute physical or emotional trauma, such as grief for the loss of a loved one or fear resulting from an act of criminal violence or involvement in an automobile accident.

Our account of mind over matter would be found deficient, if we were not to contrapose the concrete to the sublime. Why worry about what we don’t know killing us, when even the innocuousness of castor oil, rhubarb pie, sunflower seeds, and cherry, plum, and peach stones, to mention a few, can put our short time on earth to an even shorter test? Perhaps we should devote our energies and turn our sights toward what can actually kill us, instead of a witch hunt for sensationalism and magic bullets to fell the monsters inhabiting our psyches since the beginning of our time. Wouldn’t resources be better directed at automobile accidents, murder, other accidents, suicide, and cancer in the 15-24-year-old group, cancer, heart disease, and accidents in the 25-45-year-old group, and heart disease, cerebrovascular disease, chronic lung disease, Alzheimer’s, pneumonia, diabetes, and accidents in individuals 65 and older than at shadows, figments, and sounds that go “bump” in the night?

Sorcerer’s, shamans, medicine men, charlatans, and traveling snake-oil vendors are everywhere, now, at Halloween, and whenever. Calling their bluffs, however, in these times of increased evidence of the brain-heart connection, leaves this writer scared stiff!

Unkind Swine

2009-09-07T13:04:00.000-06:00

The so-called plague is upon us. As some run for the hills, and others to their favorite apothecaries or foibles in white, we are besieged by incessant calls to action and a sense of urgency. We are told to vaccinate ourselves, our children, our loved ones, and our friends, lest we fall prey to a swine virus ever so unkind. As is usually the case when heart and emotions dictate to the mind, we jump on bandwagons, follow the Joneses, and are led by the blind, all the while ruminating in self-doubt and our abilities to make the right decisions. All we want to do is what is just and healthy. With little thought for our own well-being, all we aspire to, individually and collectively, is a safe environment for our children, first and foremost (if we want to be selfish, at the least), and for the rest of our nation and the world, when we are feeling especially magnanimous. No easy task when navigating through a morass of scientific information, pharmaceutical hustling over the airwaves, and a press more bent on sensationalism and selling copy than getting accurate information out to the public in a timely fashion. So, briefly, let’s debunk the hype, and with cooler heads take a look at this thing they call the swine flu, with a predominant eye turned more toward prevention with vaccination, than damage control after Pandora’s Box has been opened.

It is designated the 2009 H1N1 flu, and never before has the old adage that “an ounce of prevention is worth a pound of cure” been more apropos. After all, a fever of over 100 degrees, cough, body chills, congestion, diarrhea, and vomiting don’t make anyone’s day. In fact, they can be downright dangerous in pregnant women, people of any age with heart disease, asthma, diabetes, and other chronic maladies, children under 2 years of age, and people over 65. To make matters worse, fever is not always present, and that can lead to a dubious diagnosis between swine flu and the common cold. So, let the buyer beware! A short course of the new swine flu vaccine, whether that be one dose or two, depending on an as yet to be made pronouncement by the Centers for Disease Control (CDC) and experts in the field, along with the regular flu vaccine, may be just what the doctor ordered. While a maximum of three doses, with the two swine flu doses in one arm and the single regular flu dose in the other, may not be the pleasantest of experiences, it sure beats the hell out of the shortness of breath, chest pain and pressure, confusion or seizures, persistent vomiting or inability to hold down liquids, and bluish lips that mandate a high-speed cruise down to the emergency room. The problem is that while health authorities expect the swine flu to peak in October, affecting up to 50 percent of the U.S. population, most vaccine doses are not expected to arrive until November or December. So, what good is vigilance and proactivity, you ask? Not much, sometimes. All we can do is wait, hope, and keep our fingers crossed. Impotence in the face of possible imminent disaster is the stuff of horror movies and Halloween, and not what we’ve come to expect from a health care system that propones to be at the acme on the world scene.

Family physicians, internists, and pediatricians would much rather receive “preemptive” calls from their high-risk patients, than cries for help after the swine flu has already set in. Care should be taken by parents and teachers alike to watch the activity levels of children and, at the first sign of lethargy or listlessness in their charges, call in the cavalry. Anti-flu medications prescribed by the men and women in white, whether they be Tamiflu® or Relenza®, stand their best chance of working if they are administered within the first 48 hours of flu symptoms. A task made no easier by still another fork in the road, and, namely, the $100-price tag of the anti-flu drugs, which many uninsured Americans can ill-afford to pay. Those fathers, mothers, young children, and extended families are precisely the foci of prospective or actual infection that need to be targeted, too! Realizing this, the federal government has gotten off its duff, for once, and shipped millions of doses of the medications to the states, with Texas taking the lead to allocate a good portion of its ration to those most wanting economically. New York has also placed its best foot forward, offering free swine flu vaccinations to its over one million schoolchildren.

The stage is now set for the unkind swine flu to materialize, with its 1-3-day incubation period for symptoms to appear after exposure to the virus. Before high tech kicks in, Mom’s age-old remedies for the flu make good sense, and should stave off or at least ameliorate its onslaught. At first sign or symptom, stay at home and rest, limit your contact with people, drink plenty of fluids, practice good cough and sneeze hygiene, and wash your hands and the surfaces you come in contact with frequently. Only then can we envision a kinder, gentler swine flu.

Appendiceal Appeal

2009-09-07T12:58:00.001-06:00

They say it’s no good to anybody. They say it serves no useful purpose. But it’s hard to believe it would exist in the first place were it not for the divine plan of a deity, evolution, or some heretofore unknown life force. Is it a mere vestige of something far greater in our ancestry, or is it the key to wonders cloaked in mystery behind still another locked genomic door? It might just be a simple fellow, and yet it is part of us all and, as such, merits a closer look. What are we talking about here? Why, that enigmatic body part known as the appendix. Darwin himself was fully aware of its existence, and, yet, the conventional wisdom of his time led him to believe that it was a mere vestigial organ, a useless sac embedded in the lower right quadrant of the body, between the small and large intestines. And he knew that it was not limited to Homo sapiens, but ran the gamut of numerous animal species, including flying squirrels, to boot. Now we know, through the advances of modern technology and medical science that the appendix dates back 80 million years, and we are learning that it may be a “magic bullet” of some sort, aiding the human body in its defense against disease by releasing a flotilla of good bacteria into our guts and white blood cells into our bloodstreams when our immune systems are most in need. Yes, the appendix may be appealing, after all.

We often hear that someone we know has had an appendix removed, due to the sudden fever and excruciating lower right abdominal pain of an appendicitis attack. In fact, 1 in 20 people has an appendix taken out, with no dire consequences. That alone has given the medical community license to declare that the slimy dead-end sac known as the appendix is of little or no need to us all. Wrong! Recently, it has been suggested that the appendix is a storehouse, a Big Wal-Mart, if you will, of good bacteria. When a subject’s colon is devastated by the ravages and diarrhea subsequent to a severe case of food poisoning or any number of acute and chronic gastrointestinal maladies, the “good-for-nothing little engine that could,” otherwise known as the vermiform appendix, comes to the rescue, releasing good bacteria or normal flora into our guts to repopulate the healthy bacterial lining that forms an integral part of our gastrointestinal systems and that is often the first to go after a nasty diarrheal attack. But the job of our newfound friend, the appendix, doesn’t end there. Recent studies indicate that it may, indeed, even make, direct, and train white blood cells, which, as you may or may not know, are key to our bodies’ defenses. So, perhaps we should reevaluate the little fella we were so anxious to write off, without giving the benefit of the doubt, a proper chance, or a respite for all the medical data to come in.

Now we must determine what actually causes appendicitis, or that potentially deadly inflammation of the appendix. In reality, the prevailing opinion of experts no longer inculpates a faulty appendix as its cause. You may, in fact, be surprised at whom the finger has been pointed. It now appears that cultural changes due to an industrialized society and improved sanitation are the culprits. The appendix, as a storehouse of what had been good and healthy for our guts and immune systems, was rendered useless and obsolete by the very advances that contributed to our clinical and public health betterment as a society, those being widespread use of sewer systems and clean drinking water. With infection of the gut on the decline due to the latter, there was really no further need of an arsenal of good bacteria and white blood cells to defend us. Why maintain a large standing army when there are no wars to fight? So, the appendix was wrongly relegated to the ranks of a mere vestige. Now, all that has changed. With what has recently come to light on the normal function of our “long-lost friend,” we must look at the question of what can be done to prevent appendicitis, to the chagrin and reduced bank ledgers of general surgeons. If we can find the means to instigate the appendix in much the same way as in the past, and consequently incite our immune systems, through release by the former of good bacteria and white blood scavenger cells, then allergies, autoimmune diseases, and even appendicitis may go the route of imminent extinction. Wishful thinking? Perhaps. But then, again, it certainly is appealing. Darwin would be pleased.

Don't Bug Me!

2009-09-07T12:22:00.002-06:00

Make no bones about it, superbugs will inherit the earth, or at least our hospitals, for the time being. There is no escaping them. Go into the hospital for one thing, and come out with something entirely different, if not in a pine box. So, those hallowed halls of healing are slowly but surely becoming more known for what ails them, than for what ails us. Methicillin-resistant Staphylococcus aureus (MRSA), an antibiotic-resistant bacterium, has passed from the exception to the rule in the 1970s to a predominant “mover and shaker” on the Ten Most Wanted list of our nation’s hospitals. The organism lives harmlessly on the skin, but just grant it access to and safe passage through a portal into our bodies, and all hell breaks loose. Its close companion and fellow hit man, Clostridium difficile, an intestinal bacterium, is no less troublesome, and is a force to be reckoned with that even that age-old “bug slayer,” alcohol, cannot neutralize.

There you have it. It’s bad enough that the out-of-the-ordinary causes your hospitalization, without being further insulted by a totally unexpected bug brigade. Unexpected is a poor choice of words, however, as each year 90,000 Americans pick up hospital-acquired infections that kill them, and many more suffer the ravages of diarrhea and other unpleasantries so severe that even Montezuma’s heirs would most likely disown them. It has been estimated that in 2008, on an average day, 7,200 hospitalized patients or 13 of every 1,000 were colonized or infected with Clostridium difficile, and 300 did not survive it. Add those numbers to the toll of MRSA infections in patients with weakened immune systems, or those requiring catheters, intravenous lines, or ventilators, and we become witness to a mathematician’s worst nightmare, that being the formula for a lethal one-two punch.

And to think, in many cases we brought this on ourselves! While the young and very old are often the first and foremost to be “bugged” in the hospital setting, whoever dreamed that the very antibiotics conceived of and developed to thwart any number of serious infectious maladies might boomerang, strip our guts of friendly, protective organisms, and, as a consequence, fertilize the terrain for florid Clostridium difficile growth and proliferation thereafter. MRSA, on the other hand, being a normal inhabitant of the skin, has a tendency to congregate around cuts and scrapes, where it is held in check by a healthy immune system. Impairment of the latter is an open invitation to bloodstream incursion, with resulting sepsis a formidable foe to even the most heavily reinforced arsenal of antibiotics and antimicrobials. The death toll and morbidity rates generated by MRSA and Clostridium difficile come at a stiff price in greenbacks also, to the tune of an estimated $250 billion a year.

The story doesn’t end there, however. The profuse diarrhea incited by Clostridium difficile is the vehicle of a riot or a wildfire, if you’ll allow for literary license, facilitating spread of the bacterium onto hands, bed rails, sheets, IV poles, and uniforms. Person-to-person transmission, from patients or medical equipment to the hands of health care workers and then onwards to other unsuspecting souls, is the name of the game. In short, the bug is spread everywhere. MRSA, for its part, while far removed in its mechanism of action from a potential enrollment in a “defecatory duo” spearheaded by Clostridium difficile, is nonetheless anything but innocuous. In fact, about 250,000 Americans a year receive a nasty surprise when catheters inserted into their large veins to provide fluids or medications become the sources of bloodstream infection with MRSA. One in four of these unlucky souls meets his or her Maker, and just for having been in the wrong place at the wrong time.

So, what’s the solution? How do we stop superbugs in their tracks? What measures can be taken against an MRSA adversary resistant to penicillin and other antibiotics? Is diarrhea lasting longer than 24 hours and accompanied by weakness, a racing heart, or blood in the stool a sign of something as sinister as Clostridium difficile infection or just symbolic of a bad night on the town and a cheap Chinese restaurant? Frequent hand washing, limited use of antibiotics to only cases absolutely necessary, the wearing of sterile gloves and gowns by medical personnel, the use of antiseptics and sterile drapes and dressings to protect patients, and even a probiotic, helpful yeast called Saccharomyces boulardii (or commonly Florastor®) taken orally can go far to checking the advance, if not exterminating entirely, the superbugs. Government and state oversight, public scrutiny, and state laws requiring hospitals to report infection rates to the public can also be strong deterrents to harmful laissez-faire attitudes on the part of health facilities. Case in point, preventives measures, both voluntary and imposed, were instrumental in reducing the rate of MRSA bloodstream infections by about 50 percent from 1997 to 2007.

Superbugs may one day inherit the earth, but not on our watch, as long as actions speak louder than our collective “Don’t bug me!”

Of Mammograms and Telegrams

2009-08-09T13:39:00.001-06:00

The ritual of the yearly mammogram screening has reached epic proportions, with vast numbers of our “over-50-ish” fairer sex trudging down to their family care providers, gynecologists, or radiologists religiously, in order to receive peace of mind for another 365 days. Mammograms were originally conceived of to preclude nasty surprises and their subsequent urgent telephone calls and telegrams. But are they foolproof? Does being a “good girl” and getting one’s annual mammogram avert a worst-case scenario, namely, advanced-stage breast cancer with little chance of cure? Lo and behold, we now learn that no two breasts are exactly alike, and that mammography can detect only about half of all breast cancers in women with dense breast tissue. And how, for that matter, is a woman to know if her breasts are dense? We need to throw some light and accurate medical information on a subject that directly or indirectly affects us all. As products of a mother’s milk, we would be remiss to do otherwise.

Breast tumors are dense and, when coupled with dense breast tissue, make for a difficult game of hide-and-seek, with anatomical camouflage making discovery difficult, at best. To make matters worse, dense breasts are not the exception to the rule and, actually, are quite frequent. The medical literature indicates that half of women under age 50 and one-third over 50 have this density dilemma, if we may call it that. The younger a woman is, the more likely she is to have dense breasts. If that were not all, even if a woman were to be aware of her individual density issue, chances are that she would be blatantly unaware of the fact that her annual mammogram might actually miss its intended target. Were radiologists to inform their patients of this particular, not only would mammograms drop below radar screens and get scratched off shopping lists, but women might protest en masse and further embarrass a health care system already reeling from assaults by Congress, local politicians, the elderly, the poor, and the downright fed-up.

So, in simple terms, one might say that the question is whether or not screening mammograms are worth their weight in biological gold. Do they, indeed, reduce a woman’s chances of dying from breast cancer? If not, why is there so much ado about nothing? In that case, we might be better served by simply moving on to another form of detection, more sensitive and specific than pressing one’s upper torso against a plate. The fact is that mammograms reduce women’s chances of dying from breast cancer by 22% when they are aged 50 and over, and by 15% in those in their 40s. No small numbers, especially when female friends and family members are set adrift in the choppy waters of cancer fear, doubts, and medical misinformation, and cling to the only life preserver and communication beacon heretofore available, namely, the screening X-ray. However, when breast density is thrown into the mix, any attempt at treading water becomes problematic, to say the least. Enter our hero, the breast ultrasound.

While screening ultrasound adds little to the diagnostic picture in women with category 1 (fatty) and category 2 (somewhat fatty) breasts, in whom screening mammography is 98% and 80%, respectively, effective in detecting breast tumors, it can nonetheless commute a death sentence in women with category 3 and 4 (dense) breasts. The latter have only a 50% chance of having their breast tumors detected on a mammogram before they become palpable on physical examination, and ultrasound excels at individuating these silent killers in dense breast tissue. It is not a panacea, however, and with the good comes the bad, and sometimes even the ugly. Ultrasound pinpoints abnormal breast findings 10% of the time that turn out to be benign, when subsequent breast biopsy is done. Not only that, but it is unavailable in many radiology centers and, at a miserly $87 dollars a pop for 20-30 minutes of work, few radiologists are ready, willing, and able to perform it. After all, time is money! Who knows that better than radiologists, who further state that the combination of magnetic resonance imaging (MRI) and mammography is almost twice as effective as ultrasound and mammography at detecting tumors in women with very high breast cancer risks. Those “roentgen masters” are just itching to employ MRI more widely, and being held back only by its $1,000 per test price tag. And when all is said and done, we save the ugly for last. Even were ultrasound to be employed on a large scale, there is no data as yet to tie improved tumor detection with ultrasound to a reduction in deaths from breast cancer. So, currently, an end justifies the means argument cannot be made.

Cancers come, and most often do not go. Until now, their early detection has been the name of the game to improve survival statistics. But what about those lazy, indolent tumors that are so slow-growing that early detection makes little difference, and similar, acceptable survival results can be achieved without a precipitous “jump on the horse,” expensive technology with little financial remuneration for its purveyors, and a rush to judgement? We must ask ourselves whether mammograms, ultrasound, and expensive MRIs influence the survival equation in a meaningful way, or whether cheaper, more patient friendly, and perhaps more delayed detection procedures and devices can achieve equivalent reduction of those fateful telephone calls, letters, and telegrams.

Vaccinator

2009-07-31T07:10:00.001-06:00

Fathers, protect your daughters from the onslaught of that perverter of all that is right, good, pure, and just, namely, the HPV vaccine! The call to arms has been sounded from belfries across the nation, to the despair of health care providers who witness another arm in their arsenal against cervical cancer cast to the wayside. The feeling of utter impotence on their parts is both frustrating and devastating, in the face of an ever-mounting body of data that appears to indicate the resounding efficacy of a vaccine that is a relentless adversary in the fight against cervical cancer, when it is unleashed in a timely fashion. Getting down to the brass tacks of the matter, perhaps you, the reader, will become convinced, and lend your daughters to the safe haven and caring hands of those who would stop a virus, the human papilloma virus (HPV), and its progression to something far more sinister dead in their tracks.

Cervical cancer is the second most frequent cancer among women, and it has been associated with HPV. The general public has not been adequately schooled on that score, and remains ignorant as to just how diffuse HPV infection is. The statistics are staggering, and go something like this. Twenty-five percent of persons between 14 and 19 years of age and 45% of those between 20 and 24 years are infected with genital HPV, with more than 80% of both men and women in the United States infected at some point in their lives. Surprised? Read on. HPV is usually acquired within months after the first sexual intercourse, and is usually asymptomatic. If the infection is not prevented, if screening with a Pap smear for precancerous lesions owed to HPV is not conducted due to health information shortfalls or a sense of physical impunity, or if treatment of HPV’s legitimate heirs, anogenital warts and cervical disease, is not instituted thoroughly and immediately, the death knoll will be sounded and direct medical costs stemming from HPV will add insult to fiscal injury. As it stands right now, each year 490,000 of this planet’s women receive a diagnosis of cervical cancer and 270,000 die from it. In 2008, 11,000 U.S. women received such sad tidings and 3,900 were as a result summoned by the Grim Reaper, at a cost of $4.0 billion in health care dollars. A good portion of these victims, and, if not them, future generations might be spared if reliance were to be placed on the “Vaccinator,” a full series of the HPV vaccine, costing $375 dollars and a whole lot less blood, sweat, and tears.

The hero of the moment, called the “Vaccinator,” for purposes of literary color and license, but commonly known as the HPV vaccine, has received a great deal of bad press, with the public continuing to be misinformed in many cases. So, the record must be set straight here, and then, perhaps, heads of households will be more inclined to offer their daughters on its preventive altar in exchange for a welcomed and precipitous reduction in the body count. The HPV vaccine has been marketed by Merck & Co., Inc. since June 2006 under the name Gardasil^®, and it is effective against the four high-risk types of HPV. Women between the ages of 9 and 26 years of age are targeted for vaccination in order to prevent genital warts and cervical, vulvar, and vaginal cancer. They should be vaccinated before their first sexual intercourse, because it is a sad, but true, “fact of life” that HPV infection is usually acquired within months after first sexual intercourse. While the vaccine is effective in immunocompromised women, the same cannot be said for pregnant women. A silver lining is the fact that women with cervical disease from one high-risk HPV type may be vaccinated against the other high-risk types. Gardasil is administered intramuscularly at 0, 2, and 6 months, and the vaccine series does not have to be restarted in its entirety if, girls being girls, a dose is missed. Let the buyer beware, however! Fainting spells may occur in adolescents immediately after vaccination. So, the rule of thumb is for the physician to observe the “vaccinee” for 15 minutes after vaccination. Wow, that was a lot of information! Exclusion of still another piece of stark reality could be construed as criminal, so it needs be said that abstinence from intercourse until marriage is no substitute for the HPV vaccine, as sexual abuse or an infected marriage partner make having been a “good girl” bad.

As the Vaccinator waits in the wings for the raging debate over whether to vaccinate preadolescents or not to play itself out, parents of young women should take no comfort in biding their time with a less is better mentality. Even with the jury out, some verdicts are forgone conclusions.

Temples to the Gods

2009-07-05T14:09:00.002-06:00

What’s a house call, you ask? For those of us old enough to remember, a cough, a fever, an upset stomach, a runny nose, a child’s pinworms, or any manner of body wake-up call left us concerned, but never troubled, for we knew that we could depend upon our trusted physician in white armor to ride to our doorstep on four-wheeled steed. Something has been lost in translation, however, as that friendly domestic cup of tea shared by doctor and patient has been transformed into a mad dash to the emergency room and a rush to judgment, as we chastise a past hero who now reminds us that time is money. So, are the healers of today, with all their bells and whistles, airs of superiority, and self-built clinical temples, better at their art and science than their good-old, bespectacled ancestors, who bore little black bags instead of handheld computers? Is technology mightier than compassion? Are robot-guided catheters and probes more efficacious in the long term than the touch and comfort of a healing hand? Can some suitable compromise be reached? Those and other questions need to be answered, before we embark on that expensive overhaul of the health care system we call universal health insurance.
Medicine has become a business, like many other noble endeavors, and its proprietors seek growing clienteles through self-promotion, whether that be media advertisement or construction of palatial offices and clinics that provide a semblance of professional success to new generations raised on material excess. After all, a doctor in rags, driving a jalopy, certainly does not project or warrant trust, in much the same way as a down and out real estate agent or practitioner of the bar. Furthermore, a “mine is bigger than yours” attitude drives a competition for numbers, both in terms of patients and consequent hard cash, as physicians vie for their piece of the American dream by drawing patients across their thresholds and then treating them with production-line efficiency. Damn feelings and close interpersonal contact, as terse replies to questions and directives to consult the nurse engender little satisfaction, growing hostility, and a sense of loss and abandonment in those seeking solace and perhaps even a cure from the men and women in white.
Those venerable statistics we like to quote have shown big-clinic medicine is a drain on pocketbooks, resulting in 60 percent of all bankruptcies in the United States in 2007 being owed to runaway health care costs. Seeing a different patient every 15 minutes does little to reel in costs or improve patient satisfaction. It is high time for a new paradigm, called “patient centered” practices, that incorporates both increased time with patients and an emphasis on prevention and education to keep them healthy, so that incessant and expensive referrals to specialists become a thing of the past. Not an easy task, you say. You’re absolutely right. To streamline procedures, processes, and administrative costs, with consequent reduction in the health care deficit, all eyes will once again have to turn to that often-touted cure all for everything costly, namely, technology, in the form of online appointment scheduling, electronic medical records, prescription of medications by computer, and virtual office visits by telephone and e-mail. As impersonal as it may seem, and as uncomfortable as we may feel about it, technology can, indeed, raise the bar of primary health care and even personalize it, when placed in the hands of practitioners in the trenches who are unafraid to try something new to safeguard a nation’s health on the verge of financial chaos.
Technology is not for everyone, however, and it will not solve all of this country’s health care issues. The high priests, keepers, and gods themselves in the temples warn that electronic patient records can be hacked, computer downtime can make patient records inaccessible for hours, small primary care clinics are not the answer for patients with multiple health issues, and small practices do not provide safe haven for practitioners who lack technical or business skills or who fear private fees versus salaries in these times of economic uncertainty. Reducing daily patient loads from 25 to 10-12, with longer patient appointments of 30 to 60 minutes, may not be the answer either, as primary care physicians watch impotently as their salary dollars undergo erosion. That, in part, is the reason why primary care remains the most unattractive field of medicine, with practitioner numbers dwindling due to the lowest compensation of any medical specialty. In 2008, the average annual salary of a primary care physician was $201,555, versus $356,166 for a general surgeon and $614,536 for a neurological surgeon. Poor babies! Lest they recall the hordes of unemployed currently walking the bread lines!
All this discussion points to a need for something to be done, and immediately. When general practitioners are scheduled to see 25 or more patients per day in large clinics or temples, whichever you prefer, sufficient time for thorough examinations, adequate discussions, and proper preventive care goes out the window, and the end result becomes the needless ordering of superfluous tests and unnecessary referrals to specialists, all at the expense of national health care ledgers that are rapidly approaching the bottom line. And heaven forbid that we discuss the unquantifiable toll on patients’ psyches of noisy and crowded waiting rooms, and the status quo, for lack of a better word, of getting in and out without wasting the doctor’s time with questions. Ignorance not being bliss in this case!
Is technology the answer? Perhaps not, in all cases. However, it can streamline processes and make small primary care practices financially viable in the current health care market, reducing their costs to half, from 60 percent of income down to 30 percent. That translates into better patient care, with physicians able to see fewer patients without sacrificing their almighty incomes. Tearing down the temples in favor of small storefront clinics with advanced technology may be a return to the future, and the name of the game. Perhaps little black bags can even be made big enough to hold laptop computers.

© 2009, Albert M. Balesh, M.D. All rights reserved.

Half-Hearted

2009-05-23T11:25:00.001-06:00

I have chosen an issue here very dear to me, and one that I will not address with my usually flippant writing style. As a physician, the pathophysiology of the heart has always interested me, and all the more so because my brother-in-law died of a massive heart attack a little over a year ago, at the ripe old age of 50 years. A lifetime of smoking was the major contributing risk factor to his demise. The short stick of smoking served no useful purpose than to exact a heavy toll on the heart and lungs of the guest of honor at a premature burial.
A patient’s insistence on smoking cigarettes is a behavior that can eventually lead to a forgone conclusion. Early exposure to what is called a well-conducted elicitation process, however, may avert that end. So, let me describe a tentative and prospective elicitation process that might have saved my brother-in-law’s life had it been implemented sooner.
Had my brother-in-law, who had smoked heavily for the last 30 years, been one of a small group of habitual smokers enrolled in an elicitation interview process, the positive (in his eyes) and negative attributes of smoking would certainly have been elicited from him, as well as a description of influential individuals in his life who would have either been for or against the importance of his behavior. A series of questions of the following nature, destined to elicit the positive or negative attributes of smoking, might have been asked of him. Does smoking make you feel and look more important? Does smoking relax your nerves and make you feel less anxious? Does smoking make coffee taste better in the morning? Does smoking help you to socialize and break the ice? Do you know that smoking is a major contributing risk factor to serious illness? Do you smoke to lose weight or curb your appetite? Have you ever tried to quit smoking? Is smoking an addictive habit or can you quit anytime? Is smoking expensive? Do you like the taste of tobacco?
The interrogation would not have ended there, either, as the social referents who might have influenced my brother-in-law’s decision to smoke would have been flushed out of the bush. Without pointing fingers, rekindling guilt, or eliciting an “I told you so,” those influential mouthpieces might have been my sister and his wife, who was a smoker also; I myself, who was vehemently opposed to smoking; my brother-in-law’s peers and football drinking buddies, who were known to “hoist and puff” a few; my brother-in-law’s personal physician, who knew that congenital heart disease and heart attacks ran in his family; my bother-in-law’s blue-collar coworkers, who fought boredom on the job via a convivial smoke; my brother-in-law’s favorite rock musician, who was both transgressive and a habitual smoker; and, finally, my mother, an ex-smoker, who frequently warned of the evils of smoking.
With my brother-in-law’s behavioral beliefs and subjective beliefs thus individuated, attention would have been turned next to control beliefs, or the environmental factors that might have made it easy or difficult for him to quit smoking. They were all too pervasive, and a direct frontal assault on the negative influences might have been warranted. To name a few of both the positives and negatives, they might have been listed as being surrounded by family and friends who smoke; radio, television, and newspaper antismoking campaigns; Hollywood movies portraying smoking as “cool;” and antismoking billboards, restaurant signs, and lighted written cues on airplanes.
My brother-in-law was nonetheless obstinate and hard-headed, and, while the elicitation interview and its discussion would have most certainly elicited some resistance in him, I cannot help but believe that in the long run, a significant amount of behavior modification would have occurred to open his eyes to the root causes of his smoking behavior and give him a fighting chance to live a long, productive life. As it was, he lived by the burning stick and died by the burning stick! His life was gone on February 1, 2008 in a puff of smoke, and, instead of cajoling the excesses of Memorial Day barbecues, I must shake my head and gaze at an empty place at the picnic table.

© 2009, Albert M. Balesh, M.D. All rights reserved.
In memoriam of Joseph Conway.

Hands Off Our Health!

2009-05-07T09:13:00.001-06:00

In this age of loss of personal freedoms and intrusions on our privacy by Uncle Sam, credit card companies, the IRS, law enforcement agencies, health insurance companies, banks, and the Internet, it is any wonder that looking over our shoulders has become as reflex as a knee jerk! Inherent in the U.S. Constitution and Bill of Rights, whether stated implicitly, explicitly, or even with duplicity, is the notion that we are free to choose how we live our lives and under what circumstances we wish to live our lives. For far too long now, big government and big business have teamed up, whether consciously or unconsciously, to gradually erode a long series of our basic and civil liberties. The right to adequate and guaranteed health care for all citizens, regardless of race, creed, national origin, or socioeconomic status (SES), however, must remain immutable and untouched. It is the cornerstone of any democracy, and a gauge by which we judge the health of a nation and its collective sanity. There is no debate on the principle of horizontal equity of health care, as any rational citizen of any country worth its weight in this world would most likely agree that “equal treatment for equal need” is a sine qua non, before any discussion of city, state, or federal implementation of health care policy can even begin. Once a decision has been made to incorporate all SES facets of a particular population in the discussion of, and under the umbrella of, a national health care policy, then free wills and open minds must prevail to determine the extent to which a community, a city, a state, or the federal government exercises control over the mental and physical destinies of its inhabitants. That is no easy matter, as private insurance companies and hospitals vie with local public and national authorities for precious health care dollars and the lucrative “baby boomer” and government welfare trades. Competition is intense in this market, and without some form of regulation and uniformity, whether it be local, state, or federal, there is the incessant danger that what one sees on paper will not be what one gets when receiving the “cold shower” resulting from close review of that first hospital or doctor’s bill after recovery. Furthermore, we, as a society, are not getting any younger, and it becomes more and more difficult to decipher the fine print and riders that have become standard fare in most health insurance statement of benefits. Not a day goes by without our parents, who for the most part are senior citizens, receiving some form of printed Medicare propaganda in the mail from nameless and faceless individuals, representing the ever-increasing cadre of private health insurance companies, hawking the pros of their companies while diminishing or excluding the cons. It never fails that such leaflets, fliers, letters, or brochures trigger a litany of questions from our elderly parents that, to be frank, we cannot answer. We would most likely need advanced degrees in law and health management to do so. Therefore, the question arises as to who guarantees the correct design, development, implementation, and communication of health care programs and health care policy. Is it the job of the city? The state? The federal government?
Developed nations like the U.S. and Switzerland have sought answers to these questions for quite some time now. With health care financed by a combination of private and supplementary insurance, out-of-pocket payments, taxes, donations, and city, state, and federal social programs, the “push and pull” for control of health care at all levels of society and governmental bureaucracy has become never-ending. Consumer-driven health care continues to reign in the U.S. and Switzerland, but those trends are destined to decline in favor of increased governmental control, as world economies “cool down” and immigration of the poor from underdeveloped nations to those more technologically and economically advanced increases exponentially. With government subsidies and tax revenues to finance hospitals outpacing local support, governments are demanding more and more “say” in how health resources are dispersed, what health resources are dispersed, and in what measure. While federal tax breaks for hospitals and institutions that strictly adhere to governmental mandates do not guarantee standard of care, they do extend a disproportionate degree of control over our lives to top-heavy agencies that may take financial bottom lines more to heart than social equity and welfare. So, we do have a dilemma here, and we are hard pressed to render unbiased, objective opinions on the matter. What we can say, however, with a certain amount of certitude, is that without U.S. government intervention, programs like Medicare, Medicaid, SCHIP, WIC, and Social Security would be “dead in the water.” Nonetheless, the efficiency of those programs in the long term remains in doubt, especially in the current economic climate. Also, while government may, indeed, control the purse strings, tailored community approaches to health care may be more efficient (both financially and logistically) to address specific local needs, and to develop and implement specific local interventions.
Hands off our health! Then, again, we’re not ticklish.

© 2009, Albert M. Balesh, M.D. All rights reserved.

Lions and Tigers and Bears, Oh My!

2009-05-05T19:46:00.001-06:00

“The sky is falling, the sky is falling!” How many times have we heard that doomsday cry of apocalypse? We are now using a similar tone to address sexually transmitted diseases (STDs) or sexually transmitted infections (STIs) in teenagers, whichever term you prefer. Trust, solidarity, cohesion, inclusion, and social capital are currently the weapons in the preventive armament against those maladies that are increasing in both incidence and prevalence at alarming rates in the adolescent population. Now, while education and confidentiality are of paramount importance in stemming the tide of uninformed, free sexuality, there are numerous issues involved here, all of which form part of an intricate puzzle. Intervening in only some of those pieces will effect minor change, at best. Unless all facets of the big picture, from peer pressure and safe sex practices to HPV vaccines and parental detachment, are scrutinized and addressed, no long-term, consistent policy will be formulated, and disparities will continue to exist between the rich and poor, affluent suburbia and urban inner city. Experts contend that education is the single most important concept to look at. However, who is ultimately responsible for the sexual education of teens? The schools? Parents? Local public health officials? The federal government? The states? Experience teaches us that education is but a “drop in the bucket,” in many cases.
The relationship between teenagers and their parents has come to the fore recently, as single working mothers and two-parent breadwinner households continue to grow. Parents can no longer take the time to “school” their teens in sex education and safe sex practices when they are more concerned with the day-to-day dilemma of making ends meet and putting food on the table. This situation is destined to deteriorate even further, as the U.S. economy continues to cool down. Furthermore, with cuts in education and public school systems throughout the U.S., parents who think the schools are competent surrogate instruction platforms for their own failings at sexual education of their teens are in for a grim awakening. Welfare rolls are also stagnant, as government resources are limited, and cost cutting has threatened programs such as WIC, SCHIP, and Leave No Child Behind. If that were not enough, while federal, state, and local public health officials continue to sing the praises of safe sex and condom use in television spots, those sound bites compete with the “machismo” and “party like a rock star” mentality of the numerous beer advertisements plastered all over billboards, popular magazine pages, and cathode-ray tubes in our homes. It has become romantic to hoist a beer and take a damsel. You’re a wimp if you stay at home, listen to your parents, dress conservatively, and don’t succumb to peer pressure.
Transportation is another issue. Even if teens are willing and able to seek professional care, they are often “paralyzed” by an inability to reach the resources they so desperately need. In surveys taken among teens and young mothers for the reasons why they have sought prenatal care so late in their pregnancies, transportation difficulties have been found to be in first or second place consistently. That means that prenatal vitamins like folic acid are, indeed, being prescribed when it may already be too late to prevent neural birth defects in their developing fetuses.
Confidentiality is also an exceedingly large issue. Young women and teenagers are often adamant about the fact that they do not want either their parents or their significant others to know they are “victims” of an unwanted pregnancy. Those are just the young women who come forward to be seen and heard, too! It has been estimated that there are many more who decline prenatal care and family planning, to remain in the shadows, only because their fear of parental and social repercussions are enormous. With the spread of HIV/AIDS also slowly but surely dropping off the radar screens of urgent public awareness, young teens are additionally being exposed in record numbers to another “can of worms” that will eventually weigh heavily on a U.S. health care system that may already be crippled financially beyond repair.
So, we have a major conundrum here on our hands, and earth-shattering answers to the questions raised are certainly not immediately forthcoming. The social capital that binds us as people and communities, and enables us to take cooperative action through trust, mutual understanding, and shared values and behaviors, has broken down and not been adequately handed down to our future generation of political, social, moral, and scientific leaders. Furthermore, social capital has taken a backseat to the more pressing issues of financial capital and economic degradation, as provision of food and shelter to our young precludes sex education in the quest for survival hierarchy.
Perhaps we need to start looking beyond “lions, tigers, bears, and bulls.”

© 2009, Albert M. Balesh, M.D. All rights reserved.

Making the Grade

2009-04-19T13:27:00.000-06:00

For those of us who are baby-boomers and old enough to remember, taking a bad report card home engendered a great deal of fear and trepidation, during what seemed an endless walk or school bus ride home. Perhaps that is the way hospital CEOs currently look at the issue of transparency and public disclosure, as they closely guard their respective institutions’ financial and clinical secrets, and damn or withhold any revelation destined to transform stockholders into what amounts to angry parents.
Healthcare consumers, the U.S. federal government, and third-party payers, however, demand the highest standard of care from our nation’s hospitals, as well as reliable performance measures to assure quality. Furthermore, such measures must be applicable to all hospitals, whether they reside in the high-tier or low-tier category. There is much evidence to support the contention that hospital report cards, based on objective performance measures, improve the overall healthcare of patients.
The Hospital Quality Alliance (HQA), based on provisions in the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 and instituted by the U.S. Department of Health and Human Services (HHS), was, indeed, initiated precisely to that end. By collecting data on key measures of hospitals’ management and quality of care (for example, the care provided, the resources consumed, the total costs of care, and the resulting outcomes), the HQA can tabulate report cards to motivate change and hopefully improve overall patient healthcare. Also, the recently proposed Deficit Reduction Act (DRA) of 2005, by instituting financial incentives to entice our nation’s hospitals to “make the grade” by adhering to established measures of performance, and expanding them when necessary, serves as an additional built-in safeguard to our nation’s health.
High performance scores on HQA performance indicators have been associated with up to 15 percent reductions in the odds of death for common clinical conditions such as acute myocardial infarction, congestive heart failure, and pneumonia. So, the initial results are in, and perhaps only a bit of tweaking and several more performance indicators are required before hospital report cards become a diffuse functioning reality.
Who would have ever thought that the long bus ride home would be good for one’s health!

Trojan Horse: What Lies within a Hospital's Report Card could Spell Trouble

2009-04-12T19:39:00.002-06:00

No one likes examinations, let alone report cards, but the stakes are just too high to let our nation’s hospitals continue with business as usual, with no form of grading system in place to hold them accountable. U.S. public health agencies and the federal government must retain the right to impose guidelines, parameters, or benchmarks, whatever one wishes to call them, on hospitals in order to ensure a standard of care that lowers in-hospital mortality rates and guarantees citizens (and illegal immigrants, too) the same level of care, whether they are admitted to high-tier or low-tier hospitals. The petty bickering of hospital CEOs must be put aside, and objective transparency must win the day, both in terms of financial ledgers and healthcare morbidity and mortality data. Without an objective set of rules and regulations to go by, if you will, and grades (based on accurate scientific data) to indicate performance and compliance, measurement of our nation’s hospitals’ standard of care and delivery will be based on quackery, hearsay, sensationalism, and the subjective. That is exactly what is occurring at this precise moment. But, wait just one minute! Perhaps we are being a bit too hasty here. Human nature being what it is, perhaps we will never truly reach our goal of objective measurement of hospital quality of care. Perhaps a hospital’s closely guarded secrets, whether they be financial or clinical, run countercurrent to the dictates of hospital quality assurance, and must, indeed, remain in the private domain. Perhaps our energies should be directed at what is realistic and what we can actually do, and that is develop subjective criteria that parallel and confirm the results of objective measurement of hospital performance.
The latter, in fact, is just what has occurred. As consumers, the U.S. federal government, and third-party payers continue to not only demand the highest standard of care in our nation’s hospitals, but also reliable and valid performance measures to guarantee that standard, the subjective perceptions of hospital executives have been compared to objective criteria used. Lo and behold, what has come to light is surprising, and that is that subjective perceptions of hospital CEOs on the organizational performance of their institutions, with particular attention being paid to subjective perceptions of financial measures such as return on total assets (ROA) and operating margin, correlate strongly with how those institutions actually perform. So, perhaps there is, indeed, some room, after all, for the subjective in the accurate assessment of a hospital’s performance and standard of care.
But that can’t be it in a nutshell, and we cannot rely solely on the subjective. We must look closer, for a cursory, subjective look at our nation’s healthcare system and its protective arsenal of hospitals is tantamount to a Trojan stamp of approval, with subsequent dire consequences when what lurks within translates into the higher mortality rates seen only by those with specialized training to view the writing on the wall. Hospital quality assurance must be based on a standardized set of objective criteria or measures, applicable to all hospitals. A step in the right direction has been the Hospital Quality Alliance (HQA), based on provisions in the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 and instituted by the U.S. Department of Health and Human Services (HHS), which has collected and continues to collect data on key measures of hospitals’ management. Not only that, but the recently proposed Deficit Reduction Act (DRA) of 2005 has also added extra “punch,” and provided the financial incentives for our nation’s hospitals to adhere to established measures of performance, to report compliance with those measures to the HHS, and to expand those measures when the HHS Secretary deems it necessary, to safeguard the nation’s health.
To date, the HQA has developed ten performance indicators for three of the most common maladies seen in a general hospital environment, namely acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Without going into specific details, summary scores, i.e., performance scores, were calculated per each of 3,720 U.S hospitals surveyed by the HQA on the basis of the sum total of the results reported for each of the ten performance indicators. It was found that high performance scores on the ten HQA performance indicators was associated with a 7-15 percent reduction in the odds of death for each of the three clinical conditions listed above. So, higher performance on the HQA objective indicators correlated nicely with lower hospital mortality rates for the three clinical conditions.
Perhaps there is hope, after all, that hospital mortality rates can be lowered without the divulging of “trade secrets” by hospital CEOs. If that is the case, then there is little need to expose what lies within a hospital’s “Trojan horse.”

© 2009, Albert M. Balesh, M.D. All rights reserved.

Making the Grade

2009-03-15T12:32:00.007-06:00

Return of the Scarlet Letter

2009-03-15T12:32:00.005-06:00

Nathaniel Hawthorne is alive and well, and currently residing in the State of South Dakota, where his “Scarlet Letter,” “A,” now represents abortion, not adultery. In July 2008, under the laws of South Dakota, physicians there were henceforth required to tell prospective candidates that abortion is the termination of a living human being’s life, to give women a description of the risks of abortion, to provide them with the age and state of development of the fetus, to answer all women’s abortion questions in writing, and to certify in writing that the women mentioned received and understood all the above information. Failure on the physicians’ parts to comply with the statute might result in medical license suspension or revocation, as well as the possibility of being charged with a class 2 misdemeanor. The South Dakota law had been heretofore suspended by a federal injunction, successfully sought by Planned Parenthood, that was lifted on June 27, 2008 (Planned Parenthood Minnesota v. Rounds). That, and the recent U.S. Supreme Court case of Gonzales v. Carhart in 2007, in which it was noted that some women had come to regret their choice of abortion, and might not have chosen abortion, had they been better informed, paved the way for the implementation of the South Dakota abortion law, with its contained informed-consent requirements.
The South Dakota statute, however, will have repercussions far beyond its state borders, as it rallies dormant state legislatures to continue where they left off, enacting laws and seeking legal means to restrict abortions, in the wake of a series of Planned Parenthood setbacks. Physicians, patients, and believers in the sanctity of the physician-patient relationship should, indeed, be worried. The posture taken by South Dakota violates physicians’ First Amendment rights, not only by forcing them to be the couriers of the state’s anti-abortion message, but also by making them part of that message, via a certification process that, in essence, relegates them to the position of guarantors of their patients comprehension of the state’s law. Some legal scholars have gone so far as to conclude that the South Dakota abortion law, and similar legislation drafted by other states, employ “informed consent” as a means to eliminate abortions.
Were that not enough, the controversy surrounding the South Dakota statute has led to some hard questions regarding violation of the constitutional rights of the aborted fetus, punishment of women who do so, and prosecution of physicians “unable” to explain the multivariegated codicils of the statute. Furthermore, some of the scientific information contained in the South Dakota abortion law is inaccurate, at best, and has not been confirmed by the medical literature in regard. To force physicians to dispense such information, without allowing them enough “wiggle room” to provide alternative, more accurate, or perhaps even contradictory scientific material on abortion to their patients is to violate the Hippocratic oath, informed consent, and the physician-patient relationship.
The subject is complex and emotional, and no resolution will be forthcoming soon. Pro-choice, however, is walking a proverbial tightrope, with no safety net below, and its proponents might as well wear large “Scarlet A’s” on their chests, for their redemption is not at hand.

"I'm so Hungry, I'm Fat!"

2009-03-14T12:04:00.001-06:00

Food insecurity, or “the unlimited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire foods in socially acceptable ways,” is the exclusive domain of the poor, and it affects 12.6 million U.S. households, with obvious repercussions on young and old alike. It is a “no-brainer” to deduce that hunger, or “a prolonged, involuntary lack of food, that results in discomfort, illness, weakness, or pain that goes beyond the usual uneasy sensation,” is an obvious consequence of food insecurity. And if that were not all, food insecurity and food insufficiency have been found to contribute to increasing incidences of psychosocial and cognitive difficulties, suicidal symptoms, and depressive disorders.
So, we are left with the dilemma of not only how to feed the poor, but of how to provide them with healthy foods that reverse the startling trend toward obesity in that population, and in the greater part of the U.S. middle and upper classes, for that matter. The latter two facets of the U.S. population, however, are not burdened by the heavy anchor of food procurement around their necks. The socially and economically indigent must employ a series of strategies to obtain food, any food, and those procurement methods run the gamut from the legal to the illegal, namely, food stamps, WIC program, shoplifting, selling food stamps, using coupons, pawning personal items, selling plasma, scavenging from dumpsters, and asking friends and strangers for food. We must ask the question, therefore, of how it is possible for the poor, with all the hardship inherent in their individuation, purchase, and procurement of food, to become obese? In fact, studies have shown that the highest obesity rates occur in poor communities, that food-insufficient older females have a higher risk of being overweight than food-sufficient females, and that high body mass indices (BMI) are common among low-income adults and youth. How do we account for this counterintuitive hunger-obesity paradigm? Why do we see such numerous examples every single day of stereotyped, racially profiled individuals (known by deprecatory terms such as “white trash,” “trailer trash,” “beaners,” “niggers,” and a slew of others), of lower socioeconomic status (SES), who give credence to the saying, “I’m so hungry, I’m fat?” There appears to be a disconnect. How can hunger possibly be associated with obesity? While the question is intriguing, the answer is not so exotic. Increased portion sizes, diets based on fast food, and food insecurity, or the memory of it, are strong inducements to the indigent and socially emarginated to overeat tasty food, or any food, for that matter, when it becomes available.
The question of whether or not to tax high-fat foods, in order to make healthier foods, the fruits and vegetables, more attractive to limited pocketbooks, is a controversial one. While the issue is difficult to address, and leaving questions of civil liberties aside, there are some of us who feel that the taxing of unhealthy foods might place undue hardship on indigent, obese populations (of low SES) already hit hard by a failing U.S. economy and financial hard times. In that light, it might not be a realistic road to follow. On the other hand, although increased taxing of high-fat foods might, in the short term, pose financial hardship for the indigent and trigger subsequent increased government spending to sustain nutritional programs and financial solvency for them, in the long haul increased spending might be more than compensated for by the savings incurred by U.S. taxpayers as a whole consequent to the reduced incidence and prevalence of psychosocial, cognitive, depressive, and suicidal symptoms and disorders tied to food insecurity and hunger in the poor.
While questions abound and results may not be immediately forthcoming in this extremely important issue, there is no doubt that intervention at the societal and community level must begin in childhood, possibly through the school system, as a history of food insecurity in the young has a way of “snowballing” into obesity in adults.

Primum Non Nocere, Secundum Treat Patients Not Diseases

2009-03-13T22:21:00.002-06:00

There is a battle raging behind the scenes over how to address the shortage of primary care physicians in the current climate of diminishing revenues, increased patient loads, and lack of universal health care coverage. Enticing recent graduates of U.S. medical schools to enter the field of primary care has become an exercise in futility, as the amount of student loan debt accrued by newly trained physicians warrants entrance into more lucrative fields of specialization, such as those which are procedure-oriented and provide substantial reimbursement for instrumental and invasive therapies. While primary care is, indeed, a rewarding arena of endeavor, the current number of board certified primary care practitioners is hardly sufficient to buttress even the “tip of the iceberg,” which is beginning to topple, as older physicians leave the field for retirement and other pursuits, and as the few remaining go home on a nightly basis worried to death that they’ve made mistakes or not completed their work. If that were not enough, the increasing amount of paperwork inherent in the profession, the growing number of therapeutic options and new drugs available, and the added responsibility of providing continuous preventive care to patients whose socioeconomic backgrounds often pose additional limitations to an already complex patient management scenario often render job satisfaction a non sequitur. And for those of you out there who say that, “It’s all about the Benjamins” (Franklins, that is, and money, in short), there is much more to this story than financial remuneration. It has been found, for example, that when payments to primary care physicians are increased, they work no harder, and, in fact, reduce the number of patients they see. So, perhaps there are things more influential than money as motivators to primary care physicians to do a better job, and to neophyte physicians to enter the field of primary care. They might be, namely, a sane life, more leisure time, and the value of a job well done. For those who have truly dedicated their lives to the study and practice of medicine, no price tag can be placed on the latter.
We know the problem. Where does it all fit in the public health arena, and what can we, the public, policymakers, legislators, medical school faculty, state medical boards, and the Department of Health and Human Services do to increase the allure of primary care medicine, or to “conscript” new physicians into the ranks, perhaps in exchange for student loan debt forgiveness or other inducements? What we already know is this, that the current U.S. health care system is chaotic and in utter disarray, and that unless we, both the public health and clinical professionals “in the trenches,” come up with suitable and workable solutions to the primary care shortfall, provision of first-line health care is destined to worsen.
Solutions have not been immediately forthcoming, and the call to arms has been hampered by the sheer enormity of the undertaking and statistics showing that, in many cases, patients are cut off and interrupted by their physicians due to time concerns after an average of only 23 seconds of explaining their problems, that 50 percent of patients leave office visits not understanding what the physician has told them, and that it would take 18 hours per typical workday for primary care physicians to provide all the preventive and chronic cares services needed by their patients. Recently, two solutions have come to the fore, and perhaps it would be wise to look at them closely. One idea proposed has been to reduce daily patient load for primary care physicians to 10 patients per day. That would allow them more time per patient, but would most likely aggravate the already acute shortage of primary care physicians. The second solution, which appears more sage, would be to adopt a team approach to primary care. As a medical degree is not needed to perform all the daily tasks of a primary care physician, the latter might be delegated to ancillary staff. Physicians would become team leaders, seeing fewer patients per day, consulting with team members, handling telephone and electronic encounters requiring a physician, and ordering medication changes. All other duties currently managed by primary care physicians would be transferred to “health coaches” on the team, and their tasks would run the gamut from contacting patients and explaining changes made by the physician to their treatment regimens to listening to patients’ concerns and following up on patient compliance to treatment plans.
The solutions mentioned here are in their experimental stages, and nothing is written in stone. However, without serious attention turned to the monumental problem of primary care, the numbers of those physicians will most likely continue to dwindle, with obvious repercussions on the concern for hurt (nocere) inflicted on patients and with the little physician involvement available for patient care directed at numbers and diseases, not at living, breathing human beings and the plethora of interactive elements composing their well being as a whole.

Not Your Mother's Common Cold

2008-11-11T10:06:00.000-07:00

In an ideal world, big business would have a heart, and bottom lines and profit margins would play backseat to the overall good of community and fellow man. A reality check convinces us of the entirely opposite, and nowhere is this more true than in the for-profit pharmaceutical industry, where marketing of popular cholesterol-lowering, antidepressant, heartburn, or erectile dysfunction medications can net thousands of dollars per year of treatment. So, it’s no wonder that tropical diseases in poor nations of the world are unarmed Davids on a field of pharmaceutical Goliaths. Infectious diseases like tuberculosis, malaria, trypanosomiasis, leishmaniosis, and schistosomiasis, which are as bad as they sound, are of little or no priority on a pharmaceutical company’s agenda, as any gains made in the expensive research and development arena to come up with new and efficacious medications to combat them, cannot be offset by sales receipts from the resource-poor, healthcare-deprived, developing nations that stand to benefit most from the new drugs. Therefore, it comes as no surprise that of the 1,393 new pharmaceuticals developed between 1975 and 1999, only 16 specifically targeted diseases endemic to tropical and/or underdeveloped areas.
The problem is clear. Now, what has the U.S., as moral champion and outspoken political leader of the free world, done to lead by example, in this area of grave international calamity, that risks even greater repercussions for peaceful and warlike nations alike, due to the looming threat of bioterrorism? The Food and Drug Administration (FDA) took the lead in September 2008, by implementing its Amendments Act of 2007, which called for the issuing of “vouchers,” to accelerate FDA regulatory review of new, prospectively lucrative drugs, to those pharmaceutical companies also willing to develop new drugs targeting tropical and/or infectious diseases, on a “1-for-1,” “tit-for-tat” basis. A policy of that nature is in keeping with current social, economic, political, and public health trends to rely on financial incentives to achieve socially desirable outcomes. A policy of that nature, while developed with the best of intentions on the part of the FDA, neither guarantees that pharmaceutical companies will, indeed, implement research and development on drugs destined for geographically isolated and impoverished nations, nor lacks the “teeth” necessary to force distribution of those drugs once they have been developed.
Critics of review vouchers abound, and their arguments against the employment of such incentives run the gamut from uncertainty that a drug company will have a potentially profitable medication in its research and development pipeline to make a voucher worthwhile to the fact that traditionally it has been small drug companies that develop and distribute medications for neglected diseases, and it is precisely those small companies that usually do not develop “blockbuster” drugs that make the voucher system lucrative and attractive. Furthermore, were the latter to be the case, collusion between large and small pharmaceutical companies might lead to “deals” of dubious transparency, with vouchers and voucher rights being sold (which is legal) to the highest bidder, and patent and intellectual property rights dictating restraint in sales of needed pharmaceuticals to nations ill-equipped financially to afford them. “Cash and carry” is the name of the game, and countries financially “strapped” would be left to fend for themselves, and face possible epidemics of infectious disease with underdeveloped health care systems lacking the latest pharmaceutical formulations in those regards. Were that not enough, speedy FDA review, via vouchers, of new drugs might just be bad policy, leading to poor decision-making, consideration of drugs with very little or no clinical urgency or practicality, and inadequate consideration, testing, and clinical trials in order to rush to market. We might, in effect, be opening a veritable Pandora’s Box of not only disease, but also of its treatment.
To guard against this, and to place critical pharmaceuticals in the hands, minds, and bodies of those who most need them, a revamping or perhaps a complete revision of the voucher system from the ground up might be necessary. One proposal has been to set up independent health funds, financed by wealthier nations and overseen by international public health groups, to compensate drug companies for development of medications against ills far greater than “your mother’s common cold” in poorer nations, and then continue to reward those companies for appropriate implementation of successful treatment programs. Another idea might be for governments to work with nonprofit organizations to first develop new drugs, and then license them to pharmaceutical companies for production, distribution, and eventual earnings.
While convinced that patents and intellectual property are the “stuff” of capitalism, we must also admit that such models are neither sound nor efficacious when the lives of the poor and destitute hang in the balance. A voucher system, conceived of with the best of intentions, nonetheless places a price on that, namely human life, which we have been taught has none. Perhaps it is the job of public health to open eyes and close pocketbooks.

© 2008, Albert M. Balesh, M.D. All rights reserved.

Mental Hell-th

2008-11-10T15:48:00.001-07:00

Hell on earth does, indeed, exist. Just ask products of a system that deinstitutionalized, with the best of intentions, the mentally ill back in the 1960s, in order to provide what was thought to be better care in the community, rather than in state-run asylums with the horrors they engendered in the minds of those who oversaw them in previous decades. The movement toward treatment of the mentally ill in the community was further buttressed by Academy Award-winning films, like One Flew Over the Cuckoo’s Nest, in the 1970s. The cycle has now become vicious today, however, and it begins with mental health agencies, child protective services, special education, juvenile justice, residential treatment centers, therapy sessions, psychological evaluations, medication management, psychiatric hospitalizations, and a plethora of other mental health services in youth, and proceeds through a repetitive waxing and waning of criminal activities and incarcerations. It appears that the mentally ill, from “modest beginnings” in their youth, are destined to reach the “big show” in our nation’s state prisons and local jails, if something is not done to create alternative mental health facilities and institutions. The numbers are staggering. More than half of all prison and jail inmates have a mental health problem of some kind, with the prevalence of mental disorders in the criminal justice system outstripping its rate in the general population by three times. To make matters worse, as many as 40 percent of people in the U.S. with mental illnesses are not receiving treatment, which “fast-tracks” them into lives of crime and eventual incarceration in state and local criminal justice facilities, where only about one-third of them will receive adequate mental health treatment. The bottom line: inmates with mental health issues released into the public domain with few “people skills,” with the inability to live self-sufficiently, and with overriding mental health deficiencies ranging from schizophrenia and bipolar disorder, to depression and acute psychosis from drug abuse, will most likely fall victim to recidivism and land once again in detention facilities, due to an utter lack of innate structure and responsibility that would enable them to live freely in society.
So, we must pose the question of why the U.S. criminal justice system has become what state mental institutions of yore once were? Obviously, when the latter facilities were closed, the “slack” had to be picked up somewhere by someone. It had never dawned on the public, our state legislatures and federal government, and communities across the nation that many “criminal” offenders, who, in reality, were victims of unrecognized or perhaps even ignored acute and/or chronic mental illnesses, would repeatedly recycle through state prison or local jail systems, draining precious dollars from state and federal coffers already stretched thin. Police officers in communities across the nation had not been trained adequately to recognize mental illness, district courts had remained nearsighted and continued to sentence offenders with mental illnesses to jails instead of treatment services, mental health courts had not existed to date, government had failed its responsibility to help the weakest links in our population chain and those who could not help themselves, funding for mental health services had continued to remain scarce, and community corrections and mental health providers had failed to collaborate with one another. All that has changed now, as mental health services, even now in times of financial shortfalls, contribute to re-entry of offenders from prison back into the community, via a series of evidence-based practices and programs.
While criminal recidivism and repeat incarceration have been reduced and continue to show signs of slow, progressive decline, the picture is not completely rosy. Money, as always, is the name of the game, and, while treatment of mental disorders constitutes greater than 6 percent of all health care spending, public health care financing for treatment and prevention of mental illnesses and for housing, employment, and other community services available to ex-incarceration populations falls substantially short of the ideal, or even the minimally adequate.
As states like New Mexico and Oregon vie for new, innovative approaches to financing community and mental health services, such as mental health call centers, transitional housing of freed offenders until gainful employment can be found, law enforcement street supervision programs, and mental health services in the jails themselves, the gap between mental health services and the criminal justice system continues to widen, although to a lesser degree than in the past.
While the descent into “mental hell-th” has been temporarily halted for many misdiagnosed “criminals,” without further availability of state and federal funding to mental health treatment and rehabilitative services, a further fall from grace and transformation of the sick role into hardened criminality is envisioned.

© 2008, Albert M. Balesh, M.D. All rights reserved.

Healthcare Reform Fit for Donkeys and Elephants

2008-11-09T15:27:00.001-07:00

Whether you are a donkey (Democrat), an elephant (Republican), or something in-between, we all stand to lose in this election year if we blindly follow the lead of U.S. presidential candidates who would convince us that universal health insurance for all is affordable, easily accomplished, and without risk of paralysis of an already fragile healthcare infrastructure, as well as embark on something far more sinister, the financial collapse of a government stretched to limits untested in the past. We go to the polls on November 4, 2008, and, exercising the trite for the sake of the message, never have the stakes of our nation’s health been so high. Both presidential candidates, Sen. John McCain and Sen. Barack Obama, would have us believe that their respective health insurance “fix-its” would extend coverage to our 46 million uninsured and guarantee continued “smooth-sailing” for the three-fifths of us who rely on employer-sponsored health insurance to stem tides ranging from the common cold to brain tumors. Unfortunately, reading between the lines and a closer look at their proposals leave us with either a bad taste in our mouths or holes in our pockets. So, with the limited space available here, let’s dissect the McCain and Obama plans, and leave a clearer field than does the college biology student who disembowels his or her first fetal pig.
Barack Obama’s vision for health insurance would cover the legions of uninsured, maintain a certain status quo of employer-sponsored health insurance, reduce waste by increasing the efficiency of healthcare delivery, and put a health insurance savings of $2,500 in the pockets of beleaguered U.S. families. Sounds good, right? What could possibly be wrong with a plan that calls for a “play-or-pay” policy that rewards employers who contribute substantially to the cost of their employees’ health plans and penalizes, via taxation, those who do not? Is their any argument to a voice that calls for a national health plan, with benefits comparable to those enjoyed by members of Congress, with premium rates equitable for all, and without prejudice for preexisting health conditions? The popularity of such a plan among America’s financially hard-pressed is obvious, until the price tag is examined closely. Sen. Obama’s adherence to a policy that slows spending growth and provides affordable healthcare to America’s masses, including the poor and the dwindling middle class, bridges the healthcare divide. Yet, in an atmosphere of projected increasing healthcare costs and diminished employment-based health insurance, the biggest losers stand to be those who have the most to gain, as they will most assuredly be the parties targeted to finance the pipedream of the “donkey.”
If that were not bad enough, John McCain presents an altogether diametrically opposed vision and solution to America’s health insurance crisis, that has us begging for more (as we are tempted by the specter of lower taxes), as we are violently thrown over the table. Sen. McCain’s plan would decapitate employer-sponsored health insurance, increase reckless and unrestrained competition in the individual health insurance market, and do nothing to lower the numbers of our nation’s uninsured and lessen the toll they take on the national safety net system. The McCain plan is no less a pipedream than that of Sen. Obama, with the former resurrecting obsolete ideas of tax credits for individuals and families that don’t keep pace with the raising costs of premiums, association health plans (AHPs) that operate on behalf of their membership, only to “cherry-pick” and exclude the unhealthy, free-market insurance that would undermine care for the chronically ill, which is notoriously expensive, and, finally, greater reliance on state high-risk pools, which vary enormously from state to state in the amount of funding they make available to the sickest of all Americans. So, as the old proverb goes, while the “elephant never forgets,” it certainly does not dote on creatures smaller (or considered lesser) than itself.
Whether we choose the “blank check” of the donkey or the egotistical capitalism of the “larger-than-life” elephant, we must recognize that symbols do not do justice to the “animals” they represent. When men behave as animals, and work ceaselessly for the benefit of a chosen few or of small-interest groups instead of the greater good, then all of us and all of society suffers, and public health per se takes two giant steps back.

Healthcare Reform Fit for Donkeys and Elephants

2008-11-09T15:21:00.001-07:00

Emerging Emergency

2008-11-08T14:02:00.006-07:00

Instead of just owning up to our responsibilities, and demonstrating a touch of compassion for our fellow man, we, as Americans, choose instead to skirt the issue of health care for our nation’s uninsured, and implement half-way measures that give progressive momentum to an already snowballing effect. Now, it’s the turn of U.S. emergency departments (EDs) to shoulder the burden, the debt, and, if unsuccessful, the blame for the lack of primary care afforded to our legions of U.S. citizens, resident aliens, and even “illegals.” We are told that EDs are the only U.S. health care entities federally vested and mandated by law, specifically the Emergency Medical Treatment and Labor Act (EMTALA) of 1986, to screen and stabilize all who seek emergency medical care. Coverage of emergency health services by EDs cannot be denied to anyone in the U.S., and, yet, EDs currently find themselves strapped with an entire series of logistic and financial limitations that render delivery of such coverage tenuous, at best. The over-one million ED visits per year, coupled with hospital closures, in-patient downsizing, the elimination of some EDs by mergers and closures, an aging population, the increasing prevalence of complex medical problems, and the lack of qualified emergency physicians and nurses makes ED crowding the status quo and a quotidian reminder of the failure of the core safety net system, as conceived of and implemented today. If that were not enough, ED crowding is the catalyst for a cascade of subsequent adverse repercussions on ED infrastructure and patient treatment, ranging from compromised quality of care, shorter patient-practitioner interaction, lengthy waiting times, and high stress levels to ambulance diversion, ambulance gridlock, “boarding” (with EDs forced to hold patients for hours), and disaster unpreparedness.
So, with the previously well-oiled gears of the ED machinery nearly grinding to a halt in the current U.S. health care climate, with its greater than 42 million uninsured residents, we are left with the dilemma of what would be required to return EDs to their position of preeminence as vital, and perhaps even cost-effective, elements of the core safety net system. That, however, might be the wrong tack to take, and perhaps the question should be one of whether EDs should play any role at all in primary care of the uninsured and the socially and financially indigent. Perhaps some form of universal health insurance should be mandated to pick up the slack and eventually bear the entire brunt of health care coverage for U.S. citizens and legal residents, whether they be rich, poor, privately or publicly insured, or not. Universal health insurance might be the only truly socially equitable option available, but at what cost to U.S. taxpayers, in what timeframe for implementation, and weighed down with what concessions to the political, industrial, pharmaceutical, social, and other lobbying powers that be?
The so-called experts have been tossing around the idea of universal health insurance for years now, with no luck at consolidating a consensus on what a workable form of such insurance might entail. While no clear trail is currently being blazed, it has become evident that EDs, for their part, are expensive, unable to connect with the community and social resources, and perhaps ill-equipped to deal with chronic management on a large scale. They should not be counted out, however. EDs, or portions of them, might be restructured into 24-h walk-in primary care centers, “social triage” centers, and entry points for later channeling into other branches and components of a community safety network. In that light, they may be “down,” due to their high cost of care, but they are certainly not “out” for the count, and may actually become cost-effective in the framework of a primary care network that would employ them as a triage and starting point that would pass off patients with chronic management issues to a primary care focal point facility, thus alleviating or draining some of the overcrowding inherent in EDs, and contributing “new blood” to a primary health care system in dire need of additional manpower and facilities.
Who knows? With a little well-directed help from EDs, the emerging emergency might even submerge!

Statin Island?

2008-11-06T02:57:00.001-07:00

No, that was not a misspelling, but a reference to the isolation and island mentality felt by many parents, as proclamations from on-high come down from the mount to tell us how to raise our children, and what is good for them. At one time, we thought we were the best judges of our own flesh and blood, and, now, organizations like the American Academy of Pediatrics (AAP) have usurped that God-given role. What are we talking about here? Hypercholesterolemia, or high blood cholesterol, in children. Why is this such a big deal? Because the AAP is now advocating pharmacologic treatment of high cholesterol in children, in order to head-off and reduce the risk of cardiovascular disease later in life. First it was Ritalin in children with Attention Deficit Hyperactivity Disorder (ADHD), then it was untested childhood vaccinations to interdict a legion of infectious diseases, and now it is even more and earlier pharmacologic therapy with drugs commonly known in layman’s jargon as statins, and more technically, as 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG-CoA) reductase inhibitors. The latter intervene to block a crucial step in the synthesis of cholesterol in the liver. While they have been shown to be safe, and their side effects reasonable in adults (namely, muscle pain and an elevation of liver enzymes known as serum aminotransferases in the blood, a possible sign of liver damage), the effects of statins in children are virgin territory, if you’ll excuse the pun. Also, as cholesterol plays a key role in the brain, accounting for 25% of the total cholesterol stores in the body, and as at 8 years of age, a child’s brain is in a dynamic state of growth, development, and flux, pharmacologic therapy with statins at an early age may result in the opening of a neurologic Pandora’s box, whose long-term effects on the youth of the world may not only be devastating, but also not evident for years to come. That is why popular press and the media have been so eager to jump on this issue.
Let’s step back a bit, however. Hasn’t obesity been declared and coded as a disease of late, instead of a condition or a mere state of being? Hasn’t childhood obesity reached epidemic proportions in the U.S. and many parts of the world, with the prevalence of pediatric obesity tripling in the last 25 years and with the majority of some minority-group adolescents being overweight or obese? If that is, indeed, the case, and we believe it is, doesn’t the end justify the means? If increasing body weight in childhood is associated with cardiovascular risk in adulthood, as well as a plethora of other maladies in adolescence and adulthood, including type 2 diabetes mellitus, known to result in a complication cascade resulting in renal failure requiring dialysis, limb amputations, and even death before 30 years of age, perhaps we should not begrudge some clinicians, doctors of pharmacy, and public health professionals a proverbial stab in the dark. Risks and benefits will need to be weighed, as well as cost-effectiveness, and that will require time, further research, and unemotional objectivity. At this point in time, it is a little premature to say how this is going to go. Also, while pharmaceutical companies would be all too happy to include childhood statins in their cluster bombing of the television airwaves, along with the marketing of other “adult” drugs to children, their parents, and their educators, perhaps clinical and public health care expenditures would be better directed at lifestyle modification, via improved diet, increased exercise, and legal action to curtail fast-food advertising and to improve fast-food offerings. The stage is set for a long, drawn-out battle, with the AAP, pharmaceutical companies, and their political allies pitted against some pediatricians, public health professionals, school boards, nutritionists, kinesiologists, preventionists, and good old Mom and Dad.
With the new 2008 AAP recommendations on hypercholesterolemia calling for statins as first-line agents, an 8-year minimum age for pharmacotherapy, and a low-density lipoprotein (LDL, “bad cholesterol”) level of ≥ 130 mg per deciliter if diabetes mellitus is present, the walls are slowly closing in. No man is an island, however, even if drug companies would have us believe that our children and adolescents could better spend their time and health on a “statin island.” Only time will tell if island breezes prevail.

Gun Done!

2008-09-27T18:25:00.002-06:00

In a recent, well-publicized news story, some were happy, others sad, to learn that the U.S. Supreme Court in a 5-to-4 decision in District of Columbia v. Heller in June 2008, not only struck down a ban on handgun ownership in Washington, D.C., but also ruled that the District’s law requiring all firearms in the home to be locked away violated the U.S. Constitution’s Second Amendment. Personally, my household, like that of the more than one-third of the others in the U.S., contains a handgun, and I have weighed the pros and cons of firearm possession. Have you? Firearm-related, suicide statistics are, indeed, sobering, and one certainly cannot blame the anti-gun lobby for its “the sky is falling, the sky is falling” proselytizing. In 2005, for example, with suicide in the U.S. reaching the unenviable milestone of second-leading cause of death among Americans 40 years of age or younger, more than half of all suicides were gun suicides, 46 Americans per day committed suicide, and gun suicide outstripped gun homicide by 40%.
Not only is suicide, in and of itself, an impulsive act, usually taking anywhere from 5 minutes to less than 1 hour between the decision to kill oneself and the actual attempt itself, but it is also self-limiting, meaning that once the acute phase of the urge or crisis passes, so, too, does the urge to attempt suicide. One begins to realize here that firearm availability in the household might, indeed, be conducive to a precipitous downward spiral and catastrophic conclusion of events.
If that were not enough, case-control studies have shown that in homes with firearms, the higher risk of suicide also applies to the gun owner’s spouse and children, the risk of suicide increases no matter how the handgun is stored, and adolescent suicide is four times more likely when the firearm is loaded and unlocked. The relationship between household gun ownership rates and suicide has been studied in all 50 states of the U.S. between 2000 and 2002, and it hasn’t taken a descendant of Einstein to determine that those states with higher handgun ownership rates also have higher rates of firearm suicide and overall suicide.
So, we know the problem. What is the solution? While many physicians and public health practitioners continue to adhere to the mistaken belief that someone who is serious enough to attempt suicide can find equally effective means when a gun is not available, there is something that can be done and two roads to follow. The number of suicide attempts can be reduced by recognition and intensified treatment of mental illness, and restricted access to handguns can be and has been proven effective as a suicide deterrent.
The gun can be undone!

HIV/AIDS by Numbers

2008-09-07T14:59:00.002-06:00

The XVII International AIDS Conference was held in Mexico City in early August 2008, and, while that clinical showcase was no longer a premier venue for dissemination of information on current, cutting-edge research being done in the field, it nonetheless served as a vehicle for spreading the word internationally and acting as a barometer of the progress in the fight against this viral plague of modern times. A total of 20,716 delegates were present at the conference, with nearly half of them coming from the United States and Mexico, a testimony to the concern and interest in the malady demonstrated by the industrialized world. HIV/AIDS is no longer considered a watershed of developing countries, but also a scourge of some of the most technologically advanced nations in the world. A quarter-century after the discovery of the human immunodeficiency virus (HIV), the conference served as a repository of facts, data, and numbers that was both surprising and encouraging in its scope.
It appears that the fight against HIV/AIDS has made a considerable amount of progress, and clinical and epidemiological evidence demonstrates that with over 25 antiretroviral drugs currently on the market, scientists are making headway in what was once considered a lost cause. That is not to say, however, that the millions of new infections and deaths each year are acceptable, nor is a cure or vaccination for the syndrome imminent. There is still a long road to go, and the statistics presented at the conference were sobering. Currently, an estimated 33 million people live with HIV worldwide, and 2.7 million of them became infected in 2007, with a total of 2 million people dying from AIDS in that same year. No real surprises there, as the picture had always been glum. A silver lining, however, did appear, when it was announced at the conference that for the first time in recent years, fewer children (who currently account for about for about 15% of the infected population) and fewer adults are becoming infected by HIV, and fewer people are dying, than in previous years. Epidemics have stabilized for the most part in Africa, although pockets of increased infection continue to exist in nations such as Kenya, and Eastern Europe, particularly Russia and the Ukraine, now lays claim to some of the largest HIV epidemics. Decreased availability of methadone and clean syringes to injection-drug users would appear to account for the latter.
The pharmacological arsenal in the fight against HIV/AIDS has grown considerably over the years, and, while no “magic bullet” currently exists, the costs of drug development continue to rise, and there is no AIDS vaccine on the current horizon, antiretroviral therapy continues to reduce viral loads to nondetectable levels in many of the afflicted and guarantee heretofore unheard of normal lives and life spans. Barriers to HIV/AIDS reduction and prevention in low- and middle-income countries still exist, however, as poverty, stigma, discrimination, and inadequate health care systems make the logistics of prevention and pharmacological treatment a proverbial distribution nightmare. Effective preventive interventions to encourage male circumcision, prevent mother-to-child transmission, and discourage multiple sexual partners are simply not in place in many areas hit hard by the HIV/AIDS epidemic. Were that not enough, time and time again evidence has shown that antiretroviral therapy, while effective, is not reaching sufficient number of the afflicted. A case in point, although far from the only example, is sub-Saharan Africa, where 2.1 million people and 200,000 children were receiving antiretroviral medications in 2007. Those numbers sound encouraging, until it is realized that only 20% of the people know that they are infected, less than a third of the afflicted are receiving therapy, and only a third of infected pregnant women receive antiretroviral medications to prevent transmission to the child.
So, one might say that although progress in the fight against HIV/AIDS has, indeed, been made, the international medical and political communities still have their work cut out for them, before the XVIII International AIDS Conference convenes in Vienna in July 2010.

At Least Kiss Me First!

2008-07-23T05:56:00.000-06:00

With physicians and the pharmaceutical industry cozily in bed together, it is the health care consumer that often feels like a nonconsenting adult who has just been violated. “At least kiss me first” is the initial reaction of those of us who are resigned to the interference of Big Business in the art and science of the practice of medicine. The statistics are disturbing, and it is ludicrous for today’s physicians to assert that their Hippocratic oath guarantees patient and provider protection against industry’s preemptive onslaught.
No physician is immune. In fact, almost all physicians, 94 percent according to estimates and surveys, have some tie to the pharmaceutical industry, whether it be something as simple as the acceptance of trinkets (for example, free pens, clipboards, calculators, or even pizzas) or something slightly more exotic, like junkets to industry-sponsored meetings in faraway places. As we all know, nothing is free in this world, and the pharmaceutical industry would not be spending upwards of $7 billion a year on such frivolities, and another $18 billion a year on free drug samples for doctors, if Shakespeare and Shylock’s famous “pound of flesh,” in the form of increased prescriptions of company-sponsored medications, were not required in return. We must ask ourselves, have our men and women in white sold their souls to the devil, or is this just the way of the world? Perhaps industry-marketing practices are nothing more than simply getting the word out about the latest advances in the pharmaceutical sector, destined to ease our suffering and make enjoyment of white picket fences and those golden years exercises in disease containment.
Actually, pros and cons abound, depending on which side of the proverbial divide you are on. One thing is undeniable, however. Each day an estimated 101,000 drug company representatives descend upon our nation’s doctors, hawking their wares in much the same way that traveling salesmen pushed their elixirs and potions, just before the turn of the nineteenth century. The unwitting public was a lot less discerning at that time, when they purchased tonics, liniments, and oils from those bards of the Old West, who gesticulated on the podiums of creaky, old, medicine show wagons. We’ve come a long way since then, and, yet, even with more education we are witnessing a revival and a return to the future. With morning stubble, expensive mortgages to pay, and waiting rooms filled to the brim with harried, hurried, and verbally trigger-happy patients, physicians seek the easiest way out. It is often much easier to acquiesce and accept the pitch of pharmaceutical reps, than to do the research and literature searches necessary to confirm the efficacy of new drugs. Indeed, industry reps have the ears of our physicians, as a minute spent with a doctor has been shown to increase drug prescription of a particular medication by 16 percent. Lending ears for a mere three minutes of time increases those same drug prescriptions by 52 percent. Wow, and to think that a common primary care physician has an average of 28 such encounters per week with drug company reps.
But are we being unfair here? Isn’t there a positive side to pharmaceutical reps and the companies they represent? Isn’t that the American way, and aren’t they just practicing the capitalism we preach? The enormous financial outlays for the marketing of new medications to physicians, up 275 percent from 1996 to 2004, are fully warranted according to industry sources, given the obvious utility of pharmaceutical marketing to disseminate education, information, or propaganda, whichever you prefer, to health care providers, in order to influence and promote evidence-based treatment decisions. Damn medical school, clinical training, experience, personal research, unbiased literature, and an objective clinical eye, it is now “the suits” who mentor.
This piece would not be complete without a further ranting and raving on the downside of such business practices. While professional etiquette and legal repercussions bar true expression of sentiment here, several points can be made categorically. When you don’t “kiss us first,” we, the public, and even doctors themselves, feel excluded from the sacred patient-doctor relationship, and we feel powerless to take ownership of our manifest health care destiny. If that alone were not enough, current pharmaceutical marketing practices are extremely costly to our slumbering U.S. health care giant, not to mention the expense of new medications versus older, generic versions, the adverse side effects that are unknown in the long term, the effects of new drugs on older patients (who have been underrepresented in clinical trials), and the prescription of medications according to company profits rather than patient needs. Need we recall the debacle of the painkiller Vioxx!
Whether you kiss us on the lips or merely hold our hands, all we are asking of our health care providers, apothecaries, and pharmaceutical companies is that you sacrifice a bit of profit for the greater good. After all, not only do you, too, have fathers, mothers, husbands, wives, sons, daughters, brothers, and sisters to think about, but also, if you do not take responsible action soon, the U.S. Congress and individual states themselves, via the Physician Payments Sunshine Act and other such pending legislation, are going to shackle your future freewheeling days. Big Brother, at times, can be a blessing in disguise.

Deus Ex Machina

2008-07-06T20:24:00.002-06:00

Machines get smaller and smaller, and so, too, does Man's brain, when he or she relies on the former exclusively. (A man connected to an EKG machine invented by the Dutch physiologist, William Einthoven, 1912. Photo taken from NEJM, 7-3-08) Dr. Al

No-Brainer

2008-06-29T17:08:00.000-06:00

The 4th of July is upon us, and flags are unfurled to annual demonstrations of jingoism, victory, and God Bless America. Forgotten in the mix, however, are the indelible reminders of what freedom or national foolhardiness costs. Car bombs and improvised explosive devices (IEDs) go off in Iraq, Afghanistan, and other faraway places, and body bags find their way back to the Patria, to the sounds of marching bands blaring the Star Spangled Banner. And that might just be the more merciful side of the coin for countless victims of conflict and their families, as something far more sinister, sad, and long-lasting clouds the horizons of young adults whose outlooks would most certainly have been rosier had financial circumstances, oil, terrorism, and political innuendo not won the day. What am I alluding to here? What could possibly be worse than lives cut short before their prime? As Old Glory is raised to the hustle and bustle of backyard barbecues and the hoisting of beers, give a thought to traumatic brain injury and its devastating effects on modern-day patriots, their loved ones, and our pocketbooks.
Do the math, which may not be intended for the faint of heart or mind. Since the start of hostilities back in 2001, more than 1.5 million U.S. servicemen and women have been deployed to Iraq or Afghanistan. They have been better equipped than ever, and protective body armor has resulted in the survival of hundreds, if not thousands, of wounded who would have perished in previous wars. Nonetheless, the situation is double-edged, as hand-in-hand with increased survival struts a concomitant increase in head and neck injuries, including severe brain trauma. According to some estimates, the proportion of U.S. military personnel with mild traumatic brain injury, defined as an injury with loss of consciousness or altered mental status (e.g., dazed or confused), may be as high as 18%, and, even if that figure were found to be exaggerated, there is no denying that postconcussive symptoms such as irritability, memory problems, headache, and difficulty concentrating are on the rise in returning “keepers of the peace.” The growing frequency of episodes of domestic violence in military families may also be tied into the rising incidence of mild traumatic brain injury and post-traumatic stress disorder (PTSD).
Mild traumatic brain injury (synonymous with the term “concussion”) has been significantly associated with psychiatric symptoms, most notably PTSD and depression. In fact, more than 40% of soldiers whose injuries involved a loss of consciousness met the criteria for PTSD. No direct link between PTSD and injury to brain tissue from the concussion or trauma itself has been found, and current theories implicate a wide variety of factors operating prior to PTSD onset, such as exposure to extreme stress, traumatic changes in the pituitary gland, altered immune system responses, disturbed sleep physiology, and distorted perception of symptoms.
Perhaps “mild” traumatic brain injury is a misnomer, as the myriad of physical and mental health symptoms resulting from it are anything but mild. While postconcussive symptoms usually resolve rapidly, usually in a matter of days or weeks, multiple concussions lengthen the recovery period, with no answers forthcoming to explain persistent postconcussive symptoms after injury. The neurologic effects of primary blast explosion on the brain are also hard to explain, which does nothing to alleviate the anxieties and concerns of U.S. military personnel about the nature of their symptoms.
Treatment methods for persistent postconcussive symptoms are unproven and have as yet to reach a medical consensus, at a time when medical disability and compensation processes have reached an all-time high, and the expectation and belief systems of patients regarding their injuries are being sorely tried. With neuroimaging and neuropsychological testing procedures often inconclusive and medical management simply symptomatologic at best, patient education has become exceedingly important in the recovery and rehabilitative phases of brain injury.
Mild traumatic brain injury is extremely difficult to diagnose and treat, and, yet, the persistent PTSD, depression, and physical health symptoms resulting from inadequate management warrant further investigation into the timeliness and cost-effectiveness of improved interventions. Digest that, along with your barbecued ribs, on the 4th of July, as U.S. troops remain on the ground in Iraq and Afghanistan!

© 2008, Albert M. Balesh, M.D. All rights reserved.

One Leg Up

2008-05-26T15:56:00.001-06:00

They buzz, they tingle, they irritate, and they’re just downright nasty! When sleep beckons, those “creepy crawlers” intervene, keeping us awake at night, watching old reruns, and making for yawning sprees and fatigue at work or at play, when the sun comes up. Restless leg syndrome (RLS) is the culprit and source of the tingling legions that strike under cover of darkness, perplexing us, and leaving us with questions unanswered. Unfortunately, current medical literature on the subject is wanting, so our illustrious health care providers must run for cover or snag the latest medical journal piece of relevance or the latest edition of the “Bible of internal medicine,” Harrison’s Principles of Internal Medicine (17th Edition, ©2008, McGraw Hill Medical, New York).
What do we know? What answers can we give the 1-5% of young and middle-aged adults and the 10-20% of adults aged 60 years and greater, who suffer from the deep aching of the upper and/or lower extremities inherent in RLS? Let’s first try to corner the pest, and define its modus operandi. It appears in the evening, usually when we are inactive, and it keeps us from falling asleep. The deep muscular aching it provokes can be temporarily relieved with movement, but that is only a stopgap measure that we can’t rely on at night, when we need our sleep. The symptoms of RLS come and go, and, frankly speaking, they can be aggravated not only by our vices, like caffeine and alcohol, but also by sleep deprivation, some antidepressants, and pregnancy. So, we’re damned if we do, and damned if we don’t, especially those of us who suffer from depression. Are we willing to accept a tingling in our toes in exchange for peace of mind and freedom from the debilitating effects of depression? You be the judge, jury, and victim!
Are there any silver linings here? Perhaps for those of us who are not White Caucasians, there may be, as RLS appears more commonly in those of Northern European extraction, a sort of reverse discrimination, if you will, and if you’ll excuse my poor attempt at humor. Multiple family members may be affected, although pinpointing the malady to a specific gene on a particular chromosome is beyond the reach of current medical and genetic research on the heredity of the disorder. So, hapless victims continue to trudge over to their doctors’ offices in search of a magic elixir or cure-all, only to find that their “pillars of medical knowledge” are as clueless as they themselves. Those in the know can assert, with some degree of confidence, that RLS can be caused by iron deficiency and renal failure in some instances. The vast majority of sufferers, however, must consider their condition an enigma, which gives no comfort when restless legs wish to walk right out from under them.
The symptoms are there, including disturbed sleep, musculoskeletal pain, and fatigue; a profound knowledge of the causes is not. That doesn’t mean that relief is not near. Success has been achieved with neurologic drugs such as pramipexole (0.25-0.5 mg, every evening at 8 p.m.) or ropinirole (0.5-4.0 mg, every evening at 8 p.m.). The latter has been marketed consistently on television, under the commercial name Requip®, by pharmaceutical giant GlaxoSmithKline. Nonetheless, while a suitable “leg up” on symptoms can be attained with such medications, until the cause of RLS is individuated and targeted, our legs will continue to run away with us at any given moment. If that were not all, we have also seen the rise of periodic leg movements of sleep (PLMS), consisting of the raising of the big toes and feet, which can accompany its big brother RLS.
Restless legs syndrome has given new life to the concept of Mexican jumping beans. Hopefully, with time, the former will be silenced. That will leave us with only Montezuma’s revenge to quell.

Gender Bender

2008-04-27T10:51:00.000-06:00

They can vote. With apron strings no longer indelibly fixed to their waists, they have become powerbrokers and have acceded to the highest echelons of Corporate America. Their numbers swell the ranks of the most prestigious institutions of higher learning that this nation has to offer. They are tough, rugged, honest, sincere, caring, and now running for the highest political office of the land. In short, the “fairer sex” has come a long way, but not without hitting speed bumps and impasses along the way. Yes, it was long overdue, and, yet, with every lump of sugar comes a grain of salt. Women’s health has become a bitter pill to swallow. After all, having their cake and eating it, too, has put women in the crosshairs of the same acute and chronic maladies afflicting their testosterone-infused, hairy, king of the jungle, Rambo-like husbands and significant others. So, perhaps it would be time well spent, examining the differences between men and women on a clinical and public health stage. Perhaps a reality check will be accorded, when the notion that gender matters in health is “slam dunked.” Let the reader beware, that what follows is not a pretty picture, and has ramifications that go beyond the circle of influence of a simple “gender bender.”
It is conventional wisdom that women outlive men, and this has been the case since the turn of the century. Reductions in the mortality surrounding maternity, labor, and birth have played a role in women’s longevity. Lo and behold, however, since 1980, the gap in life expectancies between Rambos and Rambas has been narrowing, and men’s gains in life expectancy now exceed those of women. How can this be accounted for? What or who is to blame? The answer, Dear Brutus, lies not in the stars, but in the higher rates of morbidity and psychological distress experienced by the carriers of two X chromosomes. Women, in fact, for better or worse, in this case, are subject to higher incidence and prevalence rates of anxiety, depression, worry, and demoralization. An uncertain world and a vacillating U.S. economy do not brighten immediate prospects, either.
There is a paradox here, which needs some form of explanation. Why do men continue to meet their Creators at younger ages than women, and, yet, are stricken by chronic illnesses at much lower rates than the latter? Gender differences in the patterns of disease might be revelatory on that score. Case in point, men, for whatever reason, are more often the victims of life-threatening chronic diseases such as coronary heart disease, cancer, cerebrovascular disease, emphysema, cirrhosis of the liver, kidney disease, and atherosclerosis. Women, on the other side of the coin, are more frequent targets of chronic disorders, including anemia, thyroid conditions, gall bladder disease, migraines, arthritis, colitis, eczema, and the list goes on and on. It doesn’t end there, either, as women have more than their share of acute conditions such as upper respiratory infections, gastroenteritis, and a proverbial potpourri of short-term infectious diseases.
Women are not immune to the life-threatening chronic diseases afflicting men. They just experience them later in life. Clinicians, researchers, and public health professionals have been slow to realize this, and, consequently, there has been a gender bias in health care research and clinical practice directed at those mortal conditions. A “women don’t have heart attacks” perspective has not only been abusive and dangerous, but has shaped clinical research studies. It is now clear, beyond any shadow of doubt, that treatments developed by studying men are not necessarily generalizable to women. Biological differences between men and women must be understood, with an eye to health advantages in one sex being employed to develop new pharmaceutical interventions to benefit members of the opposite sex.
Comparing the health of men and women is far from an easy task. Factors such as who specifically is being compared, the social and environmental causes of disease, the places where chronic conditions lurk, and the practice situations and social characteristics of the dominant group of medical professionals-physicians must all be considered. It is not a simple question of XX versus XY, as differences in men’s and women’s morbidity and mortality are a function of the combination of both social and biological factors, which tend to operate in opposite directions. While women derive advantages in longevity from sex differences that allow them to carry a fetus to term, men’s claims to decreased morbidity appear to be related to lower levels of role stress, role conflict, and the demands of work and play. There is, however, some controversy on the biological side. Their stronger immune systems and estrogen contribute to women’s greater longevity by lowering their risk of coronary heart disease prior to menopause, and, yet, their biology is hard-pressed to explain why women get sick more often then men.
Behavior and the socialization process between the sexes may also influence health. Women are taught from birth to accommodate others, and men to express anger and frustration more readily than the opposite sex. Those social characteristics may, in effect, account for the greater risk of psychological maladies, such as depression, in women. Social roles and their connection to disease will become fertile research terrain in the future.

All’s fair in love and war, but biological, environmental, and social skirmishes between men and women on the health front benefit no one. They drive up health care costs at a time when the U.S. economy is barely limping along. So, like the “good hands people,” in the future, steps must be taken to ensure that a simple gender bender never reaches the proportions of a full-fledged “head on.” Men and women are different. Their bodies are different. Their health is different. The sooner that lesson is drilled home, the sooner ripe, old ages can be reached together.

Modern-Day Slave Trade

2008-02-29T09:13:00.001-07:00

The modern-day slave trade is alive, well, and thriving in Juárez, Mexico and other urban areas just south of the U.S.-Mexico border. Abraham Lincoln is turning in his grave, as the U.S., Japan, and other so-called industrial giants of the world exploit the poor to give to the rich, a reversal of the Robin Hood philosophy. With employment in the south of Mexico at a premium, and the few jobs available going to younger workers, an older, migrant Mexican workforce has been lured to Northern Mexico with the promise of a salary, any salary, and food on the table. At what is comparable to $4.00 U.S. dollars a day, this highly unskilled workforce has sold its soul, its health, and its self-esteem to the new robber barons of the industrialized world and their henchmen, the low-paying factories known as maquilas. While the latter were originally conceived as a symbiotic boon to all parties involved, providing jobs to the poor on the one hand and increasing profit margins on the other, beware of what you wish for! They have turned into a proverbial nightmare, being directly or indirectly responsible for overpopulation of Mexico’s northern cities, for an upswing in their crime rates, and for the creation of colonias, a romantic-sounding term for none other than slums. The “carrot” held out to the poor of Mexico by the industrialized nations, to entice them to travel to Northern Mexico to work at low-paying maquila jobs, has been transformed into a pike on which to impale them. With hardly enough money to pay for life’s essentials, let alone adequate health care, those poor factory workers, living in overcrowded colonias with no running water, sanitation at a minimum, domestic heating in the form of combustible automobile tires, and diarrhea, dehydration, infectious diseases, chronic debilitating illnesses, and lack of childhood immunizations bred on a daily basis, have traded the dignity of poverty in their hometowns for the promise of full stomachs in faraway places, sanctioned by the thirty pieces of silver paid to faceless intermediaries. Yes, the modern-day slave trade is alive and well, and Abraham Lincoln, Martin Luther King, and Hugo Chavez have looked up from their card game in the netherworld to take notice.
With the governments of the U.S. and Mexico often up in arms with one another in regard to drug trafficking and transport of illegal aliens across international borders, it is amazing that the two crybabies reached an agreement in 1985 to permit the operation of maquila plants on Mexican soil. Mexican workers, predominantly from the country’s interior, were hired to work in the maquilas for the pittance of the Mexican minimum wage, which in 1988 amounted to less than $4.00 U.S. dollars per day. Meanwhile public health experts, researchers, and health care professionals began to see cracks in the pavement on the road to hell originally paved with good intentions. Garbage dumps sprang up in the midst of grocery stores and playgrounds, as children walked hand-in-hand along byways strewn with litter, human waste, and non-biodegradables. What had started out as a multinational experiment to elevate the human socioeconomic condition had degenerated into a public health nightmare and a pitched battle with hepatitis A, streptococcal infection, amebiasis, scabies, dehydration, diarrhea, contaminated water, and the fleeting hallucinations of a health education infrastructure.
That was then and this is now. What has changed? Not much. Inadequate resources, low socioeconomic status, and utter lack of education still run rampant in many indigent communities south of the border. Those communities, for better or worse, and with the intervention of outside experts when needed, must find ways to educate and financially remunerate community health promoters. They must also establish connections with governmental agencies, in Mexico, the U.S., and perhaps even in the “Land of the Rising Sun,” in order to secure much-needed financial backing and educational tools directed at enhancement of social reinforcement. Social planning and action phases are certain to follow community-wide raising of awareness. With communities themselves at the vanguard of their manifest destiny via a linkage approach between big business, health and innovation resources, health promoters, and community members themselves, development and implementation of health-related interventions stand a relatively good, though not certain, chance of success. At that point, immunizations can be administered, medicines can be dispensed, sewers and stagnant pools can be drained, and I can shut up.
Only when healthy minds and bodies become a reality on both sides of the border, can all eyes be turned to our next formidable adversary, the “modern-day slave trade!”

© 2008, Albert M. Balesh, M.D. All rights reserved.

Helter Culture

2008-01-27T18:55:00.000-07:00

Mix and match, shock and awe, divide and conquer. Health care and the practice of clinical medicine in the U.S. today has become a hodge-podge and jigsaw puzzle of non sequiturs, influenced more and more by national origins and less by pathophysiologic principles. The tapestry and cultural framework of our nation has changed significantly, and with it, our view of pain, suffering, disease, medications, and the almighty caregiver in white. As illegal immigration continues to remain unchecked and uncontrolled, we must first come to the startling realization “they” are here to stay. Only then, can we turn our gaze to how U.S. medical interests are best served. The days of house calls and little black bags are gone. Norman Rockwell is turning in his grave. Yet all is not lost. We can still save a wheezing U.S. medical infrastructure, if we can just understand the needs of the cultural minorities it serves. It is that segment of the population that is uninsured for the most part. It is that segment of the population that congregates around the low end of the socioeconomic totem pole. Finally, it is that segment of the population that equates preventive medicine with Cadillac, Dom Pérignon, and excesses of luxury that only the white folks can afford.
Black, Hispanic, and Native Americans have lived in and on this land for hundreds of years. They are our neighbors, our friends, the men and women we date, and our colleagues at work. Yet they are as unprepared to take their place in the social and medical fabric of this nation as the hundreds of thousands, if not millions, of Africans, Arabs, Chinese, Columbians, Cubans, Dominicans, Eastern Europeans, Indians, Koreans, Mexicans, Pakistanis, Puerto Ricans, Russians, and Vietnamese, to name a few, that pour into this country each year. We must no longer tend only to the health care concerns of “our own,” but also to the legions of our future and potential citizens, whether they drive taxicabs or the lasers that repair our hearts. So, lets take a look at some cultural mores, in the hopes that they will help us understand whether health in the U.S. is chugging along nicely, or on a sidetrack to hell.
While asthma, coronary artery disease, diabetes mellitus, and hypertension take their collective financial toll on the nation’s coffers and our individual pocketbooks, imagine the devastation and havoc they wreak on the hearts, minds, and family resources of cultural minorities, older age groups, and homeless veterans now patrolling jungles of concrete and steel. Young, educationally deprived, pregnant, minority women, and their unborn fetuses, are also at risk, as prenatal care initiated in the first trimester requires education, information, money, transportation, and the ability to understand what they are up against. Even if these requirements could be satisfactorily met, there would still be significant problems, as young, pregnant, Hispanic women might forgo first-trimester prenatal care due embarrassment with the physical examination, lack of time spent in the physician-patient encounter, and long waiting times in the clinics. Pregnant Korean American women might complain of some of these very same issues. Culture is not important, you say!
Let’s take a look at cancer now. Depending on which side of the fence you’re on, it can have a very different affective meaning. African American women view breast cancer with fatalistic resignation. Hispanic women, on the other hand, are not only less likely to perceive themselves as targets of breast cancer, but when they are, indeed, stricken by the malady, perceive a smaller chance of cure.
And we are not immune to tribal superstition either. Native American women, for example, become reticent, when it comes to discussing cervical cancer. They do not like to discuss questions of health openly, nor do they trust their physicians or their recommendations. I guess you don’t have to be a Native American to be a Doubting Tom or Thelma, as I, too, often mistrust the advice of my own sawbones. So ingrained, however, is Native American mistrust of professional medical advice, that lay health educators, called project guides, are hired specifically to present screening education programs to local Native American women. Tell that to the Lone Ranger!
And if that were not enough, the changing American physician workforce, with most U.S. family physicians being foreign and only 31 percent actual Americans, makes for interesting conversation and cultural exchanges in the examining room, that is, after one has groomed those standing hairs on head.
Where do we go from here? We can continue to lament the downward spiral of U.S. health care, or we can “cowboy up” to conjure up a solution to our multifaceted, multicultural dilemma. Bankrupt and sick is no way to go through life, either for the once mightiest nation in the world, or for the millions of its culturally emarginated inhabitants without adequate health care.

© 2008, Albert M. Balesh, M.D. All rights reserved.

The Good, the Bad, and the Downright Dangerous

2008-01-04T21:50:00.000-07:00

“Hey, little girl, wanna piece of candy?” They come in all shapes and sizes, and all colors of the rainbow. They tempt us. They rape us. They poison us. While we’ve come a long way since the times of sweets laced with toxic additives such as mercuric sulfide, copper arsenite, and lead chromate, today’s food supply may be no less responsible for driving long nails into short coffins. Let’s take a staple as simple and sacred as milk, for example. The next time we or our children have a nice, refreshing glass of that bone builder, we’ll also be enjoying the extra added “benefits” of the 50 antibiotics, hormones, blood, and pus contained therein. Cow udders and hooves are infectious vehicles. So, to expect a germless nectar would be tantamount to a belief in leprechauns, elves, and fairy godmothers.
With holsters at the ready, and a quick draw leading to slow agony, the fruit and vegetable gang also patiently awaits a showdown to take us down. We scrub those skins, we peel those orbs, and yet traces of toxic pesticides such as copper sulfate linger on that apple a day. It’s no consolation to us that the doctor eats from the very same orchard, reminding us that nutritional research progresses in leaps and bounds, as well as the more than occasional false starts and dead ends.
When we turn our gaze to modern-day Africa and many areas of South America, we see the ravages of malnutrition, scurvy, and folate and thiamine deficiencies. We thank our lucky stars that we were born here in our sanctified Mecca, and protected from an invisible oral assault on our metabolic machinery. That short-lived lure to a false sense of security comes to a screeching halt when we recall history’s lessons. Even the culturally and economically advanced, ancient Romans were prey to 1,500 years of malnutrition, under the misguided teachings of the famous physician Galen who strongly advised against consumption of any form of fruit.
When many of us were young, there was a stigma attached to the “Made in Japan” label. Then we grew up, the world evolved, and Hondas were built. Soon, connotations were modified, and the Japanese colossus took flight. We must never forget, however, that it was Japanese food researchers who invented high-fructose corn syrup, an economical soft-drink sweetener that has made most of our acquaintances on more than one occasion. It is six times sweeter than glucose, and, according to some estimates, it has single-handedly breached our pancreas’ Maginot Line, taking no prisoners while at the same time increasing rates of diabetes and obesity the world over.
The push-and-pull of the passing of time has nonetheless yielded quite a few successes to accompany the numerous shortcomings in nutritionists’ thinking. Three come to mind. Where would we be today were it not for those perspicacious investigators who connected vitamin deficiencies to serious disease? The answer is up to our necks in birth, blood, bone, cardiac, gastrointestinal, gum, and neurologic diseases. The British Admiralty also made its contribution, issuing seamen on ships-of-the-line a regular ration of rum, water, and lemon juice, which prevented the vitamin C deficiency better known as scurvy. And, finally, giving new meaning to the old adage, “you are what you eat,” we arrive at the French, who once treated constipation with large, oral tablets of toxic antimony. Back in the good ole days, those excreted metal pills were reused.
Tall tales, you say. Not exactly. Were we to discuss the trans fats, additives, substitutes, fillers, dyes, sweeteners, preservatives, colorings, and artificial flavorings currently employed in the food production industry, noses would by no means grow long.

© 2008, Albert M. Balesh, M.D. All rights reserved.

Bah, Humbug!

2007-12-23T14:32:00.000-07:00

If ankylosing spondylitics, lordotics, spondylarthritics, scoliotics, and spondylolisthetics might be granted a wish to exchange their deformities for the strong, firm, and steadfast demeanor of their robust Christmas pines, then their holiday living rooms might be adorned by the likes of this dejected Scrooge. (Sentinel Pine, Sentinel Dome, Yosemite National Park, photo taken from NEJM, 10-25-07) Dr. Al

Daycare Nightmare

2007-12-19T13:15:00.000-07:00

It’s a good thing Old Santa is ageless. Otherwise, his halls might be decked with holiday fear, not cheer, as his “little helpers” left St. Nick and Holly to wander aimlessly about lonely corridors, spotted by time’s accumulation of dust, mildew, cracked paint, and squashed Periplaneta americana, commonly known as the American cockroach. Such is the state of adult daycare today, where the best of intentions often cedes the playing field to profit margins and the attempted meeting of frazzled ends. We are an aging population with diminishing buying power, and we all desire some punch for our pound of flesh. Unfortunately, years of hard work, investments, and savings accounts are no match for the soaring costs of assisted-living facilities in the U.S.
So, what is one to do? Paying the Piper guarantees neither necessities nor creature comforts, as many hapless baby boomers have learned from their rides on the U.S. health care juggernaut. As millions reach retirement age, solutions are not readily forthcoming. The cost of the average nursing home in the U.S. can reach $5,200 a month, chump change for a Trump, an impossible dream for us mere mortals. For that handsome sum, one is guaranteed only impersonal care, at best, which has prompted an estimated 40,000 to 80,000 of our finest American retirees to seek greener pastures in Pancho Villa’s stomping grounds. After all, we as a nation have not only learned to do without, but also to seek suitable substitutes elsewhere, when “Made in the U.S.A.” just doesn’t cut it anymore.
One does not have to reach for the stars, but only for $1,300 a month to guarantee a studio apartment, three square meals a day, laundry and cleaning service, 24-hour medical care, and a potpourri of extracurricular activities, sightseeing, and adventure south of the border. An aging Indiana Jones would love it! Aging baby boomers may have to tolerate it, as many can barely afford to live in the U.S. anymore. While quality of care varies greatly in Mexico, after all, assisted-living facilities are the new kids on the block down in Margaritaville, there is something to be said for a poor country that can provide a first-rate service to foreigners whose own nation bartered away their well-being in exchange for monuments constructed to the Almighty Dollar.
There is no denying it. The soul of our nation has been soiled, and we have left dry cleaning services to a country whose immigrants we badger with high walls, electronic listening posts, and pilotless drones. The U.S. can no longer minister to the health care needs of its aging population, and American academics, government officials, and developers are slowly but surely coming to this realization. Precedents are being set, and questions are being asked. Why, for example, should one pay in the area of $5,500 a month for comparable care in the U.S., when a cottage, regular meals, and 24-hour nursing care can be had for the modest price of $550 in Mexico? Add an additional $140 a year, and an American expatriate can get his or her proverbial hands on full medical coverage from the Mexican government, including surgery, all medicines, insulin, and a battery of medical supplies for chronic illnesses. The Mexican Social Security Institute, or IMSS, which directs clinics and hospitals nationwide, allows Americans living in Mexico to enroll in its program, even if they have never worked south of the Rio Grande or paid taxes there. As we search for a universal health insurance model here in the U.S., perhaps our hearts, minds, eyes, and pocketbooks should be trained on our “poor cousins” down south, who appear to have solved the problem.
Some U.S. companies have begun to invest in assisted-living facilities in such romantic areas of Mexico as San Miguel de Allende, Chapala, Monterrey, and Guadalajara. That trend is destined to continue, and even increase exponentially, as CEOs mandate bottom lines and increased corporate profits. Let the buyer beware, however! The silver cloud may hide telltale signs of an impending storm. Mexican officials inspect assisted-living facilities but once a year, in best-case scenarios. If that were not enough, Medicare, Medicaid, the Department of Veteran Affairs, and most U.S. insurance companies will not pay for care or medicine as long as patients live outside the U.S.
So, one might say that you’re damned if you do, and damned if you don’t. Nonetheless, waking from a nightmare is more palatable in an idyllic cottage than in the poorhouse.

Nodular Noose in Hangman's Heaven

2007-11-17T12:24:00.000-07:00

Some things that go bump in the night are much more frightening than the toys in Poe's closet. Rheumatoid arthritis is one such unfortunate reality that takes a giant leap from the simple meanderings of a fertile, yet demented, imagination. (photo taken from Crush Step 3, 2nd Edition, Copyright 2004) Dr. Al

Can, Sir?

2007-11-10T08:10:00.000-07:00

What is this mystery we call death, and why do we fear it so? When the Grim Reaper comes calling, do we merely hitch a ride to some solitary truck stop in the Great Beyond, or are we delivered to a better place than this Earth could have ever provided, even in the best of times? Ask a body ravaged by cancer, and the answers will be forthcoming and clear. Ask the witness to a body’s decay, and the answers, while shrouded in doubt, will nonetheless unfetter a geyser of hope.
Cancer is a terrible adversary. In most cases, it is one whose indomitable, yet malign, spirit is every bit as pure as the good intentions of the Echoers of Hippocrates’ Oath. It cannot be begged, borrowed, or stolen. It may be placated, bargained with, or postponed, however, depending on one’s point of view. It will inevitably lead to demise. How we reach that inexorable terminus is as much a function of how we view life, as how we live death.
We are told on a quotidian basis that medical times are good, that new cures are on the horizon, and that a leap of faith will win the day. Tell it to the captive audience of a cancer ward. There, statistics mean nothing. There, the salutary effects of a smile and a gentle hand are as fleeting as a snowflake in mid-afternoon sunlight. A gift book, a box of chocolates, a bouquet of flowers, and the sincerest of sentiments mean nothing, when the path to the unknown must be trod alone. “Read? Why should I read? Don’t you know that I am dying?” are the words of the condemned, and the reaction to the feeble attempt on our parts to convince the all-knowing incredulous (or perhaps ourselves) that it is business as usual. How callous can we be!
Age brings wisdom and a good dose of religion, to boot. Resigning oneself to a fate, in the face of the American Cancer Society’s rosy proclamation that from 2002 to 2004, cancer deaths fell by 2.1 percent per year, runs countercurrent to the flow of the human spirit. The human papillomavirus vaccine, a decline in hormone replacement therapy (HRT), recognition of the anti-cancer power of vitamin D, gene mapping, new radiation techniques, a keener threshold for investigation of suspicious symptomatology, easier lung cancer surgery, and targeted breast cancer treatment are all testimony to medical progress, eliciting sighs of relief while at the same time failing to efface a healthy dose of skepticism. Go tell the good news to the throngs of the faithless, who have traded in a belief in U.S. medicine for a last-ditch, pitched battle on Mexican soil across the border, employing therapeutic weapons the U.S. Food & Drug Administration (FDA) has yet to approve.
To deny or feign ignorance of the recent advances in oncology would be tantamount to ignorance. To state categorically that we are well on the road to a cure for cancer, that the chips in the ante are sufficient to fund further wide-sweeping research, and that the speed of medical progress is adequate to support a last leg is no less reckless. People continue to die. This year, for example, 680,000 women will be diagnosed with cancer, and 270,000 will die from it. Perhaps our time would be better spent preparing the living for death, instead of giving false hope of living to the dead. After all, “seeing is believing” holds water only when “believing is seeing” is not an option. We need to ask caregivers and patients alike whether their interests and sentiments are best served by a “Can, Sir,” when a “Cannot” might be the most charitable and loving direction to follow on the short road to remaining days, weeks, months, or years of painless and autonomous life.
This year in Texas, 95,310 people, like you and me, will receive what they perceive to be a death sentence. Only 37,000 lonely souls will, however, perish under the weight of the unshackled cancer juggernaut. While we owe much to selfless researchers for aiding, abetting, and writing a new lease on life for many, questions continue to linger, compounded by a hemorrhage of blood and dollars on distant desert sands. Who will, indeed, be responsible for providing some measure of solace to individuals and families buckling under the pain, suffering, depression, and anxiety of terminal illness? Who will bear the rising personal and societal, economic costs of advanced medical technologies and research? Who will convince our knights in white armor that “terminal” does not mean “terminated,” and that a diagnosis of cancer should reinforce, not sever, close physician-patient ties?
If the money is just not there, then lip service should not be, either. “Can, Sir” is a fortress wall we hide behind, to shield us from our own worst fears and insecurities. When we do finally venture out into unfamiliar territory, our prodding, piercing, and radiation are no match for the simple, dignified, inner strength of those about to leave one world for another.

© 2007, Albert M. Balesh, M.D. All rights reserved.

In honor of Kalli Rose

Road Map of the Past

2007-10-07T13:13:00.000-06:00

If you think our nation's major highways are sorely in need of maintenance and repair, then what of our internal thoroughfares, which are no less vital! (Vascular System of the Body, an Engraving by Andreas Vesalius, 16th Century, taken from NEJM, 10-4-07) Dr. Al

Bariatric Bonus

2007-10-07T13:02:00.000-06:00

That’s “bariatric,” not “geriatric.” You know, that crazy operation they perform on fat people to tie their tummies. You’ve heard the drill before. May have even considered making the leap, to reduce those unsightly pounds, when willpower has just not carried its weight in the face of chocolate cake, French fries, and a veritable potpourri of artery-clogging delicacies. Now your back is to the wall, and it’s high time you scoured the scientific literature for an angle on this medical marvel. What does this thing they call bariatric surgery consist in? Is it true what they say that it can keep girth down on wannabe Prince Charmings and Cinderellas, while at the same time increasing their life spans? Let’s debunk the myth and proceed to the short and skinny, as we create room at the bar by unfettering space around our waists.
For years doctors have known that weight loss improves cardiovascular risk factors. To the average Joe on the street, that in itself is not an earth-shattering revelation from our Einstein’s in white. What is interesting and to date unanswered has been the question of the possible reduction in serious illnesses, like heart attacks and cancer, and their progression toward death by weight loss. In short, does bariatric or stomach surgery prevent deaths?
We have all heard that obesity has become an epidemic in the United States, with about 24% of the population defined as obese in 2005. Worldwide, 300 million people are obese, and those legions are growing. The numbers are simply staggering! The buck does not stop there, either. Abdominal obesity is not only associated with increased risks of maladies such as hypertension, diabetes, hyperlipidemia, sleep apnea, coronary artery disease, and stroke, but also contributes significantly to U.S. health care expenditures, in excess of $100 billion annually for that collective and so-called innocuous jaunt to the doughnut store daily. Shame on us! It is expected that the overall life expectancy in this great nation of ours is destined to decline if we fail to stem the rising tide of obesity. Fat, not wars, pestilence, or Mother Nature, is going to take us down.
The scenario appears bleak, but medical advances are, indeed, on the horizon. One of them is bariatric surgery. The word “bariatric” comes from the Greek word baros, meaning weight, and bariatric surgery or weight loss surgery describes surgical procedures performed specifically for the purpose of attempting to induce appetite control, weight loss, and long-term dietary modification. Bariatric surgical procedures reduce caloric intake by modifying the anatomy of the gastrointestinal tract. They do this by either creating a small gastric reservoir with a narrow outlet to delay gastric emptying, or by bypassing varying portions of the small intestine where nutrient absorption occurs. The latter procedure, known as gastric bypass surgery, while accounting for only 13% of all bariatric surgery to date, is rapidly growing in popularity and fast becoming the procedure of choice.
Although many of us believe that we should not tamper with the designs of the Almighty, in the morbidly obese the hand of man may be a useful adjunct to the hand of God. Extensive studies conducted over an 18-year period in both Sweden and here in the U.S. in Utah on a total of 12,000 patients who underwent bariatric surgery have demonstrated the undeniable benefits of the procedure. The participants in the studies lost 32% of their body weight and kept most of it off, survived longer than matched control patients who did not undergo surgery, and saw a 56% reduction in deaths from heart disease. In fact, the estimated number of lives saved was 136 per 10,000 stomach operations. So, one might say that there is no doubt that intentional weight loss, via the surgeon’s knife, improves life span.
What good would a silver lining be, however, without a few storm clouds. Indeed, bariatric surgery is not a panacea, and nowhere is the adage of the end not justifying the means more true than in our consideration of complications. Obese patients who undergo bariatric surgery are at high risk for venous thromboembolism, pulmonary embolism and death, and irreversible postoperative copper, thiamine, and vitamin B12 deficiencies leading to peripheral neuropathies, encephalopathies, degeneration of the spinal cord, optic neuropathies, and a host of other neurologic abnormalities.
So, just what is the short and skinny, and who should undergo the surgeon’s invasive hand? There is no doubt that the severely obese stand to gain, in terms of morbidity and mortality reduction, from bariatric and gastric bypass surgery. Let the buyer beware, however. The bariatric bonus may be a Pandora’s box in disguise. Opening it may unleash something far worse than the weight of added pounds. Only time and your physician’s professional opinion and experience hold the key.

© 2007, Albert M. Balesh, M.D. All rights reserved.

Headstrong

2007-08-20T06:45:00.000-06:00

Barbecues and Labor Day. Flipping burgers and drinking beer, without a care in the world. Life is good, the planets are aligned, and credit card bills have all been paid. Then a sudden fall to the ground, a slurring of speech, weakness in arms or legs, loss of coordination, partial blindness, or a failure to sense light touch on the skin signals that all is not well in Oz. The transition from devil-may-care to “I’d better care” comes at too high a price, with too little done, too late. Even if witnesses to the tragedy maintain their wits about them and remember the three simple steps to identifying a stroke, STR (asking the victim to smile, talk, and raise both arms), the damage already done may portend poor future quality of life, or worse. Do we throw in the towel, or wave a white flag? Answers don’t come easy to this complicated medical challenge, and, with stroke ranking second after ischemic heart disease as a cause of death and disability worldwide, we had better begin to look for some solutions.
Eighty percent of strokes are caused by arterial occlusion that cuts off adequate blood flow to the brain, and the remaining 20% are due to hemorrhages. Within thirty days of a stroke, it’s “adios, amigos” for between 10% and 17% of the unlucky. Throw increasing age, coexisting diseases (ischemic heart disease and diabetes mellitus), and increasing size of the brain infarct into the mix, and those numbers go up significantly. To make matters worse, consciousness is generally normal or affected only slightly during an acute ischemic stroke, breeding a semblance of normality in the hapless victim that causes precious moments to be lost. The initial headstrong “I’m ok” in the first minutes to hours after a stroke is deceptive to both victims and observers, and has little to do with the head being strong. In fact, clinical deficits appearing early correlate poorly with the irreversible damage that sets in later, as time marches on and reperfusion of the brain with blood continues to remain inadequate.
Alas, we know the problem. Let’s try to make sense of the solution. The old adage, “An ounce of prevention is worth a pound of cure,” while trite, is nowhere more relevant than when our brains become fertile for attack. You’ve heard it all before, but driving a stake through the monster requires both a cool wit and seasoned experience built on knowledge. In both victims of stroke and strong candidates for a first stroke, prevention is the name of the game, and the arsenal at our disposal consists of low-dose aspirin and dipyridamole, oral anticoagulation, treatment of hypertension, statin therapy to lower lipid levels, glucose control in diabetes, smoking cessation, and carotid endarterectomy, a surgical cleaning of crusted carotid arteries comparable to a plumber’s rodding of clogged pipes. When those measures reflect a level of impotence on the part of our defenders, we must first be certain that we are dealing with stroke, before initiating the next phase of our defense. Migraine headache, postictal paresis (impaired movement after epileptic seizure), hypoglycemia, conversion disorder (paralysis from hysteria), subdural hematoma, and brain tumors can all simulate acute ischemic stroke, and their treatment in most cases is drastically different from the emergent intervention imposed in the latter.
We set out on the trail of brain vampires such as atherosclerosis, which leads to thromboembolism or local occlusion, and cardioembolism that drain our brains of their life’s blood. The instruments in our little black bags, while not as genial and romantic as those in Van Helsing’s bag of tricks, are nonetheless much more sophisticated and efficacious. They run the gamut from signs and symptoms (irregular pulse, very high blood pressure, carotid bruit sounds), measurement of glucose level, complete blood count, prothrombin time and partial thromboplastin time (for blood clotting), electrocardiogram, and cardiac monitoring to transthoracic and transesophageal echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI). In all patients with suspected ischemic stroke, CT or MRI of the brain are required.
Once our blissful Sunday afternoon has gone from barbecue to emergency department to diagnosis of acute ischemic stroke in a reasonably short period of time, it becomes necessary to intervene in all haste. To do otherwise, and with no intent to make flippant of that which goes beyond serious, would be to harvest “vegetables” from once fertile and dynamic minds. We then turn our attention to the practice guidelines set forth by the Stroke Council of the American Heart Association and the American Stroke Association and by the European Stroke Initiative. A patient presenting to the emergency department within 3 hours after the onset of symptoms of stroke should be treated with the intravenous thrombolytic agent, called recombinant tissue plasminogen activator or rt-PA (alteplase). A maximum total dose of 90 mg of rt-PA results in a favorable neurologic or functional outcome at 3 months of 31% to 50%, and thus preserves functional quality of life and perhaps life itself in up to half of those “barbecue” victims. In addition to rt-PA, aspirin administration is recommended 24 hours after stroke (300 mg daily for the first 2 weeks, and then lower doses thereafter) to reduce rates of death and risk of recurrent ischemic stroke. This simple 1,2-combination will not only K.O. acute ischemic stroke in its tracks, but also ensure that the “headstruck” once again become headstrong.

© 2007, Albert M. Balesh, M.D. All rights reserved.

Head Games

2007-08-18T10:02:00.000-06:00

What a way to do neurosurgery! Then, again, with health care costs soaring, we may find it necessary to return to the future. (Extraction of the Stone of Madness, circa 1400, by Hieronymus Bosch, taken from NEJM, 7-19-07) Dr. Al

M.D. (Mad Doctor)

2007-07-30T18:22:00.000-06:00

When our backs are to the wall and we have nothing to lose, we write. When odds are insurmountable and we know we have given our all, we write. When that crap shoot we call life yields “sevens” and “elevens” late in the game, we write. Whether exorcising demons, seeking forgiveness, proclaiming cathartic guilt, or righting perceived wrongs, we put pen to paper, as if the action itself or the completed document placed in proper hands might lift the veil of angst that provided initial impetus.
I am no different from you. I am a man with no past, present, or future. I have lost a country, perhaps two, while seeking greener grass, and I have neither profession nor prospects for immediate salvation. Although pity is not something I actively seek, soothing words and a pat on the back would go far to easing the pain of unpaid student loans and an inability to attract gainful employment. I, like so many other native sons and daughters, have fallen through the cracks, and, while a national open-door policy benefits those born distant from these shores, those of us who have been left a legacy, a birthright, and a vested interest must man newly formed breadlines. The American dream is, indeed, alive and well, but currently in the hands of foreign nationals who pass by in shiny, new Lexuses, glance at us in askance, and warn their children to not mix blood with ours.
An Everyman, I am not. I am just an unemployed physician, and my only sin was a deep, heartfelt desire to help my fellow man, my countrymen, and a nation that long ago equated self-worth with honesty, integrity, and good deeds, not money and power. Back in 1976 my odyssey began, at the ripe old age of 24 years, when non-admittance to a U.S. medical school prompted a drastic course of action to make a dream come true. Tracing the path of Columbus in reverse, I made my foray into the European theater, and, with foreign language skills at a minimum, I enrolled in an Italian medical school. My action was laudatory, my quest rivaled that of Jason, and, yet, when I returned to the U.S. in 1996, I was a broken man whose seventeen years in medical school, graduate medical education, and private practice in Italy merited neither a tickertape parade nor a place in the sun. My parents had aged, my friends had moved on, and the white hair and age lines, which on another stage might have conferred deference and respect, made me all the more unrecognizable to a country that I, too, did not recognize.
Do the math. Often, fact is stranger than fiction. A national shortage of physicians currently grips this nation, with the poorest areas of the country suffering hand-in-hand with the most economically deprived areas of the world. Not only is this a travesty, but a national outrage to rival any of the tumultuous social issues of the last fifty years. We are 16,000 doctors short in the U.S., and, while physicians like myself would be willing to even work for free or for a nominal fee, the Association of American Medical Colleges (AAMC), the American Medical Association (AMA), the Educational Commission for Foreign Medical Graduates (ECFMG), the Electronic Residency Application Service (ERAS), the National Board of Medical Examiners (NBME), the National Resident Matching Program (NRMP), and on and on continue to shut us out. Not only are we barred from medical practice and graduate medical education, but foreign national physicians (non-citizens) are given preference over us for the few positions available. Outrage, I said. I should have said national disgrace!
More than 35 million Americans live in underserved areas of this country, and they suffer the slow, chronic, yet ravaging effects of diseases that would be well within our power to manage, treat, or cure were we to hire the legions of unemployed physicians forced to work non-medical jobs in this great country of ours. America’s rural and inner-city poor have been hit the hardest, as well as Hurricane Katrina-devastated regions, the Mississippi Delta, and the arid U.S. Southwest, to name a few. While current statistics show 280 doctors for every 100,000 people in the U.S., which is a shame, some areas of the country come in at only 103 for every 100,000, which is a downright crime. Mad, you better believe I am!
Increasing U.S. medical school enrollments will not solve the grave dilemma facing our nation. It will take years and years to educate new legions of physicians, and, all the while, the misery in the Mississippi Delta, Appalachia, and the 5,594 other Health Professional Shortage Areas (HPSA) will continue to grow. Meanwhile American citizen physicians like myself, who were trained in foreign medical schools, bang our heads against walls, as our country continues to abandon us in much the same way it did to American veterans during the Vietnam War. Make no mistake about it, this, too, is an unpopular war.
The old guard always fears change, and the medical profession itself is no exception. While good boys continue to flash wealth and lament the fact that they don’t earn quite as much as their predecessors, the urban poor continue to die. Medical graduates continue to flood high-powered, highly technical, lucrative fields of medicine, while at the same time both demeaning family practitioners and envisioning shiny, new BMWs, homes in the suburbs, vacation spas, and all manner of creature comforts as the graduate medical education phase of their lives draws to a close and they take their places among the empowered and the entitled. Meanwhile the years pass, and the 16,000 doctor shortage of today hits 24,000 by the year 2020, and perhaps even 200,000 by some estimates, based on a fast-growing U.S. population and an aging work force. Mad, you bet I am!
I continue to man the breadlines, being too educated to work menial jobs even if I so desired and too discriminated against by age and country of medical education to be given the opportunity to pursue graduate medical education and alleviate the suffering of my own countrymen here in the U.S. I have passed all the U.S. medical licensing examinations, I have paid all the high examination and legal fees, and, the good citizen that I am, I have followed all the AAMC, AMA, ECFMG, ERAS, NBME, and NRMP rules and regulations, only to have salt rubbed in my eyes, as doors are closed to me at the same time that foreign national doctors from China, Cuba, India, Korea, Mexico, the Middle East, Pakistan, the Philippines, South America, and sub-Saharan Africa are recruited for medical positions (governmental and non-governmental) subsidized by U.S. taxpayer dollars, my own included. Mad, I am raging mad!
I am a small fish, a David in the shadow of a Goliath-sized U.S. medical establishment. There is no way that I can win this battle, and yet I fight on. There are thousands like me here in the U.S., perhaps some living in your very community. We want to alleviate your pain, we want to be there for you, and, yet, the next time you need a family physician, you had better brush up on your foreign language skills, as you will most likely stand or sit face-to-face with a foreign national (there are more than 40,000 Indian doctors in the U.S., not to mention other nationalities), as American citizen physicians like myself beg for quarters, seek employment at Wal-Mart, and fight amongst ourselves for the scraps thrown to us by foreign national doctors. Mad, I am beet red!
I was once proud to be an American. In all honesty, I can no longer say that I am. So much injustice, so much dishonesty, so much hypocrisy, they have all taken their toll on this U.S. native son. My heartache is enormous, and my walls have been banged enough. I am a man with no solutions, only innumerable questions and an incessant desire to alleviate pain and suffering in my country of origin. As foreign physicians continue to pour into the U.S. for the few medical positions available, at the same time that I am denied access to medical positions in their homelands, the fires within me continue to rage. At 55-years-old, I don’t see them getting extinguished any time soon. Mad, I am without words!

© 2007, Albert M. Balesh, M.D. All rights reserved.

Written in Bone

2007-07-30T12:43:00.000-06:00

While writing in stone did little to improve the quality of life in Ancient Egypt, there is something that modern men and women can do to preserve the closest things we have in our bodies to ancient monoliths, and that is determination of bone mineral density (BMD) via noninvasive techniques such as dual-energy x-ray absorptiometry (DXA), single-energy x-ray absorptiometry (SXA), quantitative computed tomography (CT), and ultrasound in order to plan subsequent therapeutic intervention. (photo taken from NEJM, 7-26-07) Dr. Al

Bone-Headed

2007-07-30T12:27:00.000-06:00

If we are all little angels and always observe our doctors’ prescriptions, then why is something as simple as taking a daily calcium supplement and vitamin D so perplexing? Why can’t we prevent that irritating rattle of our bones? Why do we so fear that fall that may signal an end to our physical autonomy? Finally, why do we look to medical miracles like once a month, once a year, or once a life treatment regimens with such subliminal desperation, as if we could erase with a snap of the fingers the expiration date that the Almighty, Nature, and the relentless course of time have so eloquently fixed in the pages of our twilight existence? Bone-headed, we’re not. Headed for bone is another story. We desire an improved quality of life for as long as we can sustain it, and building strong bones and muscles just makes good sense. Navigating advice columns and Internet websites to find clear-cut answers and remedies, however, is an exercise in Zen, and frayed nerves and couch-potato restlessness demand answers to questions and a realistic approach to intervention. So, as is usually stated in these columns, let’s keep it simple. If we follow the rules outlined here, our lives, physically and osteogenically speaking, will be a lot less tedious and worry-ridden. Not following them will initiate the slippery slide to and through osteoporosis. The decision is ours and ours alone.
While no one likes to be reminded of the unpleasant, a jolt is sometimes needed. Here are the stats. More than 10 million people (8 million women and 2 million men) in the U.S. are affected by osteoporosis, but only a small proportion are diagnosed and treated. If that were not bad enough, an additional 18 million individuals have bone mass levels that put them at increased risk for developing the malady. Osteoporosis is defined technically a bone density that falls 2.5 standard deviations (SD) below the mean for young healthy adults of the same race and gender (so-called T-score < –2.5), and increased risk is set at bone mass T-score < –1.0. Now, that’s all well and good, but we are more interested in effects and results than simple statistics. For example, what is this thing we call osteoporosis, and how does it affect us?
Osteoporosis results from bone loss due to both normal aging and an exaggeration of the process of bone remodeling. The process of bone growth, remodeling, and repair is somewhat complicated and involves many players, but can be simplified by thinking of bone as a bank or repository of calcium, with deposits and withdrawals made daily. When there is an imbalance between the two in favor of withdrawals, we eventually go bankrupt and our bones break. Decreased activity of the bone-forming cells, called osteoblasts, and increased activity of bone-degrading cells, called osteoclasts, results in activation of bone remodeling, bone loss, decrease in biomechanical strength, more porous bone, and, finally, osteoporotic fracture, to the tune of 1.5 million fractures (300,000 hip fractures, 700,000 vertebral crush fractures, 250,000 wrist fractures, and 300,000 fractures of other bones such as the distal radius of the forearm) each year in the U.S. as a consequence of osteoporosis.
So, where does osteoporosis come from, and should we resign ourselves to the fact that it is just another inevitable sign of old age that we can do nothing about? The answer is a resounding “No!” We can do something about it, but we must first come to know our enemy. Contributing to its onslaught are inadequate calcium intake, vitamin D deficiency, estrogen deficiency in women, inactivity and lack of exercise, genetic and acquired diseases (anorexia nervosa diabetes mellitus, liver disease, rheumatoid arthritis, lymphoma and leukemia, emphysema, and multiple sclerosis, to name a few), medications such as glucocorticoids, anticonvulsants, and immunosuppressants (check with your doctor on that score), and cigarette consumption, of course.
Being less bone-headed means getting off our duffs and having our bone mineral density (BMD) measured by one of a battery of noninvasive techniques approved by the U.S. Food and Drug Administration (FDA), such as dual-energy x-ray absorptiometry (DXA), single-energy x-ray absorptiometry (SXA), quantitative computed tomography (CT), and ultrasound. All fancy names for relatively simple techniques that should be performed in postmenopausal women with risk factors for osteoporosis and in all women by age 65. If BMD is found to be > 2.5 SD below the mean value for young adults (i.e., T-score < –2.5), we play the treatment card.
After consultation with our health care providers and laboratory evaluation for secondary causes of osteoporosis, we proceed to the intervention phase in which we reduce risk factors, supplement our diets with calcium (taken in doses of ≤600 mg at a time), vitamin D (400-600 IU daily), vitamin K, and magnesium, exercise by walking at least three times a week, and begin pharmacologic therapy. Our doctors will know how to best advise us regarding the latter, as we navigate a maze of television commercials touting the benefits of agents that specifically treat osteoporosis (bisphosphonates, calcitonin, parathyroid hormone) and others having broader effects (selective estrogen response modulators or SERMS). For those of us adverse to popping pills on a daily basis, two potent bisphosphonates, zoledronate (Zometa) and ibandronate (Boniva), have unique administration regimens (once yearly intravenously, once monthly orally).
Our money, our choices, our lives. Let’s not be bone-headed!

© 2007, Albert M. Balesh, M.D. All rights reserved.