by Brooke Douglas RD

How to eat healthy on vacation is a challenge.  Vacations are a time to enjoy and indulge in experiences that you may not otherwise have, including food. However, this does not mean you should eat the highest-calorie, highest-fat foods at every meal. Here are a few tips you can use while traveling to make sure you indulge wisely, without going overboard.

Enjoy local foods and cuisine When inRome, eat like an Italian! Why go to a major fast food or coffee chain when you are traveling, part of the fun of traveling is eating at new and different eating establishments. If you are traveling to a location with special, local foods and cuisine, make sure to enjoy those foods while you are there. You may not have another chance!

Choose how many times to indulge, not which times Half the fun of indulging is stumbling across a great restaurant when traveling and enjoying a spontaneous, delicious meal. Unless you have a specific-destination restaurant planned, simply choose the number of meals you plan to have that are more lavish, and let local recommendations/fate serve as your guide. A great rule is the 80/20 rule—try eating well 80% of the time, so you can indulge without guilt the other 20%. Having a particular number of meals in mind will keep you focused on moderation. It also will give you a greater appreciation for those special meals you have chosen.

Do not turn hunger into an indulgence Be sure to make the meal you are choosing to indulge in, one that you are really looking forward to, not one that results from you walking into the nearest restaurant because you have not eaten in 6 hours. Always pack some easy-to-carry snacks for those long days of adventures, sightseeing, or beach-going. This will ensure that you can indulge when you want to, not when your body is screaming for food.

Do not worry if you go overboard one day Sometimes one ice cream cone becomes two, becomes a pastry, and then becomes an indulgent meal out for dinner. Vacationing is a departure from the normal routine of life—if you eat too many calories one day, just brush yourself off and move on! ONE over-the-top day does not make or break a healthy lifestyle. Don’t make the mistake of trying to compensate for the rest of the vacation and restrict your food choices. This usually does not work well, because you will feel deprived and are defeating the purpose of enjoying your vacation. Treat the next morning as a new day, with a new opportunity to make healthy choices. Remember Brooke’s favorite motto – Moderation Not Deprivation!

Indulge wisely - Keep these tips in mind when on vacation:

• Enjoy local foods and cuisine—when inRome, eat like an Italian.
• Choose how many times to indulge, not which times—the 80/20 rule.
• Do not turn hunger into an indulgence—pack snacks.
• Do not worry if you go overboard ONE day—treat the next morning as a new day, with a new opportunity to make healthy choices.

If you would like to schedule a nutrition consult, contact Brooke at Nutrition Authority or call 253-227-8284. Let a ‘Registered Dietitian’ help you clear up any nutrition confusion you may have. Brooke can personalize a ‘nutrition lifestyle plan’ to meet your specific needs. Most insurance is accepted.

Also Enjoy:

Healthy Snacks for the 9-5′er.

I always think of the AFIP, Armed Forces Institute of Pathology, as the final word in any difficult anatomic pathology case. As a medical student in the 1970’s, and as an Army physician in the 1980’s the AFIP was the final word on any diagnostic pathology question.   Microscope slides were sent to the AFIP whenever there was a question as to whether a biopsy was cancer or not, what grade of cellular abnormality existed, or really any other debate or uncertainty arose about a pathologic diagnosis.  When I was reminded today that the AFIP is closing in September as a casualty of the 2005 base closure decisions I was saddened to see that this proud and storied center of excellence has no longer been functioning for the last few months as the world’s premier diagnostic pathology resource.

The AFIP is most well known in recent years as a consulting resource for pathologic diagnosis to both the military and civilian medical, dental and veterinary community. Less well known is that it had a three part mission.  It was also an educational center of excellence and a research facility.  It has a proud history as a forensic pathology resource also.

The decision to close the AFIP was a part of the Defense Base Closure and Realignment Commission report to President Bush in 2005.  The repercussions of the loss of this historic resource have been the subject of many criticisms, but the decision has stood.  Some argue that we will be less able to rapidly respond to potential bioterrorism now.  Others like the WHO feel the loss of a resource for third world physicians for pathologic examination of surgical specimens will make the practice of good surgical care more difficult in some areas of the world.

One of the unique advantages of the AFIP is that it has been the central repository of many of the most interesting and challenging pathologic cases in the US and the world since 1862.  Over 150 years of existence the AFIP has accumulated over 3 million cases, 50 million paraffin slides, and 10 million formalin fixed tissue specimens in one location.  This resource has made the AFIP one of the premier places to study pathology and has allowed the pathologists at the AFIP to be widely recognized as world leaders in their field.

For anyone interested the history of the AFIP is being celebrated and documented in a coffee-table style book available at the U.S. Government bookstore in a book called Legacy of Excellence: The Armed Forces Institute of Pathology 1862-2011.  The cost is $65.00. Some of the most interesting highlights for me include:

• 1865: The precursor of the AFIP, the Army Medical Museum did the autopsy on President Lincoln
• 1866: Somewhat ironically the Army Medical Museum moved to the Ford Theatre which closed as a theatre shortly after the assassination of President Lincoln.
• 1870: The Surgeon General staff published The Medical and Surgical History of the War of Rebellion: 1861-1865.
• 1930: James Earl Ash MD was a major proponent of the role of the Army Medical Museum in diagnostic pathology. The American Registry of Pathology was established at the museum.
• 1946: As its role in diagnostic and forensic pathology increased the Army Medical Museum became a division of the newly formed Army Institute of Pathology.
• 1949: AIP renamed the Armed Forces Institute of Pathology to emphasize the tri-service role of the AFIP.  A new building at the Walter Reed Army Medical Center was designated as a new building site.
• 1996: The AFIP teamed with Russian scientists to recreate fragments of the 1918 pandemic influenza virus.
• 2001:  The AFIP plays a leading role in the forensic pathologic examinations after the 9-11 attacks.
• 2005: AFIP scientists announce that they have fully reconstituted the 1918 influenza virus genome.
• 2006: The AFIP received its 3 millionth pathology specimen.

The loss of the AFIP may not have a huge impact on the excellence of pathology in the U.S. healthcare system.  In the information age sharing of microscopic views of specimens can be accomplished through many different vehicles.  Still having a single government funded and universally respected repository of expertise and knowledge will be missed.  It is a sign of tough times economically for our country and a loss of institutional pride.  Myself I just feel like an era has passed and that we may regret this decision in the future.

The news of the last few weeks about the risks associated with medications we use in managing the risk factors in our patients with type 2 diabetes makes physicians feel like we are walking a mine field.  Take a look at the headline type of news that has come out recently regarding the meds we use to address the four major risk factors for cardiovascular disease in Type 2 diabetes.  It is felt to be very important in patients with diabetes to not focus only on blood sugar control, but to aggressively manage blood pressure, LDL cholesterol levels, and find a way to help diabetics who smoke to stop smoking.

Blood Sugar Control: Suboptimal blood sugar control has been a understood as a major risk for most of the major vascular, neurologic, and ophthalmologic complications of diabetes for years.  Physicians are encouraged to try to keep the Hemoglobin A1C levels near or below 6.5% in our type 2 diabetes patients. To do this often requires the use of multiple hypoglycemic drugs.  Recently drugs in to of the major classes used to manage blood sugars, the GLP-1 analogues including Liraglutide (Victoza) and the class of medications called the thiazolidinediones (TZDs) which included in the U.S. rosiglitazone and pioglitazone.  Pioglitazone, or Actos was the 10^th highest gross sales medication in the U.S. in 2008 with sales of about $2.4 billion.

• Rosiglitazone (Avandia):  Removed from the market over increased risks of congestive heart failure and other heart disease concerns.
• Pioglitazone (Actos): Possibly related to increased risk of bladder cancer in a FDA news release just this month.  Removed from much of the European market, now with increased warnings in the U.S. market.
• Liraglutide (Victoza):  Possibly related to increased risks of thyroid cancer and pancreatitis in a FDA news release in June 2011.  Although to date the other drug in this class, marketed as Byetta has not seemed to be associated with thyroid cancer risks, the course of the Avandia first, and Actos next seems ominous to me.
• Glargine insulin (Lantus):  The good news is that the 2009 concerns raised about a possible cancer risk with glargine insulin were declared unfounded by the FDA this year.

Lipid Control:  Ideal LDL cholesterol levels in our diabetic patients are less than 70 mg/dl, and to achieve this level most patients require treatment with a statin, often use of a high dose of simvastatin or one of the more expensive branded statins.  See my prior post Simvastatin vs. Lipitor.

• Simvastatin 80 mg, the highest dose of the most effective current generic statin had recent FDA restrictions imposed.  Now the question is what to do for our diabetic patients with recommended low goal LDL levels.  Simvastatin vs. Lipitor or Crestor is the question.  Pay more or accept possible risks.  Lousy choices.  Fortunately Lipitor is going to be available as a generic as soon as Nov. 30, 2011.
• The recent NIH decision to stop the study of niacin combined with a statin for treatment of hypercholesterolemia raises more questions than ever about how to best address suboptimal lipid profiles in our patients, especially our diabetic patients.  This is a topic for another post to fully address the subject, so stay tuned.

Smoking Cessation: Our diabetic patients who continue to smoke have much higher risks of heart disease, stroke, and it is imperative that we do what we can to help them quit smoking.  Now one of the more effective tools we have has come under increased scrutiny.

• Chantix (varenicline) has been very helpful in some patients who have been unable to quit smoking otherwise.  Its side effects including vivid dreams, GI symptoms, and depression have been ongoing concerns, but now the FDA reports just this week that the risk of MI may be slightly increased in patients with known coronary disease.  This is really unfortunate, as those are exactly the patients who need to quit smoking the most.  I look forward to more clarification of this issue, but for now may be more cautious in use of Chantix in my patients who need to quit smoking the most.

Hypertension control: Control of hypertension may be the single most important aspect of reduction of morbidity and mortality in our diabetic patients.  So far this remains relatively free of breaking news.  Actually some good news recently is more evidence that the fears of increased cancer risk in patients using ARBs are likely unfounded.  This is good, because with one generic arb now available, and more on the way, this class of medication is likely to be used with increasing frequency.

Stay tuned as how to treat diabetes hopefully becomes less controversial and we get more answers about the risk/benefit decisions on medication management.   Certainly diet, exercise, weight loss and medications are all going to have their place.  It will be interesting to see where bariatric surgery ends up in our recommendations in the future.

The reason that amoebiasis is much more prevalent in parts of the world without good human waste sanitation and clean drinking water is that the primary route of acquiring E. histolytica is from ingesting the organism after water or food is contaminated by human feces.  This is called the fecal-oral route of transmission of disease.  In areas where human feces are used for fertilizer the rates of disease are much higher.

Normally when ingested the E. histolytica organism lives within the lumen of the gut, and feeds on bacteria and ingested foods.  The intestine itself is protected by a layer of protective mucus.  If this layer of mucus becomes disrupted the amoeba can destroy the lining cells of the gut wall, cause ulcerations and a severe colitis.  Other times it can invade the bloodstream and travel to distant tissues, most often the liver, where it can lodge, destroy tissues there, and lead to abscess formation.

Cyst

Amoebiasis therefore has two common human disease manifestations.  Most common is amoebic dysentery.   This usually presents similarly to other causes of dysentery, with bloody diarrhea and cramping abdominal pain.  The diagnosis can be made in numerous ways.  The most common method in many areas of the world is by microscopic examination of the stool. In fresh stool the motile trophozoite is often seen, and the infectious cysts are shed in the stool and can often be seen.  The problem with microscopic evaluation is differentiation from both Entamoeba coli, which is much more common than E. histolytica although it has morphologic differences that make it possible to differentiate, and from Entamoeba dispar which is so similar that it cannot be differentiated.  It is estimated that in endemic areas E. dispar is found

Trophozoite

in the stool about 10x as commonly as E. histolytica, and E. dispar is not felt to cause disease.  Still in a patient with bloody diarrhea and amoeba in the stool that resemble E. histolytica treatment is reasonable.

The other common human presentation of amoebiasis is liver abscess.  All the blood from the bowel first travels through the liver circulation, so amoeba that enter the blood stream are usually trapped in the liver, and begin to destroy cells there.  Giant abscesses can occur, and serious and at times live threatening disease can occur.   Rupture of and amoebic liver abscess can often be fatal.  Often once the amoeba spreads beyond the bowel stool tests for E. histolytica can be negative.  It is felt that about 10% of amoebic dysentery spread beyond the gut, and other cases occur without apparent dysentery.   Diagnosis can be done by serologic antibody testing, with antibody levels in extra-intestinal disease usually much higher than with amoebic dysentery.  As with most infections, antibodies can be detected after about 2 weeks of symptoms.

Treatment of symptomatic amoebiasis is done with two types of drug.  One is to clear the organism from the intestinal tract, and is called an lumenal  (within the lumen or inside of the gut) agent.  This is usually idoquinaol or paromomycin.  In addition metronidazole is used to treat the disease outside the lumen of the gut.  In endemic areas asymptomatic E. histolytica in the stool if not usually treated, but in the developed countries a luminal agent can be used to treat the asymptomatic carrier state.  It’s nice to have such an inexpensive drug as metrinidazole to treat this common problem, and metrinidazole side effects are usually minimal, so it is a great choice.

Amoebiasis is felt to be a major cause of malnutrition and morbidity in the world today.  It is estimated by the WHO that up to 50% of persons in some tropical areas with poor sanitation may carry the orgainsim, although there is some concern that E. dispar carriers may inflate this number.  Still amoebiasis remains a major worldwide cause of morbidity and mortality, and is yet one more disease caused by poverty and lack of clean drinking water and sanitary sewerage disposal.

You may also enjoy posts on  Ascaris lumbricoides and Travel Clinic at Your Pharmacy.

Tweaked helmet would better protect our troops

By Tony Perry, Los Angeles Times

April 24, 2011

A slightly larger helmet with more foam padding would better protect soldiers and Marines from traumatic brain injury, researchers find. The Department of Defense says that more than 130,000 military personnel have suffered such injuries in Iraq and Afghanistan.

Read more

Gold Medal for Content goes to  John Goodman’s Health Policy Blog he writes The HMO in Your Future.  He takes to task the march towards ACO’s and suggests that this is far from evidence based.  We do seem to be moving quickly towards ACO’s whatever that really means.   Check out this post at least to hear Aretha Franklin sing I Say a Little Prayer.

Content  9.7                Writing   9.0

Gold Medal for Writing goes to At the Road the Hellth blog where Dr. Doug Perednia writes How American Healthcare Gets Hellthier in a satire and sad but believable post where he shows the unintended consequences of instituting a three handed clock to improve patient care in a hospital.    Content   9.0   Writing   9.7

Silver Medal for Content and Bronze Medal for Writing goes to  Dr John M who writes about A Five Minute Cardiac Screen for Athletes where he addresses many of the issues with testing in general.  It is such a shame that 100 young athletes die in America each year of sudden death primarily due to prolongued QT syndrome or Hypertrophic cardiomyopathy.  He presents an elegant discussion of the issues of mass screening for uncommon problems with tests that have a significant subjective component to the results,  and false-positive test rates.  Nice post Dr. John.   Content  9.5      Writing  9.5

Silver Medal for Writing goes to ZDoggMD who professes to be only slightly funnier than placebo, but I suspect just needs a bigger sample size to prove he is far funnier.  He writes Immunize, with a video worthy of my own musical doctors page.                  Content   8.5,     9.6

Bronze Medal for Content goes to Mokitas and Taquitos in Health on The Healthiest State in the Nation site.  This is an insightful list of health care Toquitos, meaning truths we know about health care, but are reluctant or afraid to admit and confront.     8.7          9.0

Special mention to the next two posts that I just really like:

In The Blog that Ate Manhattan is Essure – Bad Marketing.  FDA Pull This Ad. How bad can the taste of markerters get?  Here is a good example.     Content  8.0    Writing  8.0  ***

At Reflections of a Grady Doctor is Thursday Top Ten: Fighting Words.  This is good comic relief at the potential for misinterpretation of the common things doctors say.    Content  6.0  Writing  9.0  ***

The rest are in the order received.  Better billing for more timely submission seems fair to me.  Enjoy.

A Word About Morgellon’s Disease on Insureblog is a post about a disorder I suspect close to none of you have ever heard about.  I certainly had not.  It’s one strange disorder.    Content  6.5   Writing  6.0

In the post Health Care Reform: Politics, Computers and the Individual HUB’s List of Medical Fun Facts writes a very insightful and satirical post that because it is so true is not very fun at all.    Content 8.0 Writing  9.5

At Mad in America Robert Whitaker writes Andreasen Drops a  Bombshell:  Anti-psychotics Shrink the Brain about the release of a study in the Archives of General Psychiatry that claims that antipsychotic drug use leads to lower gray matter volume with long term use.  This is especially concerning in light of the increasingly widespread use of these drugs in children and diseases other than schizophrenia.   This is certainly not common knowledge among primary care physicians.  If any psychiatrists have a comment about this I’d love to see it here.    Content  9.0   Writing  7.5

In Diabetes Mine Allison Blass writes about Five Diabetes Dogmas that Need to Go… , an interesting discussion of some myths and dogmas that are widely believed, but have little or no science behind them.  A good read for physicians and others alike.    Content   8.5                      Writing  7.5

In Behavoirism and Mental Health: An alternative perspective on mental disorders Philip Hickey Ph.D.  writes More on So-Called Bipolar Disorder.   I have to agree that patients who carry a diagnosis of bipolar disorder are a diverse and group, but he goes so far as to suggest that for these patients the focus should be on recognizing the behavior that need to be changed, and “this behavior can be identified, specified clearly, and remediated.  And in this regard you have to do what we all have to do with life’s problems – exploit your strengths to counter your weaknesses.  In other words – use your ingenuity.  Find solutions to the problem.  Don’t give in.  Don’t go on doing things the same.  Break patterns, etc..” He is bold in this major break from the practicing norm.  See what you think.    Content  6.0   Writing  6.0

In  New York to Cap Medical Malpractice Awards? (An Open Letter to the Legislature) Eric Turkewitz writes passionately about how NY needs to avoid limiting awards for pain and suffering.    Not what most physicians want to hear, but as he stated in his e-mail a word from the “dark side.”   Content   6.5, Writing  7.0

Paul Aurebach MD from Healthline writes an environmentally focused post called Save the Everest 2011: Improving Waste Management in Nepal.  It‘s as far off the usual topics here as Nepal is from the U.S., but I post it because it is interesting, and our environment is part of our global health.    Content  6.0    Writing   7.5

Ed Silverman at Pharmalot posts Most Docs are Unaware of the “Bad Ad” Program.  I certainly was unaware of an effort by the FDA to get physicians to report inappropriate, false or off-label advertising or promotion by pharma, so he is right on when he suggests for this to be more effective the FDA needs to get the word out to docs.  Maybe this will help.   Content  8.5   Writing   7.5  ***

Julie Rosen writes at Bedside Manner on The Personal Side of Personalized Medicine.  This discusses the use of medications specifically chosen to treat individual patient’s cancers.   Content    7.0   Writing   8.0

At the Smart Blog on Social Media Adam Gaub posts Wool.lab health care panelists  see pros, cons to social media. It’s no surprise to me that patients use social media to reach out to each other, and physicians are not really sure how to be involved.    Content   6.0   Writing  6.0

The ACP Hospitalist writes about the extent of MRSA contamination of traditional white coats vs. freshly laundered short sleeved uniforms, and finds Doctor’s Garments Colonized by Bacteria Within Hours of Starting Work.  I’m glad I can keep wearing my white coat and not have to wear a short sleeve uniform.   I like to look like a doctor, not an orderly.   Content  7.5   Writing   8.0

At ACP Internist is CDC Campaign Doesn’t Slow Inappropriate Antibiotic Use where in Michigan despite a program specifically focused at reducing antibiotic use there was little change in physician prescribing habits.    To change habits is not easy.        Content   7.5   Writing  7.0

At Health Care Agenda Nora O’Brien-Suric writes Social Workers are Best for Care Transitions.  I have to agree with her premise that physicians don’t do a great job at the details of facilitating the transition of patients from a hospital setting to a long-term care setting.     Content   8.0  Writing  9.0   ***

Dr. Val at Better Health writes Don’t Treat the Number, Treat the Patient.  In this case she is her own “patient” and I don’t envy her taking spin classes.  My son has another name for the person screaming at the class riders, but it’s not fit for this venue.    Writing  7.5   Content   9.0

At Residency Notes is  Acute Gatekeeper where the blogger, apparently an annonomous neurosurgical intern writes about the role of the lower level intern or resident in care of hospitalized patients.  I think the example he gives of two ways to present a case to get two potentially different responses are seen throughout medicine.  Physicians, intentionally or unintentionally guide patients, consultants, and in the resident’s case attending physician supervisors to decisions of their choosing by the flavor put on the case presentation.  A good read.      Content   8,0   Writing  8.5

Roy at Shrink Rap posts about Running Out of Psychiatric Beds where he discusses the overall reduction of and difficulty finding inpatient psych beds when patients need them, and a new electronic registry in Eastern Ontario to help ERs find a psych bed when they need one.    Content   6.5   Writing 8.0    ***

Amy Tenderich writes at Diabetes Mine a post called  Losing Control as she vents about the struggle of burnout and wearing down for patients dealing with chronic diseases like Type 1 diabetes, especially when trying to do so with gluten enteropathy at the same time.  Hang in there Amy, you can get back on track.  Diabetes Mine gets a second post here because they host Grand Rounds next week.  Thanks.     Content  8.0  Writing  9.0

Elaine Schattner MD writes at Medical Lessons that Radiologists’ Experience Matters in Mammography Outcomes,  She reviews and discusses a study that shows that radiologists who read a high volume of breast imaging studies have a lower false positive reading rate than those who interpret a lower volume of exams.  Sounds a lot like similar studies with surgeons, hospitals, etc where high volume leads to improved outcomes.     Content  7.0    Writing   7.5

From Health is Social is a post asking Will Social Media End Stigma in Health? It’s really a rhetorical question in the blog post, but one that makes you think.  Thinking is not bad, unless it’s bedtime.   Content    7.0   Writing   9.0  ***

I decided to submit a post from a blog I follow, Cat’s Eye Writer called What to Do When Blogging Isn’t Fun Anymore.  See what you think.  No grades here since I submitted it.

Be sure to visit Grand Rounds Vol. 7 No. 25 at http://www.diabetesmine.com next week and get your submissions in to her early.  Special thanks to Better Health for organizing and managing this useful forum.   While you’re here be sure to follow @DrEdPullen on Twitter, like DrPullen.com on Facebook or subscribe so you don’t miss a post.  Thanks for reading, and leave a comment so future hosts, maybe even me, can improve Grand Rounds.

15 Ways to More Fruits and Vegetables

1. Have 1 cup of fruit (fresh or frozen) for breakfast every day.
2. Take 1 cup of fruit/1 piece of fruit with you in the car (for work or when you are running errands).
3. Eat at least one cup of vegetables at lunch. This could be a salad or vegetable soup. Try dipping raw vegetables of your liking in to your favorite low fat or fat free salad dressing.
4. Eat at least one cup of vegetables for dinner.
5. Make one vegetarian recipe each week; don’t be afraid to try new ones!
6. Take the time once a week to shop for, clean, separate and/or cut up into bite size pieces and bag (in a large baggie) a variety of your favorite vegetables.
7. Keep freshly prepared (from tip #6) vegetables on hand for snacking at home, at work or in the car and for quick side dishes, to throw in pasta, casseroles or soup during the week.
8. Start shopping in the produce section of the grocery store and build your meal ideas from what you find.
9. As a goal, aim for at least 1/3 of your grocery cart to be from the produce section.
10. Keep fresh or dried fruit on hand for grab and go snacks. Store these in your desk drawer, passenger seat, computer bag, briefcase, suitcase, locker, purse, etc…
11. Take fresh fruit to work with you every day for a snack. Always have a healthy fruit or vegetable snack available to grab when hopping in the car to run errands…just in case you get hungry while you are out.
12. The next time you visit a fast food restaurant, order a side salad or fruit cup instead of fries or chips.
13. Make a delicious fruit parfait as dessert once a week. Plain vanilla yogurt, your favorite berry (fresh or frozen/thawed) and sprinkle with Grape-Nut Cereal (or any favored high fiber cereal).
14. Make a vegetable stir fry at least once every week. Get creative with different (modest portion) lean meat choices and always add a large variety fresh or frozen veggies.
15. When eating, fill at least ½ of your plate with fruits and vegetables. Always. Every day.

New Ideas?

• When the weather is warm, freeze some grapes and sliced bananas – these make great snacks to help everyone keep cool.
• Instead of the same old boring iceberg lettuce on your sandwiches and in your salads, try some crispy fresh spinach, arugula or mixed greens.
• Put some fresh vegetables on the grill whenever you decide to grill some meat. Make it a habit.
• Toss some fruit in to your salad – you could use dried fruits like cranberries or fresh ones like berries, mandarin oranges, mangoes, peaches and pineapple.

Excellent Recipes

www.cookinglight.com

www.fruitsandveggiesmorematters.org

www.foodandhealth.com

www.NutritionAuthority.com

Hollywood has a long history of making great movies about special people with medical conditions. This year a stuttering king, but from Rain Man about Autism

to The Elephant Man about neurofibramatosis

Oscar nominated films are often about medical conditions.  As I watched the Academy Awards last night and remembered how much I enjoyed watching The King’s Speech I was prompted to review a good overview in AFP from 2008 that reviewed stuttering.  The issues in the movie are those addressed by a child and then an adult, who happens to become the king of England, with a major stuttering disorder.  Review of the article was helpful to put the things I saw in the movie into perspective. In summary stuttering is fairly common in young people and tends to improve by adulthood. Here are a few of the key points on the review article:

• 1.4% of children under 10 years old stutter.­­
• 80% of children who stutter are male.
• 80% of children with developmental stuttering resolve by adulthood.
• ­­Over to 80% of stuttering is classified as developmental and over 75% of preschoolers who stutter spontaneously recover within 4 years.
• Some developmental stutterers develop associated tics or other physical movements

The AFP article goes over the differentiation between normal speech fluency dysfluency, mild stuttering and severe stuttering.  It’s a good review for parents or physicians faced with questions about speech fluency questions.

Stuttering: An Overview

JANE E. PRASSE, MA, CCC-SLP, Stamford Hospital, Stamford, Connecticut

GEORGE E. KIKANO, MD, Case Western Reserve University, University Hospitals of Cleveland, Cleveland, Ohio

Am Fam Physician. 2008 May ;77(9):1271-1276.

Leave a comment about your favorite movie with a medical topic. I love The Pride of the Yankees, One Flew Over the Cuckoo’s Nest, and Iris.

February 21, 2011, 3:39 PM

When the Doctor’s Wife Has Cancer

In war it is just not possible to retrieve mines that have been laid as battlegrounds can be fluid and evacuations of positions can be necessarily rapid and unplanned.  Mines from many long past wars remain in the ground and a danger to residents of these countries.  As a consequence of this worldwide an estimated 15,000-20,000 people (UN data) are killed or maimed by mines annually.  Many anti-personnel mines are triggered by pressure of as little as 11 pounds, less than the weight of a toddler running across the ground. In 2008 over 60% of casualties form landmines were civilians, and of these about a third were children.

I am not a dove, anti-military, or totally naïve about the facts of war.  I was in the Army for 7 years, admittedly as a physician, but have a general understanding that in war people get hurt and killed, and that there are incredibly effective tools to accomplish these tasks in warfare today.  I also consider myself a proud American.  I understand there are times when military force is needed to maintain our republic.  Given this, I am not proud that the United States is one of the 37 countries that have not signed the Ottawa Treaty (156 countries have signed the treaty) that bars the use, production, stockpiling or production of anti-personnel mines. We join countries including China, Iran, Russia and Pakistan in the minority of countries not agreeing to the Ottawa Treaty terms.  These are not countries with whom I like believe the US shares values on human rights and the value of life. Admittedly the US abides with most of the provisions of the treaty.  Still we continue to stockpile approximately 10 million mines.  There may be some military explanation for this position, but as far as I’m concerned it is lame.

Mine clearing remains a huge worldwide problem.  There are an estimated 10 million land mines in both Cambodia and Afghanistan, and apathy to the issue is one of the major obstacles to faster progress in the search for and removal of mines.  Princess Diana was a vocal supporter of anti-mine programs, and is credited with posthumous influence in getting the Ottawa Treaty signed.  Her death left supporters of mine eradication without a glamorous supporter.  In a bizarre comment a prominent candidate for congress from New Mexico recently discussed using land mines to protect the US – Mexico border.  Thankfully he was not elected, but just the idea that an educated US citizen running for public office would of placing anti-personnel mines on US land is so horrifying that this issues clearly lacks the level of public awareness it deserves.

If enough American citizens express outrage this could be easily corrected. Let’s stop the apathy and demand that our government do the right thing. I find it impossible to believe that our country can justify the use of anti-personnel mines in warfare today.  The US has not used landmines since 1991. If we are not considering use they there is no reason not to sign the treaty and get rid of the stockpiles.    For a haunting video photo collection check out this You Tube.

Contact your congressman today, talk about this with your friends, and make it clear that you consider the US not getting rid of our anti-personnel mines as unacceptable. I just sent letters to Senators Murray, Maria Cantwell and Congressman Adam Smith. You can easily do this too. 

Let me know what you think by leaving a comment.

The Adverse Effects of Energy Drinks on Children: A Pediatrics Review

by Maria Rainier

As any parent can observe, the caffeine from a single can of soda often results in a significant and noticeable energy spike when given to children. If this is the case, the effects of energy drinks on young people must be incredibly powerful – maybe even detrimental.

This is no longer supposition. Sara M. Seifert and a cohort of doctors have recently published a study whose objective was to review the effects of energy drink consumption among children, adolescents, and young adults while identifying the consequences. The researchers found that energy drinks have no therapeutic effects, that 30-50% of adolescents and young adults consume them regularly, and that 46% of the 5448 U.S. caffeine overdoses in 2007 were reported for individuals under the age of 19. The study has been made available to the public due to its high significance and its potential to inform parents about the severe health problems that can result from energy drink consumption.

The Effects of Common Energy Drink Ingredients

Based on a review of research conducted on the subject of children and energy drink consumption, as well as energy drink manufacturer websites, Seifert and her colleagues identified a list of common additives and their medical effects. The main offenders are caffeine, guarana, taurine, l-carnitine, ginseng, and yohimbine.  Together, they have a frightening set of negative side effects that occur when they are ingested in excessive amounts. Unfortunately, excessive ingestion is almost a certainty when children consume energy drinks that are meant for adults. The effects of caffeine alone can include tachycardia, arrhythmia, nervousness, abdominal pain, vomiting, hallucinations, and even more serious problems like seizures, cerebral edema, and paralysis. Ginseng toxicity presents with headache, vertigo, mania, rashes, insomnia, irritability, and a host of other symptoms that can seriously impede a child’s ability to function normally. Yohimbine also causes tachycardia and, in some cases, death.

Other Dangers

Energy drinks, unlike sports drinks or fortified water beverages, are not meant to hydrate the body. Their purpose is to rapidly increase energy and performance, but that typically means a rapid increase in heart and respiratory rates as well as blood pressure. This can be a result of the additives in energy drinks, but it can also be traced to the large amounts of sugar and the interaction of so many potentially dangerous ingredients. Another unseen threat is dehydration. Rather than replenishing fluids, energy drinks deplete them, increasing thirst and potentially causing excessive consumption of the products in question.

Energy Drinks and Children

Because children are so much smaller than adults, the amount of caffeine that they can safely consume is significantly diminished. According to pediatric nutritionist Tara Harwood in an ABC interview, adults should consume less than 400 mg of caffeine daily while children should adhere to a limit of less than a quarter of that amount.  Unfortunately, many energy drinks are nonspecific about the amount of caffeine they contain, so it can be difficult for parents to identify acceptable drinks for their children. The best practice is to avoid them entirely, especially since some drinks have limits set on them by their own manufacturers. Redline, for example, has a package warning indicating that it is not to be sold to anyone under the age of 18. Despite purported self-regulation, energy drinks are categorized by the FDA as nutritional supplements, so their manufacturers are not legally required to adhere to caffeine regulation or package documentation specifications.

The recommendations from the doctors who completed the study are that pediatricians stay apprised of the situation, that communities promote risk awareness, and that long-term research objectives be made to identify safe dosage limits, the effects of chronic use, and the effects in at-risk populations.

Bio: Maria Rainier is a freelance writer and blog junkie. She is currently a resident blogger at First in Education where she writes about education, online degrees, and what it takes to succeed as a student taking online programs remotely from home. In her spare time, she enjoys square-foot gardening, swimming, and avoiding her laptop.

Seifert, Sara M., et al. “Health Effects of Energy Drinks on Children, Adolescents, and Young Adults.” Pediatrics 10.1542 (2/2011): 2009-3592.

The water loss of patients that is not able to be measured in any practical way is commonly referred to as insensible water loss, or fluid loss.  Although there are numerous means of insensible water loss, respiration is by far the largest in patients who are not sweating profusely. Each breath of air we inhale usually contains less than 100% humidity.  The air is humidified in the nose, sinuses, and upper airways so that the air that reaches the lungs, and is subsequently exhaled is essentially 100% humidity at body temperature.  The carrying capacity of water for air goes up rapidly as the body temperature goes up, so respiratory loss of patients with fever is higher than the respiratory loss of afebrile patients.

Sweating is another means of insensitive water loss.  Sweating obviously varies with ambient temperature, body temperature, physical activity and other variables.  We often see patients who are ill in the hospital or at home have profuse diaphoresis and the water loss from this may be significant.

What physicians call “third spacing” of fluids is a shift of body fluids into an area neither inside cells nor in the vascular system.  Inflamed tissues can swell leading to a shift of significant amounts of body fluid into areas where the fluid does not support the vascular system.  In some cases this can be rapid and in large volume, leading to shock and vascular collapse.  An example is acute pancreatitis where large amounts of edema can occur rapidly in the inflamed tissues in the abdomen and retroperitoneum.  Another situation is when the small bowel stops functioning to move the fluid contents through to the colon where fluids are generally reabsorbed.  In this situation, called an ileus, large amounts of fluid can accumulate in the gut, another third space where fluid can be lost to the vascular system.  These situations can require significant IV fluids to maintain blood pressure, renal perfusion, urine output, and to support the patient’s metabolism.

For the kidneys to function well they require water to excrete as urine.  The kidneys of a healthy person can concentrate urine only to a certain degree, after which they cannot both continue to function and preserve water needed in the body.  With inadequate fluid intake to replace urine loss, insensitive fluid losses, and fluid functionally lost in third space accumulation, a person becomes unable to maintain blood pressure and renal perfusion at a level that supports kidney glomerular filtration.  When this happens the kidneys can acutely fail, in a condition called acute tubular necrosis.  If this is brief and good fluid resuscitation occurs, the kidneys can recover.  If prolonged renal failure from acute tubular necrosis can be permanent.

A need for water that is not obvious is that the requirement for water actually increases with increased nutrition.  The waste products of the burning of calories, especially high protein foods, requires water for the needed urine output.  Although tiny amounts of water are actually produced as end products of the burning of carbohydrate foodstuffs, in general increased caloric intake requires a modest increase in water intake for homeostasis.

In summary of the fluid taken in by oral route or from IV fluid infusion either accumulates in the body or is lost from the body in one way or another.  We refer to the losses as sensible, i.e. through ways we can measure, or insensible through ways like respiration, water loss in the stool, and sweating.  Functional loss of fluids into body areas outside the vascular system and outside the body’s cells is called third space losses.  Although this is fluid that eventually may become absorbed into the vascular system and utilized, it is functionally lost for use to maintain normal bodily functions.

So when you are looking at whether you are taking in enough water the best single indicator is your urine output.  If you are not voiding at least 2-3 times a day in moderate amounts, you need to drink more.  If our patients are not putting out 30-50 ml of urine an hour, we want to try to figure out why not, and try to take measures to remedy the situation.

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XMRV and CFS – Hope Ahead of Evidence

XMRV and Chronic Fatigue Syndrome, The Drama Continues

I believe there is some unifying underlying cause of CFS that is yet to be convincingly discovered, be it XMRV or something else.

Enjoy the Article:

February 4, 2011, 2:15 PM

An Author Escapes From Chronic Fatigue Syndrome

By TARA PARKER-POPE

Laura Hillenbrand, the best-selling author of “Seabiscuit: An American Legend,” is known for her exuberant storytelling and dynamic characters. Her newest book, “Unbroken: A World War II Story of Survival, Resilience and Redemption,” is a riveting tale of the life of an athlete and war hero, Louis Zamperini.

Ms. Hillenbrand’s ability to transport her readers to another time and place is all the more remarkable in light of the fact that she is largely homebound, debilitated by chronic fatigue syndrome, or C.F.S.  read more

When patients present to the office with these complaints, it’s not difficult to recognize that they have a scotoma.  The trick is to figure out what’s causing them, and what can be done.  Causes can range from simple transient problems to really serious vision threatening diseases.  A scotoma can be an early sign of major problems like MS, or can be symptom so retinal diseases.

By far the most common cause of scotomata is migraine.  In migraine patients many times neurologic symptoms precede the headache.  One of the most common symptoms is scintillating scotomata.  These are described as flashing yellowish lights in the vision.  Usually they resolve about the time the migraine headache begins.  This is called migraine with aura, or classic migraine.   When this history is given by the patient it’s pretty simple to understand and explain the scotomata, and treatment is simply treatment for the migraine.   If the migraines are frequent patients may benefit from preventative therapy, and if infrequent abortive treatment to use early in the course of migraine is usually indicated.  The scotomata can actually be somewhat helpful in making it clear to the patient that they are starting a migraine, and lead them to early treatment to prevent the severe migraine.

Here is an simulated You Tube of a Scintillating Scotoma as an aura to a migraine headache:

Other scotomata can be causes by more serious problems.  Anything that causes a part of the retina to not function can cause a loss of part of the visual field. Examples are macular degeneration, blockage of a blood vessel in the retina, and demyelinating diseases like multiple sclerosis.  Tunnel vision is a type of scotomata where the central vision is preserved and the peripheral vision is lost.  Reinitis pigmentosa, a congenital cause of vision loss can present with a peripheral ring scotoma.  Patients with diabetes who have laser treatment of abnormal blood vessel growth can have scotomata in the areas where the retinal vessels have been coagulated.

If you suspect a scotoma you can close the unaffected eye, and fix your vision on something to hold the eye still.  Then move an object like the eraser on a pencil, or your thumb around the field of vision.  You should notice the loss of vision when the object enters the scotoma.

If you suspect a scotoma you should definitely seek medical attention to find out what’s wrong and to see how to manage the problem. Most of the time unless the problem is scintillating scotomata with migraine, an ophthalmology consultation is going to be needed.  Your opthalmologist is likely to do formal visual field testing, a dilated fundoscopic exam, and possibly brain and optic nerve imaging with MRI to try to determine the cause.  Sometimes more sophisticated ways to look at the circulation of the eye is needed.

If nothing else today you’ve learned a cool new word that is also used in by psychologists to describe a mental blind spot as in the the inability to see something that is obvious because of a psychological block.

The Best Way to Kill Germs

By Dr. Edward Pullen for Live Right Live Well

With cold and flu season in full swing, you may be wondering if washing with antibacterial soaps and using hand sanitizers are better ways to keep germs at bay than washing with regular soap. I see sick patients every day, so I’m attentive to the latest research and have my own ways of preventing the spread of bacteria and viruses. Here’s my take:

Regular vs. Antibacterial Soap
First let’s look at the question of regular versus antibacterial soap. Most antibacterial soaps contain triclosan, which kills not only bacteria, but fungi as well. However, most of the illnesses we try to prevent — the common cold, influenza, etc. — are caused by viruses. There is little evidence to show that antibacterial soaps are more helpful in killing germs than plain soap. In fact, a 2003 study sponsored by the National Institutes of Health showed no difference in bacterial counts when washing with triclosan-containing antibacterial soap was compared to washing with regular soap.

Hand-sanitizing Gels
Gels are becoming increasingly popular. They’re used when washing is inconvenient or unavailable, and sometimes they’re used to replace washing altogether. Unlike the use of antibacterial soaps, there’s considerable evidence that using alcohol-containing gels to sanitize hands kills both bacteria and viruses more effectively than washing.

So to stay healthy this cold and flu season, keep the following in mind:

• Soap and water are best for removing dirt, especially germ-harboring dirt. That’s why you should always wash your hands with soap and water after activities that get your hands dirty, like using the toilet.
• Regular soap is fine to use for washing, as there is little or no evidence that antibacterial soap kills germs more effectively.
• Hand-sanitizing gels are great for killing viruses and bacteria, and they’re especially useful for killing germs when your hands aren’t particularly dirty. I wash my hands prior to seeing each of my patients, and I use hand sanitizer after seeing patients with any type of bacterial or viral illness.

Dr. Edward Pullen is a certified family physician in Puyallup, Wash. In addition to practicing full-service family medicine since 1983, he blogs at DrPullen.com.

Thanks for reading this medical blog.  Leave a comment and contribute to the discussion.

Busybodies – Busybodies eat for one reason and one reason only—to fuel their activity. These individuals eat as a means to the end and often eat on the run when their stomach starts to growl. Busybodies are lucky in some ways, because their diet is not influenced by their emotions and food is not overemphasized for them. However, it can be hard to pay attention to the nutritional quality of the foods that are eaten when you’re just grabbing at whatever is most convenient. In addition, these people have a tendency to go for too long of a period of time without eating and can suffer medical repercussions because of this.

Feelers – Feelers are usually very emotional, and not all of these emotions are negative in nature. These people are often capable of extreme happiness and joy, as well as the negative connotations that are attached to “emotional” people. When most people hear the term “emotional eater,” they tend to conjure up images of sad people eating too much ice cream as a way of escaping pain. What about the relaxed, happy person who eats too much on vacation as a way of celebrating? This, too, is emotional eating. The good news is that feelers are often capable of enjoying food more than other people, if they approach eating in a healthy manner. The bad news is that these people are prone to eating too much. They enter into an endless cycle of eating too much, then promising to do better the next day, and then berating themselves when they don’t.

Independents – Independents live in the moment and don’t really care about following rules or keeping up with the status quo. Independent eaters are the most likely of all of the personality types to overeat during holidays or other celebrations. They often are very good at coming up with new and inventive ways to make food taste good, a quality that is useful in altering recipes to make them more healthful. Unfortunately, independents aren’t always good at controlling their cravings and may “splurge” a bit too often.

Improvers – Improvers always strive to better themselves and push their loved ones to do the same. The desire to succeed is the first step in living a healthy lifestyle, and this personality type has no problem with this. Improvers have a tendency to take nutrition advice and research findings at face value, and at times, they are quite gullible. Improvers have a tendency to cut healthy foods from their diet, if the newest fad diet recommends doing so.

Organizers – Organizers like to plan their upcoming weekend by mid-week and always have an itinerary planned for every vacation. Highly organized people like to think of themselves as being well prepared for every possibility. Organizers are exceptionally good at planning their menus and at making certain to have a healthy lunch packed the night before. The problem is that highly organized people have a tendency to be inflexible and may beat themselves up emotionally for eating a food that they deem to be “bad.”

Nutrition matters and so does realizing some of our negative and positive lifestyle patterns! Send an e-mail to Brooke at NutritionAuthority.com to obtain your FREE password to take the on-site “Lifestyle Patterns Quiz‟ under the “nutrition‟ tab. Every little tidbit of information we learn about ourselves helps us to better see the “real‟ YOU in the mirror, better enabling us to maintain healthier living.

After a week, we left for Rome, and on arrival after a red-eye flight from Portland, ME through Philidelphia and on to Rome. We dropped our bags at a hotel in town and walked to the Coliseum. It was daunting to walk where the ancient Romans walked, and our sweat may be mingled with that of Caesar, as it was very warm that afternoon. That night we visited the Spanish Steps in the city lights, and had our first of many great Italian meals. We had our first 3 hour-four course meal. I could get used to that style of eating. A good bottle of red and lots of time to talk make a great meal really memorable. The next day off to Tuscany, a week at Borgo di Vagli, a 14th century hamlet far from anything, and a week of day trips to Florence, Assisi, Cortona, the Adriatic Sea, and Montepulciano. Our trip ended with a day back in Rome, a whirlwind tour of the Vatican Museum and St. Peter’s Basilica, and a 20 hour, one stop flight home. Overall it was a trip to remember.  Here are some of photos to get a flavor.

Borgo di Vagli

Looking Down into the Collis

Spanish Steps at Night

The last week has been a whirlwind of catching up, getting ready for Kay to start chemotherapy again, and preparing emotionally to start the fight again.
So, “How’s Kay.” The real answer is complicated. Physically she is still feeling quite well. She got through the initial phase of her PARP inhibitor study without any complications. She still feels strong, is exercising regularly, and feels about 95%+ in terms of health. She has been more fatigued for the last month or so, and feels slightly full in the upper abdomen, where we suspect the remnants of her cancer are hiding, although no imaging has found it yet. Spiritually she stays strong. She feels and needs continued prayer support. Emotionally the situation is much more complicated. She finds it hard to dive back into chemotherapy when she feels so good. Last time we were desperate to start chemo, because we could literally see and she could feel the cancer destroying her. Chemo was clearly her friend at that time, and she could honestly call the port on her chest wall, “My life sustaining port.” Now we are treating a cancer that is only making itself known by a number we see on paper as her CA-125, and by this vague fatigue. The number today was 58, continuing its upward march, and the reason to start the chemo. She really is dreading losing the sense of normalcy that we have enjoyed for the last 9-10 months. She fears being on chemotherapy the rest of her life and never feeling fully strong and healthy again. She asks me how long until I’ll become the, “Finder of things again.” Chemo causes her to lose just a tiny bit of her sharpness for remembering where things are and she seems to misplace more stuff. The joke is that chemo knocks out part of the second X chromosome that somehow allows women to see things other than at eye level. We’ve had our share of tears over this anticipation of loss. Kay has had trouble sleeping, and I could sleep all the time. Still overall we are emotionally holding up pretty well, and feel ready for the battle.
This week Kay had her first infusion of the first course of her chemotherapy for the cancer recurrence. We did our old hypnotherapy regimen in the morning and the infusion went uneventfully. Sometimes I think her judgment is impaired, as she is now out for a walk with friends, just 90 minutes after arriving back home. She thinks fresh air is going to do her well. I suggested rest, but … This chemotherapy regimen is a much more time intensive schedule than last time. She will get Carboplatin, Gemcitabine, and the PARP inhibitor on day 1, the PARP inhibitor on day 4, Gemcitabine and the PARP inhibitor on day 8, and the PARP inhibitor on day 11 of each 21 day cycle. She dreads spending four half-days getting chemo every 3 weeks. Still, Kay being Kay, she has a mother-daughter road trip in her plans for the first “off week,” and they are going somewhere fun together. She is hoping, probably realistically, not to lose her hair this time, though we just looked at some pretty cute photos of Kay without hair. We are both praying for great success in suppressing and possibly eliminating the cancer this time. We know that cure is not likely at all, but miracles happen.  Now that’s more than most people expect when they ask, “How’s Kay?”