Yours, mine, ours

– “Doctor…Choosing ice cream flavors can be a real challenge—takes a lot of negotiation.”

Maria X. is a nice middle-aged lady that has been married twice already and has offspring from both relationships. She has two teenage daughters for her first marriage and Victor, her present husband, has two teenage sons from a previous bonding; they both had had a small daughter. Nowadays the family relationships cannot be solely explained by the traditional tree as there are more crossed relationships from remarried partners, homosexual marriages and adopted children.

The typical image of the stepmother as “a witch bent on mischief on her adopted children” is far from the reality sur le champ where young kids get oftentimes more attached to a close mother figure that their more distant biological one. Similarly, young children often revere more a father figure that helps them with their homework or plays baseball with them than their biological one. Sometimes the breakup of relationships entails the forced adaptation of children to another hearth and to another company without having much say in their parents’ sexual and amorous choices.

The assembly of these composite groupings occurs rather spontaneously as there is not a rational pre-planification of “who will be who”; the gregarious nature of humans makes us seek company. Everything is not always rosy as there are power disputes as in any large human grouping, eventually creating internal cliques and sub-groups; their genetic similarities will not guarantee that Maria’s two teenage daughters will see eye to eye in all their daily choices and dilemmas. She told me that one of them is much closer to the eldest son of Victor and supports him passionately.

Planning their daily chores, their weekend leisure activities, their yearly vacations and something as mundane as who gets to enter the bathroom first in the morning must be negotiated carefully. The members of the group must develop varying grades of tolerance for each other all the time. First of all, the parents must learn to love and show their sincere affection for children who are not biologically related to them but share the same hearth besides present and future family objectives. The siblings must learn how to be equitable in their dealings with each other, avoiding clannish attitudes that might damage the overall trust that young people demand from those close to them.

According to Maria and Victor, sometimes they have rough moments but so far, they have been able to avoid intractable situations that would poison their daily interactions; the fact that they are both professionals earning good income and with extensive social connections made a difference. They claim that their extended family is just a microcosmos of the much more problematic and larger inter-ethnic and multi-cultural environment of South Florida where we all live at present.

We wholeheartedly agree that this family constitutes a great example of how people from different backgrounds can eventually learn how to coexist in a closed environment for the common good. It is only natural that we tend to seek the company of people who are similar to us in the private sphere, especially when we are seeking a steady couple relationship. Things run much smoother. However, we should take a more open and tolerant attitude when we enter into the public sphere.

What do you think? Please tell us.

Don’t leave me alone.

 

Yoga and Exercise in early Parkinson’s disease

The emergence of a hyper-connected society where patients routinely check new information about treatments and medications for their diseases has completely changed the parameters that a modern medical practice operates in large, urban centers. Patients ask many questions. Patients with Parkinson’s disease and their relatives ask what non-invasive cures might exist.

The practice of Yoga has been shown to improve the muscle strength, flexibility and balance of its regular practitioners; however, its impact dynamic factors like gait, reactive balance and proprioception was not studied until a group studied the effects of a new meditation program.A new study found that YoMed was as effective as the Proprioception Training (PT) to improve the proprioception, balance and power in older patients that had suffered at least one traumatic fall.

Sixteen patients with Parkinson’s disease were randomly assigned to either the YoMed or the Propioception Training groups and they all received 45 minutes of training, three times per week for a total number of six weeks; patients were evaluated before and after the interventions. Neither the YM or the PT interventions showed statistical significant results except for the “dynamic posturography overall score” (DMA) that was readily improved in the YM group. Thus, YoMed might be clinically useful to improve the posture abnormalities in older PD patients.

Many patients are diagnosed with Parkinson’s disease based on the clinical symptoms but, given that they do not warrant starting a medication schedule yet, many of them ask physicians what they should be doing to slow the progression of this scary disease. Exercise comes to mind first. A study from the Physical Therapy department of the University of Colorado School of Medicine shows that an early start of high-intensity treadmill exercise might accomplish that benefit.

Schenkman et al. designed the “Study in Parkinson’s Disease of Exercise’ (SPARX) by studying 128 patients enrolled between 2012 and 2015, had between 40 and 80 years of age, were within five years of a diagnosis and were not exercising at moderate intensity more than 3 times per week; they were not taking any dopaminergic medication and were not expected to take it soon. They were divided into three groups as follows:

  1. High Intensity group of 43 patients that exercised four days a week at 80-85% of their maximum heart rate.
  2. Moderate Intensity group of 45 patients that also exercised four days a week but at 60-65% of their maximum heart rate.
  3. A control group of 40 patients that did not exercise.

The clinical outcomes were measured primarily by using the change of the motor scores in the “Unified Parkinson’s Disease Rating Scale” (UPDRS) from a baseline level and a six-month mark; the secondary outcomes were measured with the UPDRS subscores and the “Movement Disorders Society UPDRS” (MDS-UPDRS) The participants wore portable heart rate monitoring devices to measure the exercise intensity. The mean change in UPDRS score in the high intensity score was 0.3 compared to 3.2 in the control group; the mean change of UPDRS scoring in the moderate intensity group was 2.0. There were no serious collateral effects in this study. The data shows that high intensity-exercise is a viable alternative to defer the onset of grave PD signs. This phase 2 study is being followed by a more complex phase 3 study to provide more information.

What do you think? Please tell us.

Don’t leave me alone.

 

 

Friends with benefits

– “Doctor…An occasional tryst won’t break our marriage—on the contrary.”

Patrizia X. is a nice, attractive middle-aged professional woman with a nice family of four: a loving, considerate husband and three teenagers that are excelling at their studies. Who could ask for more? Well, she does. A few months ago, she sat down with her hubby and discussed together the decreasing eroticism of their relationship and ways to improve it. Being both Italian-Americans, the solution was not an easy one.

Finally they decided that they could each have an occasional date and sexual encounter with a partner of their choosing with the acknowledged aim to refresh their sexual desire. They could not lie or hide the romantic escapade to each other and they were not supposed to repeat the same escapade. Usually they chose mutual friends that would keep the secret or, in this time of extreme social connectivity, an old flame from the past that landed in the USA to visit or even an inconclusive high school relationship. The fact that they were not residents of the same city supposedly precluded any attachments.

They are not swingers. They do not profess the mantra of free love. And they don’t cheat. They assume, as informed and responsible adults, the need to revitalize their relationship with “un souffle au coeur” as the French had pointedly defined this novel arrangement. In order to properly function both members of the couple must be willing and ready to accept it; it cannot be the result of one of the partners co-opting the other one for a needed change. Once they complete their escapade, they erase that episode from their minds altogether.

Even though this kind of arrangement is rarely seen, it has become progressively more common, especially in young and middle-aged couples that are often educated and well off. The cross-fertilization of social habitudes in our multi-faceted, hyper-connected society has pushed out into the open something that had been an accepted practice for the closeted; when the LGBT community pushed for equal rights for marriage, they brought us a present. Homosexuals, unencumbered by the traditional view of the couple based on marriage, breeding and the patriarchate, have been tolerant of an occasional third party in their couples, as long as there was no lying, hiding or the break-up of their amorous relationship.

It all sounds very exciting and adventurous with the possibility of maintaining the status quo. However, we must respectfully disagree with the apparent “civility” of this increasingly common agreement; we will reluctantly play the part of “devil’s advocate” in this honorable court of bloggers’ forum. It is never that easy to keep a clear mind.

Long, long time ago (before I became a monk of Medicine) I had the rogue predisposition to establish clandestine friendships with duly married ladies, without any guilt or remorse. Each one of those felt like an exhilarating roller coaster ride that would jump-start our hearts. It was fun. It was invigorating. It was fabulous. But a Damocles’ sword was always hanging above us. After guilt-free sexual encounters with somebody you really liked (it’s only natural to want more of it) the bug of emotional attachment buzzed. Inevitably we tended to fall in love. And then what were we supposed to do, eh?

What do you think? Please tell us.

Don’t leave us alone.

Pain and Mindfulness in Multiple Sclerosis

Chronic pain is one of the most crippling, and oftentimes intractable to treatment, symptoms of patients with Multiple Sclerosis, many of them young people in the prime of their lifetimes. Given that most pharmacological schedules eventually bring collateral effects that intoxicate or limit the wakefulness of patients with good jobs, paths in Alternative Medicine have been explored.

Almost two thirds of MS patients experience some kind of severe pain in their daily demeanor. Patients experience different types of pain, which can be grouped in the following categories:

  1. Central neuropathic pain: dysesthetic extremity pain, tonic muscle spasm, trigeminal neuralgia.
  2. Musculoskeletal pain: cervical or lumbar radiculopathies.
  3. Mixed Neuropathies and nonneuropathic forms of pain: headaches.

Jon Kabat-Zinn initiated the practice of “mindfulness” in 1982 as a behavioral cure for pain. He wrote that it constitutes as “paying attention in a particular way; on purpose, in the present moment, and non-judgmentally.” It is as if the patient could detach himself/herself from the suffering condition and observe it in “an objective way” without expressing any judgements. It strives to let go of natural defensive mechanisms and to start the process of acceptance of pain. Various meditation practices like focused attention or open monitoring are being used, which activate some unique neural networks that modify the pain experience integrated in the CNS.

Angela Senders et al. designed a cross-sectional survey of MS patients followed in the outpatient clinic of the Oregon Health and Science University that completed several questionnaires during one study visit; patients that had a relapse or exacerbation in the previous 90 days were excluded. As a measurement device they use “pain interference”, which is “how much pain” limits the patient’s ability to perform the occupational and social tasks; they used the “Patient-reported Outcomes Measurement Information System (PROMIS) as the dependent variable in the study.

One hundred and fifty patients participated in the study, the majority were women (78%) and the mean age was 50.45 +/- 12.85 years; the majority of patients had the relapsing-remitting variant of the disease (74%) and two-thirds of them were taking MS DMT like interferon beta-1b. in the study model for every 18-point increase in the mindfulness score, the Pain-interference score was expected to decrease by 2.88 points. Six demographic features (age, sex, level of disability, type of MS, DMT and education) were studied for their interaction with mindfulness.

The study showed that the relationship between pain and mindfulness was very significant (t=-5.52, P less than .0001) For every 18-point increase in the mindfulness score, the pain interference score decreased by 3.96 points (Beta=-0.227, P less than .0001) In sum, there is a significant correlation between the practice of mindfulness and the amelioration of MS pain.

What do you think? Please tell us.

Don’t leave me alone.

 

The “hand of God”

Dear readers and fellow bloggers:

We are celebrating the Second Anniversary of our medical and literary page in May and we would like to thank all of you for a sustained and affectionate support for our work. My children and I are very grateful for the incredible success of this page. It would not have been possible without you snatching a few minutes out of your busy schedules to take a look at our articles and, in a some instances, even put some nice commentaries.

The image of this blog shows the extraordinary moment when Diego Maradona, the star of the 1986 Argentine football team that won the World Cup in 1986, pushes the ball with his hand past the English goalkeeper to score a decisive goal in the quarter finals. He blatantly cheated and made no apologies about it. On the contrary. When he was asked afterwards what had happened, he insolently replied: “it was the Hand of God.”

Likewise we would like to tell  you that this intellectual endeavor would not have been possible without the providential intervention of a higher authority: your kind support. Every day we sit down early in the morning to study and write at our desk, we have you in mind as we strive to provide you with a concise yet complete account of medical breakthroughs and the varied experiences of a physician practicing for more than 30 years. We might have dreamed of accomplishing this feat entirely on our own. No way. We carried on with our task because we counted on many readers and bloggers like you.

We would like to take this opportunity to introduce the preface of our new manuscript titled “Emotional frustration-the hushed plague”, which we are eagerly writing at present. Please read it and send us your opinion in order to steer a better course.

Thank you for all the help and attention you had granted us in these two years. We promise to continue our efforts to bring you the very best that we can offer.

What do you think? Please tell us.

Don’t leave us alone.

The cordial cohabitation

– “Doctor…It’s tough living under the same roof sometimes—we’re doing it for the kids.”

Kim X. is a very nice middle-aged nurse that has been separated from her husband for a few months already; they decided to stop their relationship because they weren’t in love anymore. They did it on good financial terms and decided to stay in separate rooms of the same house; considering that their two children are only 5 and 10 years old, they are threading carefully. For the time being they have reached an “entente cordiale” where they discreetly pursue their loving affairs outside the house but inside it they both emotionally support their young ones every day.

She confided that fact to me because she knew that I have been separated from “the mother of my children” since the beginning of the millennia but we have stayed very close all the time, with some ups and downs of course. Our two children were very small then and we made the conscious decision to relegate our personal lives a little in order to keep a watchful eye on them. I recently saw “Wind River”, an action film where the main character suffered because his daughter had been assassinated by a straggler when he had been fulfilling his duties as an Alaska park ranger. He admonished the female FBI agent that was helping him: “when you have kids, you can’t even blink. Not once.”

A few days ago, I listened to a panel discussion in “France Inter”, the leading private radio operator in France, where they discussed precisely this cohabitation arrangement. In general, the French have been quite permissive in their sexual and loving relationships, never doubting to change their spouses and or companions at the slightest hint of marital malfunction. However, the recent experience of thousands of young women, many of them working poor and members of Minority groups, has rekindled this perennial question: “do women need men to raise kids?”

Of course, they don’t, all the panelists agreed. But the presence of “the father figure” is needed. Most of the ladies confessed that raising a male child with a lot of love and dedication sometimes produced uncontrollable brats that felt entitled to anything. “Mom will give it to me” they said. The limits set by the vigilant presence of “the father” helped the youngster learn some basic civic virtues like respect and tolerance of the others, so necessary in our convulsed modern times. They even suggested that the rising crime rate of the “quartiers peripheriques” full of immigrants from Northern Africa and Eastern Europe could be countenanced by more social services. The present configuration of Paris entails the creation of a peripheral circumvoluting road that keeps those “undesirables” out of the more sanitized, clean and touristy “centre de la ville.”

What do you think? Please tell us.

Don’t leave me alone.

New test for Alzheimer’s Disease

One of our earliest articles in 2016 for this series of “Wellness” was a discussion of how dedicated researchers had found two new substances to tag in patients with Alzheimer’s disease. This grave pathology can go almost undetected for many years and diagnosis usually comes late. The new focus of pharmacological research has changed to the earliest stages of the disease when amyloid starts to build up in the brain and drugs might make a difference; in order to achieve that a new laboratory test is needed.

A new report in Nature shows that a novel blood test that measures the amyloid biomarkers could be a reliable predictor of the presence of amyloid plaques in Alzheimer patients’ brains. Drs. Nakamura and Villemagne, from research centers in Japan and Australia respectively, described initial results on a blood test for amyloid-beta 9Abeta) that is similar to an earlier test developed by another team in Washington University of Saint Louis. At present researchers believe that the deposition of amyloid plaques can precede at least twenty years the first signs of cognitive decline, for which it is critically important to detect it early on to cure the patients.

The blood testing method consisted of isolating and concentrate three amyloid peptides (Abeta40, Abeta42 and APP699-71) from a sample that contained thousands of other proteins. They took advantage of data from two different cohorts of participants (some normal, some with mild cognitive decline and others with severe Alzheimer’s disease) that were studied previously in Japan (121 people) and Australia (252 people) where they compared the results of positron emission tomography (PET) with the testing of cerebrospinal fluid for amyloid. They calculated ratios of the different amyloid biomarkers and a composite score of multiple biomarkers; a rise in the composite index suggested that there was an active accumulation of amyloid in the brain.

The researchers claim that there was a 90% accuracy rate and a high correlation between the blood and cerebrospinal fluid tests. This test is more cost-effective than other types of testing, which could be the determinant factor in its approval by the public and private payors. It is still being developed and available only in the research labs.

There is a critical need for a safe and practical laboratory test to diagnose Alzheimer’s disease to screen the potential participants in clinical trial studies that usually span for several years. Participants that were initially deemed to have early signs of the disease—a diagnosis that is often very difficult for clinicians—ended up as not having it, which skewed the study results. Getting the right participants into the numerous studies underway is of humongous importance to find safe drugs to use early on.

Researchers are still tweaking the test to find out if it could be used to differentiate Alzheimer’s from other causes of cognitive decline like Lewy body dementia or Frontal lobe dementia; they also want to know if it can be used to track the progression or the disease or to assess the clinical response of patients to new drugs.

What do you think? Please tell us.

Don’t leave me alone.