A Heroine of the Highest Order

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By Mary O’Brien, M.D.

Media reports described her as merely “an older woman.”  The implications are obvious.  “Older woman” translates into commonplace, generic, ordinary, and unimportant.  Nothing could have been further from the truth.  Lori Gilbert-Kaye was the 60-year-old lady who threw herself between the vicious 19-year-old gunman and the rabbi at the synagogue shooting in Poway, California.

Members of the congregation were observing the final day of Passover when they were attacked by unbridled evil.  Lori Gilbert-Kaye gave her life to save her rabbi. There is nothing commonplace, generic, ordinary, or unimportant about that.  Rabbi Goldstein described her valiant action at a deeply moving ceremony in the Rose Garden on the National Day of Prayer.  He lost several fingers in the horrific attack, but his wisdom, insight, courage, and compassion were only highlighted in the process.  He honored Lori Gilbert-Kaye in his brief but eloquent remarks.  A march in her honor is scheduled for early June.  No doubt many people will learn more about this kind, generous, devoted, and heroic “older woman.”

Is there something those of us in health care and education can learn from all of this?  Indeed, there is.  People have names.  They are not merely generic patients, students, or account numbers.  They are not simply old ladies or cases or room numbers.  Every human being has an identity, a personal story with challenges, heartaches, triumphs, and loved ones.  A woman who instinctively gave her own life to save another deserves to be known and remembered by her name.  Lori Gilbert-Kaye was heroic in life and in death.  She set a beautiful example for our nation.

Most of us will never have to make the split-second decision to sacrifice our own life to save that of another.  We do, however, have an opportunity everyday to honor others by using their proper names.  Lori Gilbert-Kaye was far more than an “older woman.”  She was a heroine of the highest order.

About Systemic Lupus Erythematosus (SLE)

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bhmkclteeodsgq5wrqwaSystemic lupus erythematosus (SLE) is an autoimmune disease that can cause damage to the heart, lungs, kidneys, joints, skin, brain, and blood vessels.   It is characterized by flare-ups, and symptoms, ranging from mild to severe, including extreme fatigue, chest pain, anemia, swelling in legs and near the eyes, painful joints, fever, skin rashes, hair loss, and kidney problems.

At least 1.5 million Americans suffer from lupus.  The ratio of female to male is 9:1 according to the Lupus Foundation of America.   African-American women are far more likely to be affected than are Caucasian women.   Recent research points to a strong genetic role, but environmental and hormonal factors seem to be involved in lupus as well.

Diagnosis can be difficult and may be delayed because the onset of symptoms is hard for patients to pinpoint and because the wide variety of symptoms overlap with many other conditions.  To diagnose lupus, the clinician takes a careful history, performs a physical exam, and orders anti-nuclear antibodies and other laboratory tests.

Although lupus can be life-threatening, some 80 to 90 percent of sufferers can expect to live a normal lifespan if they are carefully monitored and treated.

Management of lupus is directed at preventing flare-ups, treating symptoms, and preventing or slowing damage to organs.  According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), the principal medications include:

  • NSAIDs to reduce inflammation.
  • Anti-malarials such as hydroxychloroquine (Plaquenil®) to prevent flare-ups.
  • Corticosteroids such as prednisone (Deltasone®), hydrocortisone, methylprednisolone (Medrol®), and dexamethasone (Decadron®, Hexadrol®) to reduce inflammation.
  • Immunosuppressive agents such as cyclophosphamide (Cytoxan®) and mycophenolate mofetil (CellCept®) to inhibit an overactive immune system.  Belimumab (Benlysta®) is a B-lymphocyte stimulator protein inhibitor that was approved by FDA 2011 for patients with lupus who are receiving other standard therapies.  It may reduce the number of abnormal B cells thought to be a problem in lupus.
  • Methotrexate (Folex®, Mexate®, Rheumatrex®), a disease-modifying antirheumatic drug, may be used to help control the disease in some patients.

Other treatments may include hormonal therapies such as dehydroepiandrosterone (DHEA) and intravenous immunoglobulin, which may be useful for controlling lupus when other treatments haven’t worked.

A variety of self-care and complementary approaches can be useful, including exercise, diet, the avoidance of sun exposure, and skin protection.  Patients are advised to recognize early signs of a flare-up and get immediate medical attention.

Findings from prospective human studies have strengthened the evidence of a connection between lupus and vitamin D status.  There is evidence that increased vitamin D levels (via supplementation) may help reduce inflammation.  A reasonable dose would be 2000 IU of vitamin D3 on a daily basis.  Vitamin D levels are easily checked.

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Binge Eating Disorder

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binge-eatingBinge eating disorder is an illness that resembles bulimia nervosa. Like bulimia, the disorder is characterized by episodes of uncontrolled eating or binging—occurring, on average, at least once a week for three months, according to DSM-5 (“Diagnostic and Statistical Manual, ” version 5).  However, binge eating disorder differs from bulimia because its sufferers do not purge their bodies of excess food.

Individuals with binge eating disorder feel that they lose control of themselves when eating. While they commonly eat fewer meals than people without eating disorders, when they do eat, they eat rapidly, consuming large quantities of food.  They do not stop until they are uncomfortably full. When binging, they typically do so alone because of feeling embarrassed by how much they are eating.  They tend to feel disgusted with themselves, depressed, or very guilty afterward. Usually, they have more difficulty losing weight and keeping it off than do people with other serious weight problems. Most people with the disorder are obese and have a history of weight fluctuations.

Binge eating disorder is found in about two percent of the general population—more often in women than men. Recent research shows that binge eating disorder occurs in about 30 percent of people participating in medically-supervised, weight-control programs.

Because people with binge eating disorder are usually overweight, they are prone to the serious medical problems associated with obesity, such as high cholesterol, high blood pressure, and diabetes. Obese individuals also have a higher risk for gallbladder disease, heart disease, and some types of cancer. Research at the National Institutes of Health and elsewhere has shown that individuals with binge eating disorder have high rates of co-occurring psychiatric illnesses, especially depression.

Cognitive behavioral therapy and interpersonal therapy are the treatments found to produce the greatest degree of remission in patients with binge eating disorder.  These therapies result in improvements in specific eating disorder psychopathology and associated psychiatric problems, such as depression and psychosocial functioning (Wilson, 2011).

Epidemiology of Eating Disorders

 Estimates of the incidence or prevalence of eating disorders vary depending on the sampling and assessment methods.

  • An estimated five million Americans suffer from eating disorders at any given time, including approximately five percent of women and less than one percent of men.  The disorders include anorexia nervosa, bulimia nervosa, and binge eating disorder.
  • Estimates of the male-female prevalence ratio range from 1:5 to 1:1 (although 19 to 30 percent of younger patient populations with anorexia nervosa are male).
  • The reported lifetime prevalence of anorexia nervosa among women has ranged from 0.5 percent for narrowly defined cases to four percent for more broadly defined cases of anorexia nervosa.
  • Estimates of the lifetime prevalence of bulimia nervosa among women have ranged from 1.1 to 4.2 percent. Some studies suggest that the prevalence of bulimia nervosa in the United States may have decreased slightly in recent years.
  • An estimated 85 percent of eating disorders have their onset during adolescence.
  • Approximately 5 to 1.0 percent of adolescents suffer from anorexia nervosa and one to five percent suffer from bulimia nervosa. Female college students are at highest risk of the latter.
  • The prevalence of anorexia nervosa and bulimia nervosa in children and younger adolescents is unknown.
  • While eating disorders have generally been recognized as affecting a narrow population of Caucasian adolescent or adult young women from developed Western countries, in recent years, data are steadily accumulating to document that:
  1. eating disorders have become more common in pre-pubertal children and women in middle and late adulthood in such countries.
  2. ethnic and racial minority groups in these countries are vulnerable to eating disorders.
  3. there is nothing uniquely “Western” about eating disorders, which are a global health problem (Pike et al, 2013).

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Animal Companionship

Posted on Posted in Brain Science, Continuing Education, Homestudy, Psychology

girl-1561943_640By Barbara Sternberg, Ph.D

Our pets occupy a special place in our lives and our hearts partly because they love us no matter who we are. Successful or not, rich or poor, young or old, our pets not only don’t care, but remain constant as our own human fortunes ebb and flow.

We see this constancy in the way our pets greet us after we return from an absence. A pet’s greeting is always exuberant, as if they are welcoming home a long-lost, beloved family member. The pet makes no demands on us (other than to return its greeting and maybe get scratched) and harbors no ill feelings over having been left behind. This happy homecoming replenishes us and helps us feel that life is safe, that everything is as we left it, and that we have not changed.

When humans face serious trials—illness, loss of a job, the disabilities of aging— affection from a pet becomes even more important. The pet’s continued affection shows us that the essence of the person has remained unchanged. For this reason, pets can be of enormous value in the treatment of depressed or chronically ill individuals, as well as the institutionalized elderly.

Playing with a pet—a game of catch, or friendly roughhousing, has a kind of constancy to it because pet play does not involve true competition. Even a game of tug-of-war is played in fun — for the pleasure of both participants. Typical pet games, once learned, stay constant, just as the animal does. Playing games with our pets is reassuring and provides a break from life’s burdens. One of the great pleasures of pets—whether we are playing with them or just watching them—is their appeal and their ability to make us smile and laugh. Laughter is therapeutic, and our pets are able to induce it with great regularity.

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The “Baby Blues”

Posted on Posted in Brain Science, Continuing Education, Homestudy, Psychology, Webinars

mother-589730_640 “Baby blues” is the term used to describe the mood swings that the majority of women—approximately 85 percent—experience during the first two weeks or so after giving birth. The baby blues are considered a normal biological reaction to childbirth and tend to resolve rather quickly.

Although Post-Partum Depression and baby blues share many of the same symptoms, they are not identical. With the baby blues, symptoms such as weepiness and anxiety come and go and are interspersed with periods of happiness and contentedness. In contrast, Post-Partum Depression is a far more serious condition that involves negative symptoms and unrelenting feelings. Post-Partum Depression is also much more debilitating; with the baby blues, the new mother is still able to take care of  herself, her new baby, and any other children.

Symptoms of the baby blues include irritability, rapid mood swings, tearfulness, and anxiety, usually beginning about two days after delivery. They tend to be mild and last about two weeks, roughly until the woman’s hormones return to normal levels. The baby blues resolve relatively quickly, and no medication or therapy is needed. However, if the “normal” baby blues symptoms last longer than three weeks, get worse instead of better, or more serious symptoms like intrusive thoughts arise, it is possible that what started as the baby blues may now be a case of Post-Partum Depression.

Neuropsychiatrist Louann Brizendine points out that a negative aspect of breast feeding can be a lack of mental focus, or a feeling of being fuzzy and absentminded. The parts of the brain responsible for focus and concentration are preoccupied with protecting and tracking the newborn for the first six months or so after birth. Lack of sleep contributes to the mental fog, and a woman’s brain does not return to normal until six months post-partum.

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Anaphylaxis: Always an Emergency

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anaAbout 30 of every 100,000 people experience food-induced anaphylaxis.  An anaphylactic reaction should always be considered a medical emergency. Symptoms generally appear as soon as someone who is hypersensitive swallows a food allergen. The symptoms may not appear until up to four hours after exposure. How swiftly an anaphylactic reaction begins and how severe it becomes depends on:

  • the sensitivity of an individual to the allergen.
  • the amount of allergen swallowed.
  • how many different food allergens were consumed.
  • food preparation.
  • precipitating medical conditions.

An anaphylactic reaction may begin with tingling, itching, or a metallic taste in the mouth. Even the mildest symptoms can become severe within a short time. Anaphylactic reactions can go on for hours. They may include:

  • wheezing and other breathing problems.
  • swelling of the mouth and throat.
  • cramps and nausea.
  • rapid pulse and sudden drop in blood pressure.
  • hives and flushing.
  • itching of the palms of the hands and the soles of the feet.
  • loss of consciousness.

Anaphylaxis can be a biphasic reaction: New, more severe symptoms sometimes appear as long as two to six hours after the initial wave of symptoms has receded. These recurring symptoms often involve the respiratory system and can be deadly.

Peanuts and tree nuts are the foods most likely to cause severe food-allergic reactions. The other most common causes of anaphylaxis attributed to food allergies are:

  • shellfish
  • fish
  • milk
  • eggs

People who have asthma and food allergies are thought to have a greater than average risk of developing a food-allergic anaphylactic reaction. Having experienced one or more severe allergic reactions also increases the likelihood that an individual will have an anaphylactic reaction in the future.

The risk of fatal anaphylactic reaction is greatest among adolescents who have asthma and allergies to peanuts and tree nuts but disregard early food allergy symptoms and do not have ready access to epinephrine. Used to halt the progress of an anaphylactic reaction and reverse its symptoms, this drug is self-administered by injection. Epinephrine is often prescribed for individuals with a history of severe allergic reaction

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Emotions, Mood & Mood Swings

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girl-1149933_640The word “emotion” comes from the Latin word emovere (to move), suggesting an action or state opposite to being still or calm. Human emotions have been studied since the days of Charles Darwin, who described about a dozen separate emotions and argued that the expression of many of them served adaptive evolutionary functions. Emotions have only recently become a subject of serious inquiry in the field of psychology.

Emotion is related to goals; it stems from situations that enhance or threaten the likelihood of attaining a goal. If a person perceives a threat to attaining a goal, a negative emotion results, and if a person makes significant progress towards reaching a goal, the result is a positive emotion. Emotions, whether fear, pleasure, or love, are mostly transient in nature—a fluctuating response to our thoughts about our surroundings.

Although experiencing emotions is both natural and invaluable, emotions can also become intense and unremitting. When emotions persist and are not tied to a particular stimulus, they are called moods. Moods tend to last longer than specific emotions and set the emotional tone for what we think, feel, and do. Moods are less

Mood swings are shifts in moods that can occur over a period of time, either in the course of a day, or over many months. Most of us experience subtle changes in mood based on small things that happen during the day, and often we’re not even aware of these changes.

Extreme and persistent mood states can result in mental disorders such as depression and anxiety. Depressed people feel unrelenting sadness and an inability to derive pleasure from positive situations. Extreme mood swings can be a hallmark of bipolar disorder, with mood swings occurring as frequently as several times a day or alternating over the course of months, from depression to a euphoric or irritable mania that may or may not be pleasurable.

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Childhood Nightmares

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fantasy-1152677_640Sleep disorders occur in 35 to 45 percent of children ages 2 to 18 years,  with peak incidence in children ages 3 to 6 years.

Nightmares occur sporadically in many children and are frightening events for the entire family. Nightmare disorder is characterized by repeated episodes of a frightening or unpleasant dream that disrupts the child’s sleep. The child’s reaction often interrupts the parents’ sleep as well. On awakening from a nightmare, a child is alert and aware of the present surroundings, but the sleep disturbance causes distress and impairment in everyday functioning.

Nightmares are often confused with the parasomnia known as night terrors, which, as noted earlier, are episodes of extreme panic and confusion associated with vocalization, movement, and autonomic discharge. Children with night terrors are difficult to arouse and console and do not remember a dream or nightmare.

Other considerations include:

  • Nightmares are not associated with specific physical findings.
  • Heart rate and respiratory rate may increase or show increased variability before the child awakens from a nightmare. Mild autonomic arousal, including tachycardia, tachypnea, and sweating, may occur transiently upon awakening.
  • Approximately seven percent of individuals who have frequent nightmares have a family history of nightmares.
  • Nightmares are more common in children with mental retardation, depression, and CNS (central nervous system). An association also has been reported with febrile illnesses.
  • Medications may induce frightening dreams, either during treatment or following withdrawal. Withdrawal of medications that suppress REM (rapid eye movement) sleep can lead to an REM rebound effect that is accompanied by nightmares.
  • Nightmares may result from a severe traumatic event and may indicate post-traumatic stress disorder.

Management of nightmares is based on reassurance. Although all stressors cannot be removed from a child’s life, parents can attempt to make bedtime a safe and comfortable time. Parents should be encouraged to spend time in the evening reading, relaxing, and talking with the child.

If the child has a recurring nightmare, it may help to have parents encourage the child to imagine a good ending. Psychological evaluation is indicated when nightmares occur more than twice a week over several months. Medications are neither helpful nor indicated.

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Stress: The Silent Stalker of the Heart

Posted on Posted in Continuing Education, Elder Care, Homestudy, Pain, Seminars, Webinars

heart-915562_640Despite the many advantages of today’s technological progress, chronic stress persists as a major problem. Stress is not only uncomfortable, it can cause major damage to the circulatory and immune systems, leading to hypertension, arrhythmias, increased coagulation, and atherosclerosis.

Stress also exacerbates coronary heart disease (CHD), myocardial infarction (MI), and heart failure. Various stressors have been found to raise the risk of heart disease and even increased mortality due to heart disease—especially chronic work-related stress, marital strain, bereavement, and social isolation. Acute emotional stress may trigger myocardial infarction and a phenomenon known as stress myocarditis.

Stress, by virtue of its effects on adrenaline release, triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity. In some individuals, the intrinsic effects of stress include exaggerated heart rates and blood pressure responses. Emotions that often come with stress, namely anger, hostility, anxiety, and depression, bring a heightened risk of cardiovascular disease, coronary heart disease, and cardiac events, and — in those with heart disease — poor prognosis.

Depression is related to greater risk for developing coronary heart disease (CHD), poor prognosis in CHD, and higher mortality in those with CHD. It is also associated with arrhythmias, higher risk of acute coronary syndrome, and poor prognosis after myocardial infarction.

Those who are depressed are less likely to make lifestyle changes important for heart health. Mood disorders such as depression and anxiety may also affect lipid metabolism. Twenty percent of individuals who have cardiovascular disease or a previous history of MI have been found to have major depressive disorder (MDD). Psychosocial stressors can be both a cause and a consequence of cardiovascular disease events. Stress management might reduce future cardiac events in patients with cardiovascular disease.

Unless medications are required, patients can often make lifestyle changes that markedly decrease chronic stress. Some recommended strategies include:

  1. exercising on a regular basis.
  2. meditating for one or two 20- to 30-minute sessions a day. Studies show meditation can have lasting effects on blood pressure and heart rate.
  3. taking a vacation or a long weekend off.
  4. writing about stressful events.
  5. participating in a support group.
  6. regularly doing deep breathing exercises.
  7. using progressive muscle relaxation, which reduces muscle tension by relaxing individual muscle groups.
  8. practicing yoga, tai chi, or qi gong, all forms of exercise and meditation that are effective in reducing stress.
  9. spending more time outdoors.
  10. disconnecting from electronics and social media.
  11. listening to soothing music or silence.
  12. engaging in creative endeavors or hobbies.

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Essentials of Hypothermia

Posted on Posted in Continuing Education, Homestudy, Pain

 

tyrol-69661_640Surviving hypothermia after being left for dead in the wilderness makes an interesting story line in the movies.  In real life, hypothermia kills over a thousand people each year in the United States alone.  Knowing how to recognize it and treat it (or better yet, prevent it) can save lives.

Systemic hypothermia involves a core body temperature below 35 degrees Celsius.  Accurate measurement is crucial and the core temperature probe must be able to measure as low as 25 degrees Celsius.  Resuscitative measures must always be continued until the patient’s core temperature is clearly over 32 degrees Celsius (unless there are obvious fatal injuries).  As every physician, nurse, and first responder has been taught, “you’re not dead until you’re warm and dead.”

Susceptibility to hypothermia is increased by extremes of age, heart disease, exhaustion, hunger or malnutrition, dehydration, hypoxia, immobility, intoxication with drugs or alcohol, low body mass, contact with moisture or metal, and loss of consciousness.  Even in the movies, victims of hypothermia try desperately to stay awake and keep moving.

Clinical signs and symptoms of hypothermia vary based on the patient’s underlying status.  In general, however, there are four stages:

  • Stage I- CBT (core body temperature) is between 32 degrees Celsius and 35 degrees Celsius.  The patient is shivering and may be losing good judgement and coordination; still conscious and hemodynamically stable.
  • Stage II – CBT is between 28 degrees Celsius and 32 degrees Celsius.  Shivering stops, pulse slows, and pupils dilate.  Reflexes slow and “cold diuresis” develops as a result of renal dysfunction and low levels of ADH (antidiuretic hormone). Eventually, this will lead to hypovolemia and shock.  The patient becomes increasingly confused and lethargic.
  • Stage III-CBT is between 24 degrees Celsius and 28 degrees Celsius. Vital signs may still be present, but the risk of cardiac arrest increases dramatically, and the patient is now unconscious.
  • Stage IV – CBT is less than 24 degrees Celsius.  Vital signs are absent.  There is coma, loss of reflexes, asystole or ventricular fibrillation and rigor mortis. The patient appears dead but may still be salvageable.

The cornerstone of treatment in hypothermia is rewarming.  Rapid assessment with support of airway, breathing, and circulation must occur almost simultaneously.  All cold, wet clothing should be removed and replaced with warm, dry clothing and blankets.  The patient’s head should be covered and every effort must be made to prevent additional heat loss.  In general, raising core body temperature by 1 degree Celsius per hour is safe.  Giving warmed IV fluids (normal saline at 45 degrees Celsius) may be helpful.

Great care and caution must be used when moving or transporting a hypothermic patient.  The combination of vasoconstriction, hypovolemia, and return of cold peripheral blood to the central circulation can cause ”core temperature after drop.”

This phenomenon, combined with lactic acidosis, can precipitate potentially fatal arrhythmias known as “rescue collapse.”  This is where real life must break with the movies.  Dramatic scenes where the rescuer frantically rubs and massages the victim’s extremities may be riveting, but they’re also wrong.

Preventing hypothermia is much easier than treating it.  When in doubt, rely on the old adage: Keep warm, keep dry, and keep moving.

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