My prostate and yours: benign and malignant

April 10th, 2013
At my age, I'm not scheduling this.

At my age, I'm not scheduling this.

I just printed an article from the Annals of Internal Medicine that confirms my own leanings toward prostate screening tests. In one of my old posts I told the story of having an abnormal blood test for kidney function and seeking out our senior urologist at Duke. I was a clinical Nephrology fellow at the time and when I was seen, the Chief of Urology asked what kind of diet I was on.

I groaned at that point since I realized I was in the middle of a research project and eating a very high-protein diet. That's why the more accurate of the two blood chemistry tests was entirely normal and the other, clearly influenced by my diet, was high.

He then said, "As long as you're here, Peter, let me check your prostate.

The digital rectal exam (DRE) revealed I had a mildly enlarged gland for my age and the urologist said, "You're going to have a TURP by the time you're sixty.

I knew a TURP was a transurethral resection of the prostate. If you look at the Mayo Clinic website I've provided, you'll see it's a procedure to relieve partial obstruction of the urethra, the tube that runs from the bladder through the penis to allow normal urination. The prostate itself, whose major task is to provide seminal (sperm-carrying) fluid, is a walnut-shaped, one ounce gland, or at least it is in younger men. As men age the prostate commonly enlarges. If it does so in a non-cancerous way, the condition is called BPH, benign prostatic hyperplasia (or hypertrophy as I was taught in medical school; the first term implies more cells; the other a bigger gland without specifying how it got that way).

As the prostate gets bigger and partially blocks the outflow of urine, men have a decreased urine stream, difficulty starting its flow, dribbling after urination or a more frequent need to pee, especially at night.

Urologists do about 150,000 TURPs a year in America, although there are a number of other procedures to treat BPH. And they want to do a DRE and draw blood for a PSA on more of us guys than I would agree with. There are other tests in their repertoire: rectal ultrasound, urine flow study and cystoscopy (inserting an instrument into the urethral to actually look at how narrow the passageway is).

The American Urological Association's (AUA) webpage on the surgical management of the condition says 88% of men who have a TURP will have significant improvement in their symptoms. But there are lots of complications that can occur right after the procedure: infection in 15%, bleeding requiring blood transfusion in 5-10%, impotence in 14%, incontinence in 1%. Ten percent may require a second operation within 5 years.

There also are medical therapies for BPH; I take two different pills a day for my BPH and will turn 72 in two weeks. I haven't needed a TURP yet.

But that's benign disease: how about prostatic cancer?

The ACP says there's debate on screening; what does your physician think?

The ACP says prostate cancer screening should be individualized; what does your physician think?

The recent Annals article I mentioned looked at four sets of prostate cancer screening recommendations, all from national organizations: the American College of Preventive Medicine, the American Cancer Society; the AUA and the U.S. Preventive Services Task Force (USPSTF).

After doing so, the Clinical Guidelines Committee of the American College of Physicians (ACP), a national society of internal medicine physicians, issued two guidance statements. ACP wants all clinicians to tell their male patients who are 50 or older and under age 70 that the positive effects of screening for this malignancy are limited and there are considerable potential negative effects.

That being said, if I were an African American man in that age range I'd be much more likely to ask to be screened. Both the incidence rate and the mortality rate from prostate cancer are higher in black men. And if I had a family history of the disease in a first-degree relative (father, brother or son), I might be first in line for a PSA and possibly a DRE. With one such having had it, my risk doubles and with two close relatives having the disease, my chances go up fourfold. That's especially true if they were diagnosed before they turned 65.

Overall a sixth of all men will eventually be diagnosed with cancer of the prostate. It will lead directly to death in a much lower percentage (2.9% was the figure the ACP quoted from a National Cancer Institute fact sheet). So although 2.3-2.5 million men in this country are living with this malignancy and last year nearly a quarter of a million got the diagnosis of prostate cancer in the U.S., a considerably smaller number were likely to die from the cancer itself.

Why does this make sense?

Well let's start with the second of the ACP's guidance statements: the organization says that men with an average risk of the disease shouldn't be screened until they are 50 and those of us 70 and older also should avoid having a PSA as a cancer screening tool. They go further and say men who are not expected to live more than 10 to 15 more years also should not be screened.

The fact sheet from the Prostate Cancer Foundation says it is the most common non-skin cancer in America with a new case very 2.2 minutes and a death every 17.5 minutes. But it's rare in men under 40 with 1 in 10,000 being diagnosed with the ailment versus 1 in 14 who are aged 60 to 69.

If we look at the totals: 97% of men diagnosed with prostate cancer are 50 or older and nearly two-thirds  are over 65.

The USPSTF came out with an update to their take on screening guidelines in 2012. They agree that the benefits of these tests, primarily the PSA, are less than the potential harm associated: false-positive tests, psychological effects, biopsies that are not necessary and over-diagnosis of cancers that often do not reach any clinical significance in the lifetime of the patient involved.

In other words, elderly men may well have prostate cancer, but they most commonly die from something else. And screening men at age 40, as the AUA suggest, doesn't appear to be based on any major studies.

If you are a man over 50, but less than 70, or black or first-degree relatives (father or brothers) have had the disease, have a sincere talk with your doc about the risks and benefits of screening.

But I don't fit into any of those groups, so I don't plan to get a PSA unless or until I see different data.

Thank you, ACP, for clarifying the subject, especially since you agree with me.

 

 

Tags: , , , , ,
Posted in BPH, DRE, prostate cancer, prostate cancer screening, PSA, TURP | No Comments »

But won't I gain weight if I quit smoking? You may die if you don't.

April 3rd, 2013
A sign for our times

A sign for our times

Half of those who smoke die before their time. And there's a direct linkage between their smoking habit and the diseases they die from.

I stopped smoking as a junior in medical school forty-eight years ago. I was helping take care of a Veterans Administration cancer ward and saw one of our patients, smoking through his tracheostomy. I had only been a smoker for two years and had been thinking of quitting: that visual image cinched the matter.

My father, who lived to almost ninety-five, gave up the habit as a young doc. One morning he realized he had ashtrays in all three rooms of his medical office and a cigarette that he had lit was burning in each one. He snuffed all of them out, threw his pack of "cancer sticks" away and got rid of the ashtrays as well.

A May 2010 fact sheet from the World Health Organization (WHO) with the simple title "Tobacco," states the clear-cut, nasty facts. The noxious weed kills almost six million people a year; in all smoking leads to one out of every ten adult deaths. WHO states that ten percent of those are nonsmokers who've had the misfortune to be exposed to second-hand smoke. They breathe in some of the 4,000+ chemicals in tobacco smoke with a least 250 of those known to be harmful and more than 50 known to cause cancer.

But there is even worse news; over 40% of kids have a parent who smokes and those kids are among the group exposed to all those dangerous chemicals from second-hand smoke. One estimate is that ~30% of those who die from second-hand smoke are children.

Overall, the World Health Organization says tobacco caused 100 million deaths in the 20th century and, unless something changes radically, our smoking trends worldwide could lead to a tenfold increase in those deaths in the 21st century. Current estimates say there are at least one billion smokers across the globe and roughly eight of every ten of those live in low- and middle-income countries. We've got a considerable share of smokers in this country as well, many of them are relatively young.

Growing the plant raises another problem for children. Although most of the world's tobacco is raised elsewhere, with China Brazil and India leading the pack, the United States still has a $35 billion per year industry for the "pernicious weed" with 303 billion cigarettes sold in 2010 and 122.6 million pounds of smokeless tobacco. The kids who live in regions that raise the plant are often employed in cultivating and harvesting it.

Don't handle these in any form, kids!

Don't handle these in any form, kids!

Those children are potential victims of green tobacco sickness (GTS), even if they don't smoke or chew it themselves. The occupational disease they contract is actually acute nicotine poisoning and reports of cases in children and adolescents have been reported only in the US in the medical literature and rarely even there.

Agricultural occupational illness, for example from pesticide exposure, is well known, but the risk factor is ordinarily not  plant itself. In the case of tobacco (as is the case for opium) the crop is actually the major biohazard, with a major component being the nicotine dissolved in rain or dew on the tobacco leaves. Children usually haven't developed tolerance to nicotine like long-term adult smokers have and frequently lack any knowledge of the risks involved in handling the leaves of the plant.

Nausea, vomiting, headaches, weakness and dizziness are among the symptoms of GTS. It's quite uncommon for the affliction to be severe enough to be fatal, but the 2005 report above quotes a child who said he felt, "like I was going to die."

With most of the world's production of tobacco coming from outside the US, especially in developing countries where pediatric emergency and intensive care is considerably less available, much more attention needs to be paid to the risk factors for GTS and potential strategies for its avoidance.

JAMA, the Journal of the American Medical Association, recently (March 13, 2013) published a research article and two other commentaries on smoking cessation.

One of the reasons, actually rationales (or better yet, excuses) smokers give for not quitting is, "I'll gain weight and that's just as bad for my health!" An article with the ponderous title "Association of Smoking Cessation and Weight Change with Cardiovascular Disease Among Adults With and Without Diabetes," attempted to parse this belief. The short take on this article is available online on an NIH webpage. Data was gathered on cardiovascular disease (CVD) events and weight gain among 3251 Framingham Offspring Study participants followed for a mean time of 25 years (the study ran from 1984 to 2011).

Smoking cessation was associated with a considerably lower risk (about half) among those in the study who were not diabetic. Long-term weight gain was mild (typically a couple of pounds after an initial bump of perhaps five pounds) and did not affect the CVD benefits of stopping smoking.

An associated question, "Helping Smokers Quit Around the Time of Surgery," was discussed by three academic physicians, one from Yale and two from UCSF. It is common for smokers to have no pre-operative counseling on cessation programs before they have elective surgery, yet their post-op complication rate is markedly higher if they haven't quit.

Two randomized, controlled studies, one in Lancet in 2002 and the other in the Annals of Surgery in 2008, have shown a marked decrease in after-surgery problems, including pneumonia, wound infections, strokes and heart attacks, through a 4 to 8 week pre-op smoking cessation program. .

It's clearly time to focus our attention on the huge issues associated with growing, harvesting and smoking/chewing tobacco.  The enormous health costs involved are well worth our best efforts.

Otherwise ten million surgical patients (in this country alone), children workers in the tobacco industry in many countries, all those who are hooked on the weed and those of us exposed to second-hand smoke will continue to be at risk.

 

Tags: , , , , , ,
Posted in green tobacco sickness, second-hand smoke exposure, smoking cessation programs, smoking-related deaths, tobacco | No Comments »

Still too much salt for adults and for kids

March 25th, 2013

The American Medical Association newsletter for March 22, 2013, focused on our excess salt (sodium chloride) intake threatening the health of both adults and kids in this country. Two major studies were discussed.

Let's leave most of this salt sitting there.

Let's leave most of this salt sitting there.

The ABC Medical Unit blog on the subject had the title "1 in 10 U.S. deaths blamed on salt." The research came from a Harvard epidemiologist, Dr. Dariush Mozaffarian who links excess dietary sodium worldwide to almost 2.3 million deaths yearly (2010 data). The same researcher had a project looking at the impact of added-sugar beverages; now he concludes that excess sodium was a worse culprit.

The question has always been whether reducing dietary sodium intake, widely acknowledged to reduce blood pressure, can also positively impact the occurrence of cardiovascular disease. One classic article, published in the British Medical Journal in 2008, originally studied ~3,000 adults with prehypertension (i.e., blood pressures that aren't over the 140/90 limit, but are trending that way; Mayo Clinic staffers uses 120-139 over 80 to 89 to define the entity). The group, age 30 to 54, were enrolled for one to four years in randomized lifestyle intervention trials, called TOHP (trials of hypertension prevention). The long-term effects on the TOHP participants (over 10 to 15 years) showed  cardiovascular disease events (heart attacks or strokes) were less frequent (25-30%) in the group originally assigned to a lowered salt intake diet.

Many of us eat (or in my case used to eat) a diet higher in sodium than is currently recommended. I cut way down on salt nearly thirty years ago when my blood pressure crept up, eating out less often, not purchasing packaged foods unless their labels revealed relatively less salt, cooking with half to a third of the salt a recipe suggested and not adding salt at the table. There is evidence that our preference for eating salty foods can "reset" in about three months on a reduced salt diet and I would certainly concur with this; salty foods just taste bad if I try them now.

Dr. Mozaffarian's data, recently presented at an American Heart Association (AHA) meeting in New Orleans, was a compilation of 247 surveys on sodium intake and 107 clinical trials. The latter set examined both salt's effect on blood pressure and the logical, though unproven corollary that lowering BP can have a positive effect on the development of cardiovascular disease (CVD).

The results strongly support the evidence that high-salt packaged and processed foods contribute to our epidemic of CVD. Dr. Mozaffarian was quoted as saying bread and cheese are the top two sources of sodium in the U.S. diet.

Another of the researchers involved in the study was quoted as saying, "This study is the first time information about sodium intake by country, age and gender is available. We hope our findings will influence national governments to develop public health interventions to lower sodium."

That would be wonderful, but in the meantime, it's up to us (and I'll say this over and over) to read labels for sodium content.

As usual the Salt Institute tried to minimize the research's impact on the average American, saying it hadn't yet been published in a peer-reviewed journal and was misleading. Of course they make their living selling and promoting salt, so I take their comment with a grain of...pepper.

A second study, presented at the same AHA conclave, said that 75% of people around the world consume much more than the recommended amount of salt. Figures from 2010 said the worldwide average was close to 4,000 milligrams per day as opposed to the World health Organizations suggested 2,000 mg and the AHA's newer 1,500 mg figure.

The clues to having less salt in your diet: start with reading labels (we've done this for years, deliberately picking, for example, lower-salt versions of spaghetti sauce and cheeses. Obviously, as I've written before, avoiding pre-packaged meals in favor of fresh vegetables and fruits is another salt-avoidance technique. Re-training your palate, as noted above, may be easier than you think.

Not a great choice for this toddler's snack; try carrots instead

Not a great choice for this toddler's snack; try carrots instead

Another study, headed by Joyce Maalouf, a fellow at the CDC's National Center for Disease Control and Prevention, was featured online by Science Daily on March 21, 2013. This one looked at pre-packaged foods for young children in the United States. Over 1,100 products sold in our grocery stores and designed for the baby and toddler market were evaluated. A cutoff level of 210 mg of sodium per serving was established and toddler meals, on average, exceeded that level 75 percent of the time, some by a factor of three (630 mg of sodium per serving).

Let's look at the logic. If it only takes three months to educate an adult's sense of what's enough salt in a meal, then it seems to me we're training our toddlers to prefer high-salt food items when they are too young by far to be doing their own shopping.

The take for us as parents and grandparents is to read labels, not only on foods that we may choose for ourselves and the adult members of our families, but also (and especially) for our youngsters.

Maalouf's data, highlighted in a CNN article online mostly looked at pre-packed meals that are typically heated in a microwave. She noted that the USDA recommended total intake levels for toddler sodium consumption were 1,000 to 1,500 mg per day.

My experience with kids at the that age is like hers (while much more limited); they are "walking appetites" and in some households are allowed to eat six to eight snacks a day. That can add up to an enormous amount of salt and form dangerous eating habits that last a lifetime.

Again the basic lesson is the same: read labels and vote with your choices of lower-sodium foods. If enough of us quit purchasing high-salt items, they will eventually go off the market.

And ignore the voices of those whose basic interest isn't your health or that of your children, but rather their own profit margin.

 

Tags: , , , , ,
Posted in cardiovascular deaths, salt intake | No Comments »

Stroke updates: new symptoms and old associations

March 22nd, 2013

Most strokes (AKA cerebrovascular accidents or CVAs) cause multiple symptoms and often develop suddenly, but in some cases you may be having a stroke and not be aware of it. The NIH website on stroke has lots of basic information that may be helpful; the most important fact, I think, is that stroke is a medical emergency. If you believe you're having a CVA, call 911.

The saying is, "Time is brain," in other words the more rapidly you can receive modern emergency stroke therapy, the more brain cells you can potentially save. The Mayo Clinic website has a through discussion of modern emergency therapy for stroke, but urgency is crucial.

We commonly think a person suffering a CVA suddenly loses feeling or muscular control in an arm or leg or one side of their body, but changes in alertness, hearing or taste, clumsiness, confusion, vertigo, loss of balance, personality changes, visual difficulties and a host of other symptoms/signs may also result from a stroke

Text messages should make sense.

Text messages should make sense.

Recently a new symptom has appeared, not dyslexia, a very broad term defining a person's fluency or comprehension accuracy in being able to read, but dystextia, the loss of ability to send coherent text messages. Two cases of this bizarre presentation of a CVA have been reported in the last four months. JAMA Neurology had a March, 2013 article concerning a previously-health 25-year-old pregnant woman, brought to an emergency room after sending her husband garbled text messages about the baby's due date. In retrospect she had encountered some difficulty in filling out forms during a visit to her Ob-Gyn physician and had also experienced a brief episode of weakness in her right arm and leg.

Her workup revealed other neurological signs and an MRI showed evidence of a stroke. Fortunately she had a rapid improvement and was given low-dose aspirin and another blood thinner for prophylaxis of leg clots (since she had an atrial septal defect (AKA hole in her heart) that could allow a clot to go to the brain. Her fetus suffered no harm.

Another person initially presenting with dystextia, in this case a 40-year-old man, was reported in a New York Times online article recently. By the following day the businessman involved had developed some speech difficulties and a CT scan showed an abnormality in a portion of the brain involving language production. So, in this era, with many people using their cell phones and their digits, but not their voices, to communicate, sudden development of garbled texting may be an early symptom of a stroke. It could be considered a form of aphasia, a condition that robs you of the ability to express yourself to others.

In October, 2010 the World Stroke Organization launched a "1 in 6" campaign" saying that's the proportion of us that will have a stroke in our lifetime. The statistics are grim: every six seconds a stroke kills someone, with estimates of 15 million CVAs a years worldwide resulting in 6 million deaths. In the United States, stroke is one of the leading causes of death with 130,000-140,000 fatalities a year.

Risk factors include high blood pressure, a family history of stroke, an irregular heart rhythm called atrial fibrillation, diabetes, race (blacks are more likely to die of a stroke), high cholesterol and increasing age.

In December, 2012, JAMA published an article titled "Sex, Stroke and Atrial Fibrillation." Before I go into the article itself, let's talk about the malady, AF for short. It's the most common type of abnormal heart rhythm, affecting millions of Americans, according to the NIH's National Heart, Lung, and Blood Institute. AF is caused by conditions (like high blood pressure or coronary artery disease) that damage the conduction system of  heart, its equivalent of the electrical wiring system in your house. The result is a heart rhyme that is the antithesis of being regular; it's irregularly irregular with heart beats coming at odd intervals.

The upper chamber receive blood and lower chambers pump it out

The upper chambers receive blood and lower chambers pump it out

During AF, the hearts upper two chambers, the atria, don't pump every bit of their blood to the lower two chambers, the ventricles. When that happens, clots can form and can migrate up to the brain, causing a stroke.

The recent article studied more than 83,000 patients over the age of 65 who were admitted to a hospital in Quebec with a recent diagnosis of AF. Slightly more than half (52.8%) were women and they tended to be somewhat older and had a more frequent history of high blood pressure, diabetes, congestive heart failure (CHF implies the heart doesn't pump as effectively as it should), and prior stroke or TIA (short-term neurologic changes suggestive of a stroke), than the men did.

The women in the study may have been older and had more co-morbid (existing) illnesses than the men, but even after statistically adjusting for these differences in the sexes, women had a higher risk of stroke than men did.

Why this was true is not known, especially since the study group contained women who were post-menopausal and therefore estrogen can't be the culprit. Current therapy with anticoagulant drugs, if such can be given safely, appears to be highly effective in preventing strokes in women with AF. New drugs are beig developed, but many experts in the field think the old ones have a reasonable safety profile and work just fine.

I have not read anything to suggest that most of us should be taking anything prophylactically to prevent stroke. About 85-88% of CVAs are ischemic (too little blood going to a portion of the brain), not hemorrhagic (caused by bleeding). If you've had a stroke already or a TIA, your doctor may recommend blood-thinning medication, but for the vast majority of us, controlling our risk factors, especially our blood pressure, appears to be the safest route to take.

Remember that phrase, "Time is brain." It's been estimated that only 29 to 65% of stroke victims utilize EMS in various communities. Yet for every minute a CVA is untreated you can lose 1.9 million of your brain cells.

So the phone is your best friend if you believe you're having a stroke.

 

 

 

 

Tags: , , , , , , , , , , ,
Posted in anticoagulants, atrial fibrillation, CVA, dystexia, medical emergencies, risk factors for stroke, stroke, time is brain | No Comments »

Memory Part 3: Old or New; False or True?

March 19th, 2013

Today I went back to Nelson Cowan's article, "What are the differences between long-term, short-term and working memory," as he appeared to be a definitive expert on the subject. Cowan is the Curators' Professor of Psychology at the University of Missouri and specializes in working memory research.

I'd certainly heard of long-term and short-term memory and could conceptualize those fairly easily, or so I thought. I can vividly remember a scene with each of my paternal grandparents. Grandpa Sam was angry with my first dog and kicked at her; so I kicked him. I was four or five and in trouble!

Years later, after my grandfather died, I remember Grandma Pearl dancing in her living room while watching American Bandstand. She must have been in her mid-seventies and seemed very old to me then.

These come in handy

These come in handy

Short-term memory, to me, has always been the capacity to recall something told you a brief time ago. I just got a phone call from a woman my wife Lynnette had contacted about someone who wished to volunteer at Bas Bleu, the local theatre we've been connected to for the last fourteen years. The staffer from the theatre said to tell the potential volunteer to go online to the Bas Bleu website and fill in a preliminary form.

I heard that message, but knew I'd be doing at least three other things before Lynnette got home, so I wrote her a note rather than trying to remember, later in the day, that I had a message to pass on to her.

An online article in psychology.about.com mentions the Ebbinghaus forgetting curve, published by a German psychologist in 1885. In one of the first scientific studies of how we do or don't retain information, Herman Ebbinghaus, who had begun his memory work in 1879, used himself as a research subject. He utilized three-letter "nonsense syllables. All began with a consonant, followed by a vowel and another consonant. He eliminated any where the consonant was a repeat (e.g., CAC) or where an actual word or prior meaning could play a role (DOT or BOL ~Ball). That left 2,300 possible combinations.

Then he'd put the syllables in a box, pull out some at random, write them down and repeat them many times to the beat of a metronome.

His results are still thought relevant now with later research by others to support them. The forgetting curve is the most famous. The sharpest decline occurs in the first twenty minutes and the decay is significant through the first hour. The curve levels off after about one day.

Ebbinghaus noted he could concentrate and have a "fleeting grasp" of the series of three-letter syllables, but, in order to stabilize their order in his memory, he had to repeat them over and over.
A memory specialist named Elizabeth Loftus, past president of the American Psychological Society, thinks there are four reasons why we forget: our memory traces decay over time; some memories compete with others; we may never have made the particular datum into a long-term memory; or we may have suppressed or repressed the memory.

Loftus, now a Distinguished Professor of Social Ecology, Law and Cognitive Sciences at UC, Irvine, is famous (some would say infamous) for her research in "false memories," as published in a 1997 edition of Scientific American. She had studied the "disinformation effect" since the early 1970s with studies revealing that memory may be affected by later suggestions. In one of her studies, after research subjects viewed a simulated MVA, half were told there was a yield sign at the intersection where the "accident" occurred (the initial viewing actually showed a stop sign). Those who had not been given the later suggestion that it was a yield sign were considerably more accurate in remembering the scene; the other group tended to remember a yield sign.

Loftus reviewed a number of legal cases in which suggestions had resulted in false memories and eventually was involved in the famous Jane Doe case: a published article in the medical literature had claimed an accurate "recovered memory" of childhood sexual abuse. Loftus and a colleague uncovered information strongly suggesting that the memory of abuse was false. The woman involved accused Loftus of invasion of privacy, and the University where she worked confiscated her records and conducted a year and three-quarters investigation, eventually clearing Loftus who published her findings in 2002. She then was sued by the woman, but the California Supreme Court dismissed all but one count which was eventually settled as a nuisance claim for $7,500 (the plaintiff in the case had a legal bill over $450,000).

Loftus is certainly not alone in researching false memories. She mentions a study by two other professors, Lynn Giff and Henry Roediger III, where the subjects were to knock on a table, lift a stapler, break a toothpick or similar fairly simple tasks. Later they were repeatedly asked to imagine doing some of the tasks they hadn't actually carried out. Finally they were questioned as to which of those actions they had done.

The more times they had repeated an imaginary physical act, they more likely they were to answer that they had actually done it.

Cowan's paper mentions that those two forms of memory differ in some fundamental ways: short-term memory exhibits temporal decay and has chunk-capacity limits. In other words, over time we lose memories we have not committed firmly to long-term memory and we are only able to focus our attention on a limited number of items at a given time.

Ah, yes, I need to go to the grocery store after I finish this post.

Ah, yes, I need to go to the grocery store after I finish this post.

If you are asked to remember a hypothetical phone number, e.g., (800) 264-7813 and repeat it often enough, you may remember it next week. But, unless it's a number you use frequently, you're unlikely to remember it next month. And if you are presented with the task of remembering a number with forty digits, you probably can't memorize it at all.

Cowan notes three differing definitions of working memory: they all make sense to me, but I'll give examples of only two. The first is using your short-term memory to solve a problem (Cowan terms this a cognitive task). So if you give me the ingredients you'd like in an omelet, I'll start breaking the eggs. Another, that I've become more and more familiar with as I age is the use of attention to manage short-term memory. I watch teens and twenty-somethings multi-task with considerable amazement; if I want to remember something, I need to focus on it and if I'm in the midst of doing something that requires my attention and another item pops up (e.g., the phone message I received a few hours ago), it's best if I write it down.

Enough for today; I just remembered I have another task to finish this evening.

 

 

Tags: , , , , , , , ,
Posted in chunk capacity, Elizabeth Loftus, false memories, forgetting curve, Herman Ebbinghaus, long-term memory, Memory, Nelson Cowan, short-term memory, temoral decay, working memory | No Comments »

Memory Part 2: what's old and what's new

March 13th, 2013
Her's one way to remember things.

Her's one way to remember things.

In my last post I wrote about what I call short-term memory and my own issues with remembering; I also mentioned typical aged-related memory problems. Now I'd like to delve into ideas for improving our own recall.

I leave myself notes on things to do and I tend to use acronyms or short phrases to remember names. For instance, I had noted a diminutive lady on the recumbent bike next to mine in our health club. She was about my age and was in the gym almost as often as I was. I finally introduced myself and found out her name and, eventually, that of her husband. She's Allison and I quickly decided that my mental picture of her was hurrying to follow a rabbit while she was carrying an umbrella and wearing a short skirt, i.e., "Allison Wonderland."

I tend to be be bad with remembering names, but hers is certainly fixed in my mind.

I also use acronyms. Her husband's name is David, so together they became a court room scene with the acronym "DA." David is the prosecuting district attorney and Allison is there because she jaywalked following the rabbit.

Another person I frequently encounter there is perhaps 15 years older than I am and his name is Jerry...I rendered that as "Jerryatric."

But there are other ways, some of them quite old, to hit the memory bullseye

But there are other ways, some of them quite old, to hit the memory bullseye

Reading about the varied approaches to memory over many years, I became aware that prior to there being a generalized ability to read written language, people were able to memorize long segments of epic poems. I'm unsure if this was training from a young age or the use of a particular system for memorization. One possibility that has been explored came to my attention from the fictional character Hannibal Lector.

His method of memorization led me to a 1966 classic, The Art of Memory, The author, Frances Yates traces the history of systems of memory; one was the Memory Palace of Mateo Ricci, supposedly utilized by Lector, in which a well-visualized structure can be utilized to place objects.

For instance you could visualize your own home or the rooms of a building that you visit regularly. We tend to be good at remembering places we know well. The concept of the "Memory Palace" is just a metaphor, one that can be as complex or simple as you like, perhaps being a visual map of the places you saw walking to school or driving to work. Whatever the place that you choose, you then have to have it well-visualized because you're going to "drop" memories at a particular corner or on an object you see in your house every day.

I thought this wouldn't work for me, but I just memorized a shopping list of ten items (bacon, eggs, wine, batteries, bubble gum, milk, envelopes, spinach, coffee, tomato) using the technique of mind pegging, the basic start to this concept for remembering a number of items.

When I decided to utilize this method on my list I pictured myself sitting at my kitchen table planning an omelet (bacon and eggs) while drinking a glass of wine. Then the lights went out.

I had to put new batteries into my flashlight and used it to look for additional items in my refrigerator to add to my creation, only to first find I had stashed bubble gum (I've done similar things before) next to the milk.

I still wanted to write down ingredients for my omelet, so I looked for paper and found the most accessible source was in a drawer where I keep envelopes. I made a list adding spinach while I drank a cup of coffee and then finished my recipe with a tomato.

It really worked! I may have to try a similar approach the next time i really do plan to go shopping.

Let's skip to what's current advice and research in the field.

The March 12, 2013 edition of The Wall Street Journal  had an article titled, "The New Power of Memory." It referred to a recent publication in the journal Cerebral Cortex  by Daniel Schacter, the Chair of the Department of Psychology at Harvard, and colleagues.The WSJ article had an illustration that tied in with my exercise in using a visual link to a list of objects. In this case someone was planning a party for a friend. If they relied on hunches and assumptions about their pal (this step was called "access the past"), then continued in this manner with guesswork in piecing together the image of their friend's personality and imagining their mindset, the end result was a dud, a failure.

If, on the other hand, they remembered specifics about their buddy's past likes and dislikes, as well as incidents that revealed their personality, then used those to imagine their likely mindset, the end result was a hit.

Dr. Schacter was quoted as saying, "using past experiences to anticipate future happenings" lets people weigh approaches to a coming situation without needing to try out the actual behavior.

In other words, if you hone your recall skills until they are sharper, you may be able to avoid a party that's a dud or even prevent a business decision that's a catastrophe.

I'll have to use this approach more often.

 

 

 

 

 

Tags: , , , , ,
Posted in Daniel Schacter, Memory, memory improvement techniques, memory palace, memory pegs, visualization skills | No Comments »

Memory issues Part 1: Is it Alzheimer disease or something else?

March 9th, 2013

'Alzheimer's disease', under 'Alzheimer's'A while back I read an article in the Wall Street Journal with the intriguing  title, "Detective Work: The False Alzheimer's Diagnosis." The story was that of a man who developed problems in the memory and movement arena, was treated for Parkinson's and eventually found to have normal pressure hydrocephalus (NPH), a buildup of the cerebrospinal fluid (CSF) that surrounds and helps protect the brain and spinal cord.

Hydrocephalus, sometimes called "water on the brain," can occur at any age, but is more commonly seen in infants and seniors. When it is present in the very young, often due to a birth defect in which the spinal column doesn't close properly, it puts pressure on the brain and skull usually resulting in an abnormally large head and a bulging of the fontanel, the soft area on the top of the baby's head. It's treated, in many cases, by insertion of a shunt, a tube placed in one of the brain's ventricles (these are a communicating set of cavities filled with CSF). The tube has a one-way valve and is tunneled under the skin of the patient and usually empties into the abdomen.

The other age group in which hydrocephalus is seen more commonly is the over 60 age group. But it can certainly happen to younger adults as well.

One morning in 1990, when I was forty-nine, my wife noted I was having considerable difficulty with a particular kind of memory; the ability to recall something that was just told me was impaired. I turned out to have a benign mass in the center of my head (the technical term is a colloid cyst of the third ventricle) and had it removed by a neurosurgeon. Although the pathologist said it was benign, its location in that crucial area could have resulted in major brain damage or even sudden death.

If that were to happen today, it could be removed via endoscopic neurosurgery (an endoscope is a tube, usually flexible, for visualizing the insides of a hollow organ; it typically has one or more channels to enable passage of forceps or scissors). That procedure takes 45 minutes to an hour, is done via a one-inch incision and the patient goes home in one or two days.But, as you can see by clicking this link and then the photos in the article, colloid cysts have fairly large draining veins and they need to be most carefully attended to.

An MRI can guide the neurosurgeon's path

An MRI can guide the neurosurgeon's path

In my case, prior to the advent of the neurosurgical endoscope, the mass was removed the typical old-fashioned way by making several round holes in my skull and then the cyst itself. One of the veins leaked and I had a major seizure in the recovery room. That left me with a good-sized scar; on an MRI it's more of a cavity in the front part of my brain.

The scar impaired my short-term memory. I've managed to compensate, writing reminders and keeping a calendar, but I developed an interest in Alzheimer Disease and related memory issues, many of which are age-related and some of which are reversible.

The article on "False Alzheimers," notes that >100 medical conditions can present with memory loss, confusion and personality changes. Medications, or drug-drug interactions should be high on the list of things to rule out. An April 2012 article on autopsy studies of over 900 patients thought to have Alzheimer disease found over a sixth had been misdiagnosed.

The prevailing opinion is that NPH is the cause of five or six percent of all patient felt to have dementia. Adult-onset hydrocephalus is different in many respects from that which happens in the very young. It results from a gradual blockage of the conduits that normally drain CSF. It's not uncommon for the person with NPH to think that their symptoms are typical for the aging process.

But difficulties in focusing your eyes, an unusual series of headaches, personality changes, seizures, leg weakness and/or sudden falls should be investigated; it's wise to see your physician if  any of these occur, especially if there are associated memory problems.

Then there are, as Dr. Daniel Schacter, the former Chair of Harvard's Psychology  Department calls them, "The Seven Sins of Memory ," age-related memory issues that we all will likely encounter as we grow older. Being absent-minded, blocking the retrieval of a piece of information (It's on the tip of my tongue), or not remembering a complex chemical formula you learned for a college freshman course fifty years ago all can be totally normal. His book on the subject book revolves around the theory that "the seven sins of memory" are similar to the proverbial "seven deadly sins," and that if you try to avoid committing these sins, it will help to improve your ability to remember. Schacter, on the other hand, argues that these features of human memory are not necessarily bad, and that they actually serve a useful purpose in memory.

My comment over the years has been, "Whenever I put a fact in the front of my mind, one falls out the back."

So don't assume the worst if you forget something; on the other hand, don't ignore memory problems if they are persistent.

 

 

 

 

Tags: , , , , , , , , , ,
Posted in age-related memory problems, Alzheimer's, colloid cyst, drug side effects, False Alzheimer's, hyponatremia, normal-pressure hydrocephalus | No Comments »

Marijuana controversies: Part 2, state laws, health issues and DUI

March 6th, 2013

When I was a Veterans Administration Research and Education fellow (1970-1972) working inTorrance, CA, at Harbor General Hospital, I volunteered at the Long Beach Free Clinic once or twice a week to keep up my clinical skills. One evening I made an emergency "house call" across the street from the clinic at the headquarters of the "Peace and Freedom Party." I didn't know anything about that group, but as I attended to the ill member of the Party, I realized that many of those in the rooms I passed through were smoking pot.

It was clearly an illegal drug then, even in California, but my role there was that of a physician, not a policeman, so I just took care of my patient, eventually calling an ambulance to take him to a local hospital.

Fast forward to the 21st century.

Should this be legal for adults? Voters in Washington state and Colorado said, "yes."

Should this be legal for adults? Voters in Washington state and Colorado said, "yes."

Now a Colorado state amendment has legalized the drug as of December 10, 2012 with 55% of voters approving use, possession, cultivation and distribution by anyone 21 and older. A group called "Sensible Colorado" has outlined the development of Colorado laws regarding pot. As of March 1, 2013  a state task force on recreational marijuana has recommended special sales and excise taxes on it as well as rulings barring smoking it in bars, restaurant and social clubs. The group also said the plant should only be grown indoors, but could be sold to those visiting from out of state and given away, an ounce, at a time to adults.

In late February the Colorado House Judiciary Committee unanimously passed a Marijuana DUI bill, setting a 5 nanograms (ng) per milliliter of blood as the THC level as which a person could be ticketed for driving while impaired.

In past legislation, the 5 ng limit was considered a “per se” limit, which meant that if a driver’s blood level is 5 ng per milliliter of whole blood, the driver is assumed to not be in a fit state to drive safely. Similarly a driver's blood alcohol content (BAC) of .08 per milliliter is sufficient to issue a DUI ticket.

HB 1114 states that in a marijuana DUI prosecution , a jury may "infer" that a defendant was under the influence with a 5 ng level, but that defendant has the opportunity to prove that he/she was not impaired.

The 5 ng limit is based on the amount of active THC (delta 9 THC) in whole blood,  This form of THC functions for a short period of time following ingestion, typically from two to four hours. Latent THC, the kind that remains in the blood after active THC has dissipated, can remain in the blood for days after ingestion, according to a toxicology expert who testified in the Colorado hearings on the subject.

In early December, 2012 the state of Washington also legalized recreational marijuana for adults over 21. An article in the Huffington Post online said that there would be state licensing for those who grow pot, process it or sell it in a retail setting. Although smoking it in public is still illegal, much like drinking in public places, the Seattle Police Department told its officers not to issue citations for those who do so...pending further notice. Instead police officers will advise people to smoke pot at home. Washington's Initiative 502, much like Colorado's Amendment 64, allows the state to regulate and tax the drug's sale and sets limits for DUI.

The website of the Office of National Drug Control Policy says the Justice Department is reviewing these state initiatives and has no further comment at present. Federal law currently doesn't permit even medical marijuana, much less recreational pot use.

Gallup polls, as reported in a December 10, 2012 online review, show nearly two-thirds of Americans surveyed (64%) believe the federal government should not take active steps to enforce its policy on marijuana in states that have legalized its use.  Amazingly forty percent of those who oppose the legalization of pot still think this should be a state by state decision, decided by voters. Overall 48% of those surveyed were in favor of the drug being legal and 50% were against it. This is a marked change from the 1969 poll where only 12% wanted it to be legal or even 2005  when about one-third favored legalization.

As I would have expected, the survey results varied by age. Sixty percent of those under 30 are pro-marijuana; those in the 30 to 64 age range are equally divided into pro- and anti-pot camps and sixty percent of those 65 and old are against the new state laws.

A number of studies conclude that heroin, cocaine, alcohol and cigarettes are more dangerous to those who use them than marijuana. That by no means implies there aren't potential major issues with smoking pot. One of the physicians who commented on the New England Journal of Medicine discussion on medical marijuana had a mid-twenties patient with a 10-year history of smoking marijuana frequently and now needed a tracheotomy for cancer of the larynx. An online review of the medical dangers of marijuana focused on negative effects on the immune system, potential for carcinogenesis, and effects on memory and brain function, but some of its conclusions have been denied by other scientists.
DUI is DUI, but maybe we need to develop a better test.

DUI is DUI, but maybe we need to develop a better test.

A High Intensity Drug  Trafficking Areas (HIDTA) website comments that 9% of Washington eighth grade students, a fifth of 10th graders and over a quarter of seniors in high school are current marijuana users. Teen drivers are involved in motor vehicle accidents (MVAs) disproportionally and  data strongly suggest that marijuana users who drive have significantly increased rates of increased rates of MVAs. The combination of teens smoking pot and then driving is scary.

Are we at a tipping point concerning marijuana? It seems like that may be true.

If so, what will the next few years show about the risks of recreational pot use?

Tags: , , , , , , ,
Posted in Colorado marijuana laws, DUI, Marijuana DUI, marijuana-associated health issues, Motor vehicle accidents, recreational marijuana use, Washington state marijuana laws | No Comments »

Marijuana controversies: Part 1, background and medical use

March 1st, 2013
Now physicians can prescribe marijuana in some states

Now physicians can prescribe marijuana in some states

Last evening I glanced at the table of contents of the New England Journal of Medicine and was somewhat surprised to find there was an article online on medical marijuana.It discussed a hypothetical patient with metastatic breast cancer who had considerable pain issues and had asked her primary care physician if she could use pot to relieve her pain, nausea and fatigue. There were pro and con discussants with a psychiatrist from the Mayo Clinic in favor of "thoughtful prescription of medicinal marijuana,"  but wanting those to occur within established doctor-patient relationships.

That latter comment made sense to me; if medical marijuana (AKA Cannabis) is recommended by a physician, it should be by a doctor who knows that particular patient well, not someone who writes Rx's for dozens of people a day in a "pain mill."

On the other side of the issue were a Clinical Professor of Psychiatry at Georgetown University (a former White House Drug Czar) teamed with the Chief of the Pain Management Services at a Florida University. They noted that most of the research efforts have focused on specific chemicals from the marijuana plant and that there is limited, but high-quality, data supporting relief of some kinds of pain by smoking pot, but not the type of pain the patient being discussed had. They mentioned two prescription "cannabinoids" that are currently FDA-approved as oral agents specifically for the treatment of nausea/vomiting secondary to chemotherapy.

There have been over a hundred comments to date in the online discussion of the article. One was from a Colorado anesthesiologist/acute pain specialist who commented that patients who use marijuana on a daily basis may become cross-tolerant to opiate drugs, therefore requiring much higher and more dangerous doses of them to have a desired effect in pain control.

A major issue remains the 1970 classification of marijuana as a Controlled Substance Schedule 1 drug, therefore, putting it into the company of heroin, LSD and mescaline, chemicals that have a high potential for abuse and a lack of any medical value.

To date eighteen states have legalized physicians to prescribe the drug, but Federal policy lags far behind and, in theory, docs who write Rx's for marijuana could face legal action. In Israel, on the other hand, over 10,000 patients use marijuana under government license  according to a July, 2012 NPR article.

I found an online article titled "How Marijuana Works." This comes from one of the HowStuffWorks websites, not a medical publication, but seems fairly well balanced. It mentions that cultivation of marijuana is not at all new, with written reports in China dating back over 2,000 years. The plant apparently came from India where it can grow to heights over 13 feet. It contains an enormous number of chemicals, over 400 of them with 60 falling into the cannabinoid group. The National Cancer Institute's webpage on Cannabis and Cannabinoids define these as chemicals that activate specific receptors found throughout the body to produce drug-like effects.

So what's a receptor? I read a superb analogy in Discover magazine with science writer Gary Taubes comparing them to miniature locks on the surface of cells, locks that can only be opened with the correct chemical key.

Cells, including those involved in immunity and the central nervous system, have receptors that bind with substances such as hormones, antigens, drugs, or neurotransmitters (brain chemicals that communicate information from nerve cells). Two different kinds of receptors, termed CB1 and CB2, bind with cannabinoids. The CB1 receptor, when triggered, causes the drug high; THC (the full chemical name is delta-9-tetrahydrocannabinol) is primarily the cannabinoid that leads to this effect. A March, 2012 study from the Mount Sinai School of Medicine focused on the CB2 receptor after research showed that a medication that triggered only CB2 might prove a significant adjunctive treatment to standard anti HIV therapy in late-stage disease.

Other articles in the medical literature discuss the use of marijuana versus cannabinoids in glaucoma therapy. Smoking marijuana lowers intraocular pressure in roughly two-thirds of glaucoma patients. One issue, however, is smoking marijuana is smoking and in end-of-life care probably poses acceptable risks, but done in other situations it may cause a host of problems. Other means of administration include drinking raw cannabis juice, the use of inhalers or administering only specific active cannabinnoids.

In my state, Colorado, there's an organization, headed by an attorney and calling itself Sensible Colorado, that has advocated for medial marijuana. One of their websites outlines the "History of Colorado's Medical Marijuana Laws." Over thirteen years ago our voters passed Amendment 20 to the state constitution, legalizing limited amounts of marijuana for patients and their primary caregivers.

Checking for high intraocular pressure, a precursor of glaucoma

Checking for high intraocular pressure, a precursor of glaucoma

The statute listed the diseases for which a person could be prescribed marijuana/cannabinoids. The first group included cancer, HIV/AIDS and Glaucoma. As I read background articles I could see some reason behind those choices. I'm less impressed with data on most of the other reasons to give the drug  to patients.

In 2000, Colorado voters support the legalization of medical marijuana. In our city and around the state there followed a proliferation of "pot shops," without a great deal of unified regulation. Some cities were stricter in their approach toward the sale of marijuana than others.

All this may have been overcome by events; I'll write about the recent changes in the law in my next post.

 

Tags: , , , , , , ,
Posted in cannabinoids, marijuana controversies, medical marijuana, NEJM, receptors | No Comments »

I meant cholera, not typhoid

February 27th, 2013

I just re-read my last post. Somehow, I substituted typhoid for cholera in one section (the Haitian outbreak).

Sorry

 

Tags:
Posted in Uncategorized | No Comments »

« Older Entries
Newer Entries »