There is also an excellent interview that you can access on this site, by Terri Gross from Fresh Air, a radio program on NPR. In it she talks to Dr. Carolyn Bernstein, a neurologist who started a migraine clinic in the Boston area.

Finally, for those interested in a herbal approach to treatment, check out this article, Feverview for Migraine Prevention.

What bears explaining is that I couldn’t give blood the last time I tried either. My hospital’s blood bank uses an automated hemoglobin machine that reads a drop of blood that comes from a quick finger prick. My hemoglobin read around 11. Because of medications I’m on I get my blood checked every three months so the next day I decided to get a venous blood draw – that is, blood that comes from a vein rather than a finger stick. The results were decidedly better and showed that I wasn’t anemic at all. Technology being what it is though, the hospital computer kicked me out of donating until 1 week had passed – it couldn’t be manually overridden.

Capillary blood testing (finger sticks) have shown equivalency when testing using either capillary or venous blood on such measures as blood sugar levels and cholesterol and I wasn’t able to find anything that suggested that measuring hemoglobin using finger stick rather than a venous blood draw would be any different.

Nonetheless, the hemoglobin machine results read 11 and I needed 12.5 in order to donate – so I decided to double check the foods I had remembered to be high in iron. As I thought, dark, green leafy vegetables are high in iron but what I didn’t know was that the iron from plant based foods, are less readily absorbed unlike animal based sources of iron (ie, red meat, chicken, pork etc) which is more readily absorbed.

Called non-heme iron, the iron found in plant foods, is what our foods tend to be enriched with, as in iron-enriched cereal for example. Yet as I mentioned above, this is the iron that is harder for the body to absorb. In fact, 15-35% of iron from animal meat will be absorbed but astonishingly, only 2-20% of non-heme iron get absorbed by our bodies and that will depend on the type of protein consumed with the meal as well as other food components.

Vitamin C greatly enhances the absorption of iron so citrus fruits consumed with your meal will help your body boost iron absorption. Foods that negatively impact iron absorption include tannins (found in tea), calcium, phytates (found in legumes and whole grains) and polyphenols (found in wine, beer, chocolate, walnuts, peanuts… sigh, the list goes on). And as a vegetarian, I consume a lot of tofu but it turns out that some of the proteins found in soybeans actually inhibit iron absorption.

So I will be much more mindful of the combinations of foods I eat in order to maximize the absorption of vitamins and minerals. I found two excellent sources of information – one is a dietary supplement fact sheet on iron that includes 2 tables, one for animal sources of iron, the other for plant based sources of iron.

The other source I found very useful is a web page called Natural Food Hub. It had an excellent page on the Vitamin C content of many fruits including lots of interesting side facts. Happy reading!

Treating her was a real challenge. She was elderly and very debilitated as a result. Anything she ate passed right through her. Protecting her skin from further breakdown was paramount. If we couldn’t stop the diarrhea and prevent further skin breakdown, she would die.

I can’t remember now how we were able to stop the diarrhea – presumably we used stool bulking agents as well as metronidazole to stop the infection. I called a friend who worked in wound care, and she proposed a unique regimen of a thick layer of a zinc based cream (the white cream you used to see life guards use on their noses) topped off with an equally thick layer of vaseline. Whenever she stooled, the aides were instructed to clean her by gently wiping away the layer of vaseline but not the underlying layer of zinc. In this way we managed to protect her skin from the burning effects of the stool.

She eventually healed but I never forgot how potentially deadly C diff can be. C diff is a bacteria that is found in the environment – in stool, soil, air, or water. Healthy people don’t normally get the disease because our gut has many more colonies of good bacteria that keep C. diff. in check. When we take antibiotics however, the medication indiscriminately kills the good and the bad bacteria and in some people, especially the elderly, C. diff. out numbers the good bacteria causing inflammation of the colon, which leads to chronic watery stools. There are some particularly vicious strains of C. diff. that can kill.

Treating C. diff. by taking antibiotics (yes, antibiotics do cause C. diff. but it’s also treated by taking antibiotics) can take many weeks but there are new treatments being used in dire circumstances: fecal transplantation.

Since the colon is lined with healthy bacteria, some specialists are now treating difficult cases of C. diff. with stool specimens given by family members and mixing it with normal saline. In one particularly horrendous case, a patient had lost 60 pounds in 8 months until one gastroenterologist mixed a small amount of her husband’s stool with normal saline and delivered it in her colon. Within 1 day, her diarrhea had stopped. Within 2 weeks, her gut was populated with normal bacteria.

The procedure is known as bacteriotherapy or fecal transplantation, and involves using bacteria normally found in the body to combat certain bacterial overgrowth that is detrimental to the body. In fact, scientists have calculated that there are more than 10x more microbes in our bodies than human cells and a new field of treatment is developing around this.

To read more about the fascinating use of microbes to treat illness, read the NY Times article entitled, “How Microbes Defend and Define Us“.

What I wanted first and foremost was a hospital that specializes in this type of surgery or at least does a large volume of this type of surgery. US World and News Report is a great place to start and their results are published on line. The report is separated into specialty areas, so in this case I chose orthopedics.

The hospitals reviewed are  all experienced in treating difficult cases and qualify for inclusion in the report only if a certain volume is reached or if surveyed specialists recommended the hospital.

The rankings are based on the following:

1. Reputation with physicians
2. Relative death rate
3. Patient safety
4. Patient volume
5. Level of nurse staffing
6. Nurse magnet status
7. Technology score
8. Patient services score
9. Trauma center

The relative death rate is a ratio that compares the number of medically complicated patients who died within 30 days of their  hospital stay with the number of deaths expected after adjusting for severity and other risk factors. The lower the better.

Patient safety rates the number of medical errors and accidents from 1 to 5. Again, the lower the better.

Patient volume is important because again, you want a hospital that has a high volume of the type of surgery you need. This number is derived by looking at the number of patient discharges in the particular medical speciality (in our example, orthopedics). Anything greater than 2000 is considered high volume.

Level of nurse staffing is actually the patient to nurse ratio – again the lower the ratio, the better patient care you can expect.

Nurse magnet status is a sign of excellence awarded to a hospital by the American Nurse Credentialing Center.

Technology score denotes whether the hospital uses the up-to-date technology for orthopedic surgery.

Patient services score denotes the number of other ancillary services available for this particular specialty – the higher the number the better.

How to Select a Surgeon

Once you’ve narrowed down the hospital, the  next thing is to find a good surgeon. Essentially, you want someone who specializes in the type of surgery you need. I usually recommend that people talk to their friends, relatives and other medical providers. When you ask a medical professional, ask him or her who they would want to operate on their own family member.

Don’t be afraid when meeting with the surgeon to specifically ask how many surgeries s/he has performed in the past year. Studies show that surgeons who do 50 or more replacement surgeries a year generally  have fewer post-op complications.

Some hospitals keep registries that track knee and hip implants that are associated with  higher than average revision rates. Talk to your surgeon about the kind of implant that would best serve you and what problems are associated with that particular device.

The NYTimes published a great article entitled, “Getting a New Hip or Knee? Do It Right the First Time” by Leslie Alderman. I highly recommend reading it for further tips on selecting a surgeon.

As for my dear friend, the hospital I recommended to her was Hospital for Special Surgery, in NY, NY. It’s an orthopedic hospital close to her family and is rated #2 in the country (Mayo Clinic was #1). I wasn’t able to recommend a surgeon – that’ll require some interviewing on her part, but the hospital publishes a list of ortho surgeons who specialize in knee replacement.

Tamoxifen is known to prevent a recurrence of breast cancer by suppressing endogenous estrogen. You take it every day for 5 years. In fact, it’s even given to young women who have not been diagnosed with breast cancer but who have a strong family history of breast cancer. It’s well tolerated and has a great track record in preventing a recurrence. It’s a great drug to use in our arsenal of medication to treat the # 2 cancer killer of women (lung cancer is #1).

So perhaps you can imagine my shock when I read the recent findings published online in the July 2010 issue of the  Journal of Clinical Oncology which reported that only 49% of women  (whose breast cancers were positive for the estrogen or progesterone receptors) completed the 5 years of therapy. The remaining women simply stopped taking the medication with a shocking 13% of patients nonadherent right from their first refill.

Even more shocking was that the age group most likely to stop taking tamoxifen were women under 40.

If you think that this study is an anomaly, you would be wrong. Two previous studies of tamoxifen also found that young women were likely to discontinue their medication. As the researchers reported, “young adults with cancer may be a particularly vulnerable group”. Other studies show discontinuation rates between 30%-50%. Why this occurs was not made clear in the study.

So please, if you know someone with breast cancer who has stopped taking tamoxifen or the other aromatase inhibitors, inquire why and urge them to speak with their oncologist.

For an abstract about the study, follow this link - from  here you can download the complete report in PDF format if desired.

We really don’t have enough data on the possible long term complications of this radical surgery in such a young population but with her abnormal blood sugars and elevated cholesterol, she was facing, in the very near future, a life filled with multiple medications and frequent medical visits.

 How did she get this way? As she exeplained it, she had always been a “little” overweight since childhood and over the years (not so many in her case), she had continued to gain weight – 30#s in the last year alone. She felt miserable about herself.

 Interestingly but not surprisingly, the markers for adult onset diabetes (DMII) are actually present in childhood/adolescence. Using only blood pressure readings and body mass index (BMI), the National Growth and Health Study (NGHS) followed 1,067 ten year old girls and 822 boys and girls aged 6-18 years in the Princeton Follow-up Study.

 The results showed that children in the top fifth percentile for BMI were 4 times more likely to develop diabetes in adolescence or adulthood. Additionally, an elevated systolic blood pressure (the top number) in the top fifth percentile increased the risk of diabetes 5.78 times.

 Given that the cost of treating diabetes and its complications (heart attacks, heart failure and kidney disease) will only continue to rise, we need to be hypervigilant about treating childhood obesity aggressively. The problem is, how?

 A recent study reported on by the National Institutes of Health, linked childhood obesity to the rise in working mothers – yet another hit on the chin for mothers – stating that these children were 48% more likely to be overweight or obese. Those percentages increased if both parents were obese/overweight.

 But obesity doesn’t happen in a vacuum and we can’t simply single out mothers to blame for increasing obesity rates. School lunches are often pre-packaged food high in sugar and salt. With a decrease in school funding, physical education classes are often cut back. Schools have been seduced into providing soda machines in exchange for a percentage of the money to help boost their falling coffers. Students now have less activity and easy access to junk food.

Some local school councils are under increasing pressure however to remove vending machines, or stock them with healthy snacks and drinks. There are also states who are closely examining the quality of the food served in schools and movement is underway to radically improve the quality of school food offering seasonal fresh fruit and incorporating fresh produce from local farms. 

Leisure time activities are more often sedentary – video games and TV predominate. Limiting TV/computer time and encouraging your child to be outside playing will help him/her burn more calories.

 Super-sized drinks and junk food advertisements are promoted everywhere as well as all-you-can-eat buffets. How about posting calorie counts on all food sold in the grocery-store bakery and take-out restaurants so that we can make informed choices? (I recently found out that the cinnamon scone I so enjoyed eating from Whole Foods actually had more calories than a donut – and here I thought I was choosing my food carefully). Although unpopular, we could apply a higher tax on foods we know are unhealthy – you know, those chocolate cereals, sodas, candies etc. After all, higher taxes on cigarettes has helped to reduce smoking rates.

 Truth is, obesity has many causes and as much as no one wants to be nagged about their eating and exercise habits, behaviors can change if there is a national will to do so – just consider how far we’ve come as a nation in decreasing smoking rates. With the same concerted efforts by public health officials as well as parental, local, state and federal involvement, we can reduce the rates of obesity in this country.

The data was taken from the Health Professionals Follow-Up Study (HPFS) which has followed men in the health professions since 1986. There were 26,917 men between the ages of 40 and 74 in the study who received a questionnaire  every two years about their use of analgesics, disease and health related matters. The  study also compared different age groups to the types of analgesic used. Hearing loss had to be professionally diagnosed.

Breakdown of Hearing Loss in Men under 50 :

• acetaminophen users were 99% more likely to experience hearing loss
• NSAID users were 61% more likely to experience hearing loss
• aspirin users were 33% more likely to experience hearing loss

The longer NSAIDs or acetaminophen were used, the greater the risk of hearing loss. This did not apply to regular aspirin users. The risk for men over 60 was considerably less.

You can read the complete report, Analgesic Use and the Risk of Hearing Loss in Men, published in the American Journal of Medicine.

The study conducted by medical researchers working at the Imperial College London and the University of South Australia, examined 39 autistic children along with 28 of their non-autistic siblings and 34 unrelated children. They found significant differences in the urine of those children diagnosed with autism that is linked to metabolic changes that occur with certain types of clostridium. They hypothesized that these changes would appear in the urine, which was confirmed by using magnetic resonance spectroscopy.

One of the compounds identified, N-methyl nicotinamide (NMND) also plays a role in Parkinson’s disease. Further research is needed but if this proves to be a marker for autism, then treatment can begin at a much earlier age.

Why autistic children have different gut bacteria than non-autistic children is unclear and it is not known if the bacteria causes autism or some other process leads to these changes.

Autism affects approximately 3 to 6 children out of 1,000 with males four times more likely to be affected than females. It is a range of neurodevelopmental disorders along a continuum from mild to severe. The mild form of the disease is known as Asperger syndrome with the most severe known as Autistic disorder. The National Institutes of Health publish an Autistim Fact Sheet.

Symptoms of autism can appear in infants and toddlers and involve decrease in social interactions, delays in verbal and non-verbal communications. For more information about this research, follow this link.

Illustration of how tamoxifen works

A team of researchers from the Mayo Clinic released its findings on which drugs should be avoided by women taking the well known anti-breast cancer medication, Tamoxifen. The findings were reported in the on-line edition of  the Journal of Clinical Oncology. These drugs are strong inhibitors of the active ingredient in Tamoxifen.

Because these drugs interfere with the metabolism of Tamoxifen, women taking this medication should familiarize themselves with the following because not all health care providers will be aware of this.

The drugs are:

• certain popular antidepressants – paroxetine (Paxil), fluoxetine (Prozac) buproprion (Wellbutrin) and duloxetine (Cymbalta)
• antipsychotics – thioridazine (Mellaril), perphenazine, and pimozide (Orap)
• cardiac drugs – quinidine and ticlopidine (Ticlid)
• medications for infectious disease – terfenadine (Seldane which was removed from the US markets in 1998) and quinidine
• miscellaneous medications – cinacalcet (Sensipar which is used to treat hyperparathyroidism)

Not all drugs in the above categories need to be avoided – only the ones that are metabolized (broken down in the body) by the cytochrome P450 system, primarily by the enzyme CYP2D6. There are alternatives within each class of drugs, so the ones with that interfere the least with this system should probably be used.

For medications to work  effectively in the body, they must be broken down into the active component of that drug. The active ingredient in Tamoxifen is endoxifen and it is released by the CYP2D6 enzyme system. Any drug that interferes with this system lowers the blood levels and therefore the protective benefits of this medication.

The list of alternative medications that can be used without interference are:

• antidepressants – venlafaxine (Effexor), desvenlafaxine (Pristiq), reboxetine (Edronax), escitalopram (Lexapro) and mirtazapine (Remeron)
• antipsychotics – thiothixene (Navane). clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), ziprasidone (Geodon) and quetiapine (Seroquel)
• cardiac drugs – diltiazem (Cardizem)
• medications for infections – indinavir (Crixivan), saquinavir (Invirase), nelfinavir (Viracept) delavirdine (Rescriptor), nevirapine (Viramune) and efavirenz (Sustiva)
• miscellaneous medication – gabapentin (Neurontin)

In addition, many well known antihistamines are intermediate inhibitors of CYP2D6 and should be used cautiously.

If you know anyone on Tamoxifen, be sure to let them know about these recommendations. For more information, follow this link.

Commissioner Goodell signed a letter urging the governors of 44 states to pass a law similar to the one passed in Washington state that doesn’t allow young athletes who have suffered a concussion from returning to play too soon.

Washington state passed Lystedt’s law, named after the young athlete, Zachery Lystedt, who suffered a severe brain injury in 2006 after returning to play in the second half of middle school football game. Called the “shake-it-off-law” referring to how many youngsters try to shrug off the injury, five states have passed similar laws to Washington: Oregon, Connecticut, Virginia, New Mexico and Oklahoma.

According to the CDC, there are about 3.8 million sports and recreation related concussions each year.

Recent research found that young athletes are more likely to sustain concussion and to recover from them than adults. The research out of C.S. Mott Children’s Hospital National Poll on Children’s Health, surveyed parents of children between the ages of 12 and 17 who play school sports and found that nearly 2/3 of parents didn’t know if their child’s school had a concussion policy. More concerning, 1/3 of parents did not know the signs of concussion (headache, dizziness, confusion, memory loss, balance problems, nausea, vomiting or vertigo).

Most parents wanted to see strong school support for concussion policies that include:

• evaluation and clearance by a doctor before returning to sports (84%)
• a mandatory period of no sports participation after a concussion (71%)
• educating coaches about the risks of concussions (81%)
• certified trainers onsite for practices and games (67%)

Repeat concussions can cause severe damage that may not be evident immediately. One helpful tool to evaluate concussion is the ImPact test (Immediate Post-Concussion Assessment and Cognitive Testing) which has become the standard tool for many coaches, trainers and medical professionals.

Find out if your child’s school has a concussion policy and become familiar with the signs and symptoms of concussion.

More information about diagnosing concussion by measuring reaction time and a short video about why concussion matters are available on this site.