“THERE ARE hundreds of types of pain, and scientists don’t understand how best to treat their unique features,” reads the NIH Heal Initiative’s announcement of a $50 million, 12-center study to evaluate treatments for pain “…because pain is a lived experience affected by biology (such as an injury or a disease), psychology (such as anxiety or depression about not getting better) and cultural expectations (such as the urge by some to just ‘tough it out’).”
Desperate pain sufferers take drastic measures—from possibly dangerous treatments like DMSO, to unproven ones like sound vibration healing. Other people rely on medication like Advil despite notorious side effects, such as stomach ulcers. For chronic pain that “lasts longer than three months, is taking over your life and hasn’t improved with surgery and medication,” medical centers, such as Cleveland Clinic offer residential programs lasting weeks or months—to work on all “medical, physical and psychological” contributors to chronic pain.
For a DC-area student (who asked that no identifying factors, including her initials be used), infection with the bacteria Bartonella— in the US best known as cat scratch disease—led to months of unbearable nerve pain in her feet that often confined her to home or even bed. Three weeks at Cleveland Clinic’s Chronic Pain NeuroRehabilitation Program did not lessen her pain, she said, but helped her to “handle activities, walking and even playing soccer, and to engage in social events that required standing for periods of time”—with the belief that she was better able to manage the pain, and she feels ready for college next fall.
“You can’t see it, you can’t feel it, and you can’t touch it,” University of California, San Diego pain specialist Mark Wallace told the Heal Initiative. “Pain is the main reason people go to a doctor but…a diverse set of medical conditions is a difficult target to hit,” according to the Heal site. And then there’s the fact that any type of pain—a migraine, bone pain from a tumor, sickle cell disease, pain after surgery, or many others—can feel very different depending on personal circumstances…Because pain is invisible and difficult to define, it’s hard to assign it a simple numerical value, which complicates the search for treatments.”
A different way of thinking about pain—commonly referred to as “Explain Pain”—is based on the idea that pain is an output of the brain—rather than a signal from the body to the brain, from Australian practitioners David Butler and Lorimer Moseley in books that include The Explain Pain HandbookProtectometer. Writes Butler, their “biopsychosocial” approach teaches “people that pain can be over-protective” and “that the brain can turn down the danger message at the spinal cord…it is always the brain that decides whether or not to produce pain.”
Dietary solutions based on the idea that inflammation is a major contributor to joint pain include a 30-day diet that “emphasizes large amounts of antioxidant-rich produce, like berries and dark leafy greens, plus a relatively high intake of healthy fats and seafood, such as salmon and nuts—all of which may be helpful in removing inflammatory triggers,” according to EatingWell.” For those who blame sugar, the “100 diet” limits daily sugar calorie consumption to 100—including natural sugars, for example, apples that contain about 80.
But for some people, the best or only relief comes from prescription drugs, notably Celebrex— “developed with the aim of reducing the common side effects of traditional NSAIDs,” according to the Mayo Clinic. COX-2 inhibitors, “commonly used for arthritis and pain resulting from muscle sprains, strains, back and neck injuries, or menstrual cramps…are as effective as NSAIDs and may be the right choice with less risk of stomach damage.”
For local pain, topical NSAIDs can be helpful on smaller joints and those that are closer to the surface, such as hands, knees, elbows and ankles, according to the Arthritis Foundation. Voltaren, which is topical Advil, can work quickly – but because an uncertain amount reaches the bloodstream, it might not be a good alternative for people concerned about stomach pain with NSAIDs.
Among topicals is the unproven DMSO, dimethyl sulfoxide—which surfaces from time to time on questionable health sites, but is “possibly effective [for] limb pain that usually occurs after an injury (complex regional pain syndrome),” according to WebMD. Even among pain treatments, DMSO is notoriously difficult to test because of the “death breath” give-away for individuals taking the active drug.
With all the drawbacks of drugs and challenges of long-term programs—especially those involving diet and psychotherapy—some people pursue alternative medicine options, such as sound vibration healing. According to Ohmazing Art of Healing, vibroacoustic therapy (VAT) uses low-frequency vibrations, delivered through specialized devices such as mats or chairs, which can penetrate deep into tissues to promote relaxation and potentially reduce pain sensations. Alternatively, whole-body vibration (WBV) therapy—standing or sitting on a vibrating platform—can help with various health conditions, including peripheral neuropathy.
With any new, severe pain, I begin the days-long drug regimen of Aleve, maximum medical dose morning and night, plus Tylenol as needed in between. For chronic arthritis pain, I apply Voltaren—trying to abide by the no-slathering precaution. And I investigate new treatment candidates—until I get to the drawbacks: for example, tart cherry juice for pain requires two 12-ounce bottles a day for seven days—starting a week before a strenuous event. For the future, I am planning a session or two of vibration therapy—with the hope of an interesting experience, if not relief of pain.
NOTE: To all my good readers and commenters, this is my last post for MyLittleBird. The site will no longer publish new pieces but will remain open for reading archived posts. I will post future Well-Being articles at https://carmedpub.substack.com. Please email me with story ideas, questions and comments—and to receive Substack notifications—at carmedpub@gmail.com. Thank you for being loyal readers of MyLittleBird.
WHEN ALTRUISTS go out of their way to help people they don’t know—along with the risks they take of harming themselves—it may stem from having different brains than most people, also very different from those of psychopaths. In Confessions of a Good Samaritan, filmmaker Penny Lane presents her experience and that of others as they become living donors of kidneys to people they have never met.
Compared to typical people, MRI scans of “non-directed” kidney donors reveal an amygdala, dubbed the “fear center” of the brain, that is larger and more active—along with higher levels of the hormone oxytocin—that enable them to ignore the risks and endure the pain and lengthy recovery time of major surgery to make these donations, according to the film. Even as she suffers weeks of pain and depression following the surgery, Lane’s attitude persists—that because people have two kidneys, it seems obvious to donate one of them.
(Not only is there a waiting list for donated kidneys of about 100,000 people, many of whom will die soon without new kidneys, kidneys from living donors have a much better chance of surviving transplantation than those from cadavers. Most people awaiting donation rely on dialysis, usually requiring four exhausting hours a day, three days a week. Among “non-directed kidney donors,” however, 90% change their minds; and only two percent of all live kidney donations come from someone who does not know the recipient.)
“Most people are more generous toward their family and friends than they are toward strangers, a behavior called social discounting,” according to Georgetown psychologist Abigail Marsh, featured in the documentary, whose research shows a “caring continuum that extends from psychopathy to extreme altruism.” Marsh contends that accounts from “real-life heroes [about] feeling decidedly un-stoic during rescues…helps support the role of the amygdala” in altruism.
The amygdala plays a role “in a wide range of social and emotional processes, but it’s probably best known for [that of] coordinating responses to threats,” writes Marsh. For example, the amygdala might link sensory information about the smell of leaking gasoline to previously learned information about its dangers. In altruists, increased levels of the hormone oxytocin would help shift attention away from dangers (of gas) toward caring for others—similar to elevated levels of oxytocin in mother rats that smell danger but act bravely to protect their babies.
“Neural activity in the amygdala directly mirrored [behavior, so that] the scientists could actually predict when certain monkeys were going to be generous and charitable,” writes Christopher Bergland on PsychologyToday. And when the hormone oxytocin “was introduced into a specific region of the amygdala, prosocial behaviors increased instantaneously.”
But those who disagree about the role of the amygdala believe it is merely a processor of sensory information, such as the sights and sounds of danger—with no role in decision-making or social behaviors. Writes Northeastern University researcher Philip Deming, who studies brains of psychopaths, “There is even mounting evidence refuting the notion that a circuit devoted to the emotion category of fear, or any other discrete emotion category, for that matter, exists in the human brain.”
“The “fear center” view of the amygdala…proposed that psychopathy is rooted in “fearlessness,” a diminished capacity for experiencing fear and for associating actions with, for example, the threat of punishment,” according to Deming. “After two decades of neuroimaging research on psychopathy, the reproducibility of amygdala findings is questionable…instead, the amygdala may be better understood [with the] primary function is to sense and control the viscera…include representing affect [such as arousal].”
Confessions of a Good Samaritan made a strong case for the unusual behavior of extreme altruism—as Lane showed her medical struggles in the aftermath of donation, without questioning her decision to donate. “Because social discounting is so ubiquitous, the question of why certain people choose to be altruistic toward strangers has long puzzled researchers,” according to the Georgetown University post about Marsh’s research—specifically, their ability to ignore possible risks and dangers. Focusing on empathy, the ability to distinguish emotions in others, the researchers observed MRI scans of altruists that showed more active responses to expressions of fear in others, but not to anxiety or anger—compared with typical brains.
Psychopaths, on the other hand, feel less fear, anger and anxiety than average—giving them less capacity to recognize these emotions in others, notably in their victims. While not an official diagnosis, psychopathy encompasses extreme forms of several personality disorders, notably antisocial personality disorder (APD) and often narcissistic personality disorder (NPD). In general, people with APD are unable to consider the feelings of others without help.
Our research “helps us understand the brain mechanisms that allow altruists to value and care more about others,” writes Marsh. For comparison, testing with an online loving-kindness meditation training “could not induce generosity”—although researchers note “there could be future opportunities to mine deeper into this intervention.”
Donating a kidney to a stranger, much less to someone close to me, seems impossibly risky and unpleasant—especially the weeks or longer of painful recovery. Watching Confessions of a Good Samaritan, though, made me feel a little better—enabling me to blame, at least partially, my reluctant altruism on an average-size amygdala. And whether or not there is a physiological explanation, the film gave me even greater appreciation for people who commit such seemingly selfless acts to help others.
Note: Confessions of a Good Samaritan is available for streaming on Netflix.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
NEW LIGHT on the question of whether drinking alcohol might benefit health came in the past six months from two large-data studies. But because the data come from two different Biobanks—in the UK and at Mass General —and the studies focus on different health risks (either cardiovascular disease or a range of diseases), people are still arguing.
Questions persist mainly because earlier research—“gold-standard” double-blind studies—that demonstrated health benefits of drinking alcohol made the mistake of using people who abstained entirely as a control group. As it turns out, according to CNN, “nondrinkers often don’t drink because they can’t, perhaps due to health conditions or medication use…could make drinking look less harmful or even beneficial.”
The CDC, echoing findings from the UK Biobank study, states that ”compared to not drinking, drinking alcohol in moderation may increase your overall risks of death and chronic disease…Even low levels of alcohol use (less than one drink per day) can raise the risk of certain cancers.” The CDC site also notes, in addition to non-drinking control groups, “some past studies failed to consider genetic factors or behaviors like exercise, diet or tobacco use.
Rather than using non-drinkers as controls, Spanish researchers used the UK Biobank data to compare health effects at different levels of daily drinking for adults—average age of 64 at the start of the study and no one under age 60—between 2006 and 2010. According to their report in JAMA, they found “health risks, including cancer and heart disease, at every level of regular daily drinking.”
Even in the “low risk” group, women whose daily alcohol consumption was less than one standard drink, at 10 grams of alcohol, were about 10% more likely to die of cancer than the occasional drinkers. And in the high-risk group, women drinking more than 20 grams or a little under two standard drinks per day were about 33% more likely to die of cancer, heart disease and any other cause than the control group. With per-day amounts twice as high for men, the health risks were similar.
Forty-nine underlying health conditions —along with places of residence as an indicator of income level—were among variables taken into account by the Spanish researchers, according to CNN. Increased risks associated with drinking were more pronounced in people who scored as having lower incomes and more health conditions, while people who mostly drank wine or beer or who drank alcohol only in certain situations, such as with meals, “had slightly lower risks…compared with those who drank only on occasion.”
“So what we think is that maybe what is causing this beneficial effect is not wine itself or drinking with meals itself but other factors that we cannot control,” UK Biobank study author Rosario Ortola, professor of preventive medicine at the Universidad Autonoma de Madrid, told CNN. People in these two groups might, according to Ortola, “appreciate moderation in other areas of their lives…more likely to have other healthy behaviors.”
Cardiovascular disease was the single health risk evaluated by the study that used Mass General Biobank data on 53,064 patients, median age 60 and 60% women, with a 3.4-year follow-up. According to the report on Time, “One reason why alcohol might be linked to better heart health: it reduces stress signals in the brain in a sustained way, leading to less of a burden on the heart.”
Brain scans from 713 participants showed dampening of activity in the amygdala in “light/moderate” drinkers, who consumed one to 14 drinks/week—compared to activity in the “none/minimal” group drinking less than one drink per week, according to the researchers from Yale and Mass General. Panic signals sent from the amygdala form part of the brain’s stress-related neural network activity (SNA)—known, as the study authors explain,”for its association with cardiovascular disease.
“Drinking alcohol is known to ease the amygdala’s alarm effect,” Mass General cardiologist Ahmed Tawakol told Time. “But we asked a different question: Does it have long-lasting effects on these systems?” Ongoing dampening of activity in the amygdala among light/moderate drinkers over the course of the study occurred, along with a 22% reduction in cardiovascular disease. But the authors add that, “given alcohol’s potential health detriments, new interventions with similar effects on SNA are needed.”
“It remains unclear whether the potential cardiovascular benefits of light/moderate alcohol consumption result from alcohol itself or whether they may stem from confounders (e.g., associated health behaviors, socioeconomic factors),” the authors write. Also, they noted that “subjects with no/minimal alcohol intake were more likely to be female, hypertensive, diabetic, and to have a history of anxiety and depression…light/moderate drinkers were more likely to be male, smokers, and physically active, and had a higher neighborhood income compared with participants with no/minimal alcohol consumption.”
Important caveats exist in both studies, mainly that Biobank participants tend to be healthier than people who do not enroll. In addition, most of the UK Biobank information about drinking habits was self-reported, and 94% of participants were white. In the end, Ortola’s “factors that we cannot control” —i.e. individual differences—may play the greatest role in long-term health effects of drinking alcohol.
Rather than resolving arguments among my friends, these studies seem to be prolonging them. But because I am a non-drinker for various reasons—and thus reluctant to weigh in on the topic—I appreciate having published data on both sides that I can talk about. Also, I can admit to possibly having less good health—more subject to the ravages of anxiety—than my friends who drink in moderation.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
WHEN THE air quality index (AQI) soared around the Northeast over the last few weeks—with wildfires spreading in the extreme drought— news reports emphasized immediate potential risks to the heart and lung from fine particulate matter. There is little evidence, however, showing long-term health effects from a few days’ exposure in otherwise-healthy people—aside from a casual comparison of one day’s high AQI levels to smoking about six cigarettes.
Fine particles that come directly from wildfire smoke tend to be “more toxic than other sources of [particles smaller than] PM2.5,” Francesca Dominici, Harvard professor of biostatistics, population and data science told the Washington Post. The reason is wildfires burn everything—which includes “various household materials, such polyvinyl piping and batteries, that produce toxic emissions when combusted.”
(Because so-called “wildland fires” burn plant material, their smoke can be less toxic than fires burning through inhabited structures. Most firefighters use water in their hoses—sometimes with added salts or chemicals used in fertilizer that are poisonous to fish but break down over time; but sprays for Class B fires, such as in jet fuel at airports and oil at refineries, include PFAS (“forever chemicals”) —pronounced P-fuz—linked to serious human health effects.
Wildfire smoke in lab experiments “causes more inflammation and tissue damage than the same amount of air pollution,” according to Reuters, and “has been linked to higher rates of heart attacks, strokes and cardiac arrests.” Moreover, wildfire smoke lingers in the air for weeks and travels hundreds of miles.
Fine particulates can penetrate deeply into lung tissue, leading to “transient reductions in lung function. . . and may also affect the body’s ability to remove inhaled material such as viruses and bacteria from the lungs,” according to the EPA. In air pollution, particles smaller than PM2.5 come from combinations of airborne chemicals emitted from industries and automobiles—but mostly from coal-fired power plants.
There is no “safe” level of small particulate matter or wildfire smoke exposure, according to Marshall Burke, Stanford smoke pollution researcher. “We see impacts basically starting at zero.” (See updated wildfire map.)
While Canadian wildfires last year sent DC’s AQI numbers into “Code Purple” (AQI scores from 201 to 300) indicating risk to everyone—and closing the National Zoo as well as postponing a Nats baseball game–this year’s AQI with the autumn wildfires has been in the orange range of 50 to 100. New York City’s numbers have been higher both years – with last year’s numbers rising into “Code Maroon,” indicating AQIs in the high 400s, considered “hazardous for everyone”—briefly ranking it number one on the world’s most polluted cities list, above the usual high-scorers in India and Pakistan.
“We haven’t seen something like this with smoke ground level in over 10 years,” said local DC-area WTOP News meteorologist Eileen Whelan last year. Ground-level smoke is notably the big offender—meaning that even when skies appear ghastly orange or murky brown, smoke may be too high to create serious health risks.
In DC’s average AQI, however, the most villainous offender is ground-level ozone, which has earned the city an F —with fine particle pollution considered acceptable on a 24-hour basis but with regular spikes that exceed guidelines. Ground-level ozone comes from the reaction of “precursor pollutants,” such as hydrocarbons and nitrogen with sunlight, causing an AQI number that tends to rise over the course of sunny days. Stratospheric ozone, in contrast, acts as the earth’s sunscreen to help protect against harmful UV rays—but excessive carbon emissions deplete or create holes in this layer.
“I cannot think of many things more frightening,” Elena Kagan wrote about last year’s Supreme Court decision that loosened coal-industry pollution standards and, to some, indicated the court’s takeover from the EPA as climate decision maker for the country.
“The climate signal is very strong,” Robert Scheller, professor of forestry at North Carolina State University, told the BBC —speaking of climate change’s contribution to wildfire surges of recent years. “We are seeing both a larger area burned, and more severe fires . . . Spring in Canada has been much warmer and drier than usual, creating a tinder-dry environment for these vast fires.”
“Across the [U.S.], the number of people exposed to . . . extreme smoke days has grown 27-fold in just a decade,” writes David Wallace-Wells, author of The Uninhabitable Earth. And “already the health impact of American wildfires is larger east of the Rockies than to the west.” Pointing to what one historian calls “the pyrocene,” Wallace-Wells notes that 10% of the world’s forests rise from Canadian soil, and he quotes writer John Vaillant describing a 1950 Canadian wildfire: with a smoke plume so large it created weird visual effects “including widespread reports of lavender suns and blue moons.”
Blame for the U.S. world ranking of #46 for average life expectancy—79.11 years in 2020—falls on U.S. industries that make it “the world’s largest producer of oil, its second largest producer of gas and its third largest consumer of coal, and also its largest historical emitter by an outrageous margin,” writes Wallace-Wells. The U.S. is “responsible for about twice as much carbon damage already done to the planet as any other country on Earth.”
When AQI numbers are high, recommendations include staying indoors as much as possible; and for outside activities, wearing high-quality N95 or KN95 masks. But I took comfort from surgeon and co-director of the Climate Institute at George Washington University Neelima Tummala’s comment to the Washington Post that “everyone has slightly different responses to environmental irritants . . . Do I want people to be outdoors exercising and doing good things for their mental and physical health? Yes.”
Also comforting to me, after spending time outdoors on two unhealthy AQI days without noticeable health effects was a good friend’s report of the comparison to six cigarettes a day. On a Code Purple AQI day in DC, with that number sounding lower than the daily cigarettes we had smoked in our early years, we went ahead with a planned swim that was only slightly shorter than usual—and lovely.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
At the same time readers were asking for an updated post on sleep, Well-Being Editor Mary Carpenter got a book recommendation—in a random conversation with a physiatrist, who was listening to it with his son—of Why We Sleep, by Matthew Walker. It challenged her assumption there could be very little new to read on the subject.
HIGHLIGHTING the spectacular achievements of the sleeping brain, Walker traces “society’s apathy toward sleep [in part to] the historic failure of science to explain why we need it”—and explains why each person benefits from paying close attention to their body’s unique natural sleep schedule. He concludes, however—acknowledging that some people need wake-up alarms to stay in synch with the rest of the world–with advice for those people struggling to do that, along with measures beneficial to everyone, called “sleep hygiene.”
Insufficient sleep “disrupts blood sugar levels so profoundly that you would be classified as prediabetic, [and] physical and mental impairments caused by one night of bad sleep dwarf those caused by an equivalent absence of food or exercise,” writes Walker. Referring to the CDC position that “most adults need at least 7 hours of sleep each night,” Walker explains that too little sleep also “appears to be a key lifestyle factor linked to risk of developing Alzheimer’s disease.”
Setting an alarm to wake two hours early means “you may lose 60 to 90 percent of all your REM sleep,” Walker writes.” Or, if you “don’t go to bed until 4am, then you will lose a significant amount of your normal deep NREM sleep [with an effect similar] to an unbalanced diet.” NREM refers to the four non-rapid-eye-movement stages of deep sleep that occur within each 90-minute sleep cycle—and that ends with the fifth, rapid-eye-movement (REM) stage of dreaming. But the increased length of REM stages within each cycle throughout the night—along with longer NREM stages in the hours after falling asleep—create the disproportionate loss linked to curtailing sleep at either end.
Think of “NREM sleep as reflection (storing and strengthening those raw ingredients of new facts and skills [garnered during the wake state], while the wake state is “reception (experiencing and constantly learning the world around you),” writes Walker. He considers NREM sleep “one of the most epic displays of neural collaboration that we know of. Through an astonishing act of self-organization, many thousands of brain cells have all decided to unite and ‘sing” or fire in time.”
And think of REM sleep as “integration (interconnecting these raw ingredients with each other, with all past experiencing, and in doing so building an ever more accurate model of how the world works, including innovating insights and problem-solving abilities),” he writes. In a sleep lab, measurements of eye movements during each stage help assess the quality of an individual’s sleep—with those during REM periods reflecting the “movement-rich experience of dreams.”
“Morning larks” make up about 40 percent of the population, according to Walker, with “night owls” accounting for some 30 percent. The remaining 30 percent fall somewhere in between larks and owls “with a slight leaning toward eveningness. …most unfortunately, owls are more chronically sleep-deprived [with] greater ill health…including higher rates of depression, anxiety, diabetes, cancer…”
Of two factors that affect sleep schedules, one is the familiar 24-hour circadian rhythm—which responds to environmental factors, including light, food and exercise. “Sleep pressure” is the other, increasing throughout the day as the chemical adenosine builds up in the brain. But this buildup can respond to artificial muting, for example, by caffeine—which Walker calls “the most widely used (and abused) psychoactive stimulant in the world.”
No sleeping medication induces “natural sleep,” in Walker’s opinion. He explains that older, sedative hypnotics, such as diazepam, “sedated you rather than assisting you into natural sleep.” And newer drugs, including Ambien and Lunesta, create sleep that lacks the largest, deepest brain waves—and often come with side effects that include next-day grogginess and forgetfulness.
Cognitive behavioral therapy for insomnia, CBT-I—the remedy currently deemed “the most effective,” according to Walker—offers each patient a “bespoke set of techniques.” Number one for most people is sleep restriction—also called sleep consolidation —limiting time in bed, often starting with six hours or less. Explains Walker, “by keeping patients awake for longer, we build up a strong sleep pressure—a greater abundance of adenosine …patients fall asleep faster and achieve a more stable, solid form of sleep across the night.”
Sleep-restriction goals start by using the hours of actual sleep recorded in a sleep lab—for example, five hours of deep sleep out of the seven or eight spent in bed. A 2015 meta-analysis of CBT—that included 1,162 patients—found improvements in total sleep time and sleep efficiency by eight to ten percent, reported in the Annals of Internal Medicine—with the note that “psychological approaches are likely to produce sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches.”
With CBT-I —“generally…the first treatment recommended,” according to the Mayo Clinic, the cognitive component “teaches you to look for and change beliefs that affect your ability to sleep…help you control or get rid of negative thoughts and worries that keep you awake.” One recommendation is to “remain passively awake”—by suppressing thoughts about falling asleep.
“Stick to a regular sleep schedule. Go to bed at the same time each night and get up at the same time each morning, including on the weekends “is the number one recommendation from the CDC and elsewhere for “sleep hygiene”—suggestions that apply to everyone, regardless of sleep challenges. Also on most lists: “take a hot bath before bed;” and the familiar “don’t lie in bed awake” — instead, get up for a while.
Following a sleep schedule helped Connecticut organic farmer L.P. who had battled insomnia for decades using various methods and medications—but the most effective for her was sleep restriction. Having known L.P. since childhood, I was relieved she’d finally found something that worked better than drugs—with their risks of side effects and of increasing tolerance that included her inability to sleep without them. And because I cannot wake without an alarm, what I appreciated most about Walker’s book was his description of sleepers like me—who fall somewhere between larks and owls—and have “a slight leaning toward eveningness.”
—Mary Carpenter regularly reports on topical subjects in health and medicine.
A TWENTY-SOMETHING athlete fell to the ground recently at a DC-area gym, telling those nearby he had asthma and couldn’t breathe. No one called 911 —because most listings of emergencies requiring immediate treatment do not mention asthma and because most people underestimate its dangers. While his worried friend was rushing to purchase an inhaler, the boy died.
Published medical emergency lists are predictable, with heart attack usually at the top—and most people assume they know the symptoms: “mild pain or discomfort in the center of your chest… pressure, squeezing, or fullness…complicated because these symptoms may be related to something less serious, such as heartburn,” according to PennMedicine.
But familiar heart attack signs don’t always apply to women—who are “much more likely to get…indigestion, shortness of breath and back pain, sometimes even in the absence of obvious chest discomfort,” according to Johns Hopkins Heart Failure Clinic Director Lili Barouch. Following heart attack, most lists prioritize choking, car accident, fire and profuse bleeding.
On many lists, stroke often appears first under headache—way down the list, and after that under “stroke symptoms”—although in the stroke-warning acronym FAST, the “T” points to the crucial element of time elapsing before treatment to achieve the best outcome. For the other three letters, symptoms that necessitate emergency care include F for drooping face (check the smile); A for arm weakness (raise both arms and compare); and S for speech difficulty (repeat a simple sentence like “the sky is blue”).
Asthma kills about 10 Americans each day, although some 25 million people in the U.S—one in 13—live with the condition—compared to almost 2,500 from CVD (cardiovascular disease); and just over 400 per day from stroke. Female adults are more likely to have asthma and to die from it than male adults, according to the Asthma and Allergy Foundation of America, which says, “Nearly all of these [asthma] deaths are avoidable with the right treatment and care.”
Symptoms of chest discomfort or pain that signal asthma, however, can be similar to those of a heart attack—and asthma increases the risk of heart attack. But determining the correct diagnosis is important because treatments for each are quite different. According to EmergencyPhysicians, one clue that someone might be having a serious asthma attack is “the inability to complete a sentence without pausing for breath”—as well as having to strain chest muscles in order to breathe.
“It feels like an elephant is sitting on your chest,” said local filmmaker L.K., a family friend of the boy who died recently, and who always carries with her the prescription “rescue” inhaler albuterol. (“Rescue” or “reliever” inhalers differ from “preventer” options that include different inhalers as well as long-acting bronchodilators.) L.K. traces her asthma to early childhood years spent with parents who smoked several packs of cigarettes a day.
Usually beginning in childhood, asthma narrows the airways and produces excess mucus—and can result from the environment, such as with family members who smoke as well as from inherited genes and from having respiratory infections during infancy or childhood. But it can also arise in adults, linked to smoking, obesity and female hormones. Of three telltale asthma symptoms, the “classic” one is wheezing, a high-pitched whistling sound created by obstructed bronchial passages, along with shortness of breath and cough.
Like asthma, bronchitis can also involve wheezing and shortness of breath, but the main symptom of “acute” bronchitis is a cough lasting at least five days. Both bronchitis and asthma result in less air than usual entering the lungs, and both can create excess mucus (coming from the nose and sinuses) or phlegm (produced by the lower lungs). But while asthma causes airways to narrow due to inflammation, bronchitis causes cells to become inflamed as the immune system fights infection.
Bronchitis, whether viral or bacterial, commonly lasts one to three weeks and clears up on its own. By contrast, asthma is a chronic condition involving damage that cannot be repaired—and symptoms can flare in response to triggers such as pollen and changes in weather. Frequent respiratory infections, however, can also lead to chronically persistent bronchitis.
The two conditions can also occur together in “asthmatic bronchitis”—with bronchitis making symptoms worse in those who have asthma. In addition, “exercise-induced asthma” occurs in about 90% of people with the condition but can also arise in those without asthma. “Reliever medicine” taken before exercise can help both groups.
Deadly sudden asthma attacks are rare—and are more likely to occur in asthma sufferers with a history of sudden attacks. In a small study, deadly attacks occurred in the presence of high levels of specific allergens that activated an immune system response, in several cases involving soybean dust—in the Minnesota farmlands and at docks receiving soybean cargoes. Most severe asthma sufferers carry an EpiPen, a device containing epinephrine that spurs quick recovery—but only if bystanders know they should search for the pen and call for emergency help.
I had always been hesitant to dial 911—even when my young son had a temperature above 105 degrees in the early morning hours with wintry weather threatening. On the evening when someone slipped on ice in our driveway, I called 911 only because the person wanted me to. But after inspecting the ankle, the EMTs told me they suspected a compound fracture—and because that comes with a high risk of going into shock and requiring emergency help, they carried the patient out on a stretcher.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
Lichen sclerosus is a vulvar disorder—found in a Danish study to have increased seven-fold in recent years—that can cause severe itching and, if untreated, lead to tightening and fusing of the skin, and in rare cases to cancer. Yet, gynecologists often miss the signature patchy white skin—in part because cases have only increased recently, but also because medical training has traditionally focused on the internal organs of the vagina but ignored the vulva—the external female genitals including the labia and clitoris. (Sclerosus is the adjective form of sclerosis—referring to the stiffening or hardening of tissues or anatomical features.)
“By some estimates, one in 30 older women has lichen sclerosus,” according to Harvard Health. “Itching is usually the first symptom, and it may become severe enough to disrupt sleep and other activities [with physical signs that include] white (sometimes crinkly or shiny) patches. Some may contain tears or red areas from bleeding (often the result of scratching), and these areas may be painful and sting.”
“Medical education has consistently emphasized female reproductive anatomy and ignored vulvar anatomy, particularly clitoral nerve anatomy,” writes Dallas plastic surgeon Paul Pin. “[It’s] a clear indication that medical education has historically seen women as ‘baby machines’ and not as sexual beings.”
“Less than 19 percent of vagina owners [may] orgasm from penis-in-vagina sex alone”—according to a 2017 study reported by Healthline. (“Vagina owners” refers to people assigned female at birth.) “Estimates suggest that the clitoris has 8,000 nerve endings [while inside the vagina] the number pales in comparison.”
The uterus, vagina, cervix, fallopian tubes, ovaries, bladder and rectum are all on the list of “pelvic areas” to include in the gynecological exam, according to WebMD—but not the vulva. An additional problem, many skin conditions, such as eczema and psoriasis, are more familiar when they appear on other parts of the body—with lichen sclerosus often arising on the back and chest—but harder to recognize on the vulva. Eczema on the vulva can form crusts, and scratching may lead to the thickened skin of lichen simplex chronicus (a different condition); while psoriasis on the vulva can cause pink patches that may develop into lichen sclerosus.
With postmenopausal women at higher risk for lichen sclerosus, “low levels of the hormone estrogen may be a cause,” according to YaleMedicine. Lichen sclerosus (LS), however, most often falls into the category of autoimmune disorders—though the Yale site also refers to evidence that “suggests a genetic predisposition in some people, for whom the condition may be triggered by injury or trauma to the affected area”—or by environmental factors.
Uncertainty about the origins of LS can complicate the decision of where to turn for diagnosis— with the Lichen Sclerosus Support Network listing dermatologists, gynecologists and urogynecologists—and the choice of specialist may play a role in treatment choices. Topical steroid ointments are usually the first-line treatment, while both topical and oral immunosuppressants can reduce skin inflammation. And even after symptoms clear, Yale dermatologist Alicia Little recommends “a long-term maintenance treatment regimen [to] reduce scarring and may prevent progression to skin cancer.”
The Mona Lisa laser is a treatment recommended mostly in private gynecological practices—despite the statement in a British dermatology review article that, even for patients who don’t respond to steroid treatments, “the best second‐line therapy is unclear.” These dermatologists, based in London and Nottingham, describe laser therapy’s “uncertain efficacy”—while noting that “its use is gaining popularity in the private sector.”
The Danish lichen sclerosus study—comparing biopsy-verified LS incidence from 1997-1998 with that from 2021-2022—found “the rate increased approximately seven times, from 4.9 to 35.7 per 100,000 person-years.” Clinical guidelines recommend vulvar biopsies for LS only in cases of diagnostic uncertainty, and for a few other reasons—but clinicians may be performing them more often due to “increasing awareness of the malignant potential of vulvar LS,” according to the researchers. They also note the coincidence of increases in vulvar LS—with the “etiology…hypothesized to be autoimmune”—along with other autoimmune diseases, “with several possible explanations including environmental factors.”
For check-up gynecology visits after age 65, forgoing the Pap test is safe “if you have had several tests in a row that didn’t find cancer within the previous 10 years, including at least one test in the previous 5 years,” according to CDC guidelines—which specify having “3 normal tests in a row.” The guidelines also point out that because “most cervical cancer is caused by the human papillomavirus,” screening tests can include “a Pap test, an HPV test, or both tests.”
I am only slowly learning about the multiple benefits of supplementing post-menopausal estrogen—both topically and systemically—along with the many negative health effects of stopping routine hormone replacement therapy (HRT), based on a flawed 2002 study. Just last week, physicians coined a new term for menopause-related effects on bones and joints, the musculoskeletal syndrome of menopause—that includes loss of muscle mass, loss of bone density and progression of osteoarthritis—to join the earlier collection, GSM (genitourinary symptoms of menopause) that may one day include lichen sclerosus.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
Ebe, a LimbForge patient in Haiti, with her 3D-printed prosthetic arm, an evolved version originally crafted by Arthur Hobson and Jeff Erenstone. LimbForge is an organization dedicated to aiding the shortage of prosthetic rehabilitation in the developing world. / Photo courtesy of LimbForge.
By Mary Carpenter
THAT TREATING infection has garnered the greatest medical advances in wartime is one highlight of the recent exhibit, “Bespoke Bodies,” at Kansas City’s World War I museum. In addition to covering infection-related amputation, the display cases feature revolutionary developments in prosthetics–and portray women dressed in short skirts and short sleeves that proudly reveal prosthetics decorated in gold leaf, lace and fine-art drawings.
“Most people with limb loss…today are not veterans or survivors of war,” writes Lindsey Roy in a Teen Vogue article. In photos from her KC visit, Roy shows off her below-the knee prosthesis, acquired after the 36-year-old mother and Hallmark Cards executive lost her leg in a boating accident. Roy chose an undecorated but Bluetooth-enabled model for better movement control but describes innovations that give high-fashion models “access to customized, alternative limbs.”
Amputations soared in World War I with the advent of machine guns and tanks, resulting in amputations for about 100,000 Britons and Germans “when the procedure was often the only one available to prevent death,” Roy reports, quoting the Wall Street Journal. But in every war since then, more soldiers continue to die of infection—whether coming from outside the body to cause wound infections, or from viral and bacterial infections that attack from within.
“It takes a thief to catch a thief” is the mantra that came from antibiotic research that surged during World War II —referring to new drugs created by modifying viruses and bacteria. Before that, isolation was the only weapon for fighting these dangerous beneath-the-skin infections, according to The Life Savers of World War II, by Wendy Schoenbach Reasenberg and Anna Kade Schoenbach. In 1941, during the months after Halifax, Nova Scotia, became a major port through which thousands of soldiers moved, the only response U.S. medical teams could mount against three simultaneous epidemics—diphtheria, scarlet fever and meningitis—was mass quarantine and testing.
The next challenge for U.S. medical teams during that period was to develop antibiotics—which even today involves modifying infectious agents sufficiently to kill the virus or bacteria without creating side effects in patients. Life Savers describes an early candidate, streptomycin, which rather than treating, acted as a growth factor for infectious meningitis. And the greater problem that has emerged since then is antibiotic resistance developing in the most dangerous bugs—notably Clostridium difficile (C.diff) “associated with severe infections, high rates of recurrences and mortality.”
“That resistance out there is actually now one of the leading causes of death in the world,” Institute for Health Metrics and Evaluation Director Chris Murray told NPR. According to the report, “bacteria are mutating to evade antibiotics at a pace far faster than many researchers had previously forecast.”
The failure of antibiotics—always thought to be a so-called first world problem—is now “happening all over the world [with] deadly new strains of bacteria…causing untreatable blood infections, fatal pneumonia, relentless urinary tract infections, gangrenous wounds and terminal cases of sepsis, among other conditions,” according to the article. “Minor wounds that in the past may have needed only a bandage are now developing multidrug-resistant infections.”
Limb amputations in the U.S. today number almost 500,000 per year, mostly in patients with diabetes and vascular diseases, according to the Amputee Coalition. While lower smoking rates have brought down the numbers of lower-limb amputations, increased rates of diabetes, peripheral artery disease and chronic kidney disease have kept the total numbers high. And for veterans, wound infections still rank as a major cause.
Meanwhile, decorative innovations have begun appearing on medical devices—from ostomy bags to hearing aids—that address a range of medical issues. Diagnosed with rheumatoid arthritis, British designer Destiny Pinto used weightlifting gloves to support her wrists and compress aching joints and found that both discomfort and the embarrassment related to her condition decreased with the addition of fashionable accessories—adorning “red hot compression gloves … with silver buckles or [wore] lacy white gloves decorated with roses.”
OTC braces, often bulky and beige, have been my only experiences with medically assistive devices—for issues with ankles, knees, hands and wrists. But when the white wrist brace became slightly soiled from use, I dyed it bright blue: then, instead of questions related to disease and injury, people asked me about dyeing. And I had a much better time—telling dyeing tales from long-ago days in my hippie commune.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
EATING UNRIPE brie and bananas—as well as a host of fermented foods—can help combat anxiety, according to the recent food-as-medicine movement that involves specific personal recommendations from medical specialists, such as nutritional psychiatrists. Addressing “underlying metabolic pathologies associated with mental illness,” Harvard researchers in a 2021 Frontiers review article focus on the gut “microbiome and inflammation as influencers of anxiety.”
Choosing specific foods for health can depend on individual goals—reducing anxiety, lowering blood pressure, losing weight—while individual physiological differences can cause different foods eaten at different times of the day to have varying effects: for example, some people do better eating protein-rich breakfasts. In addition, personal preferences vary on the degree of specificity desired—with specific foods suggestions issued by nutritionists based everywhere from health care settings to pricey residential programs, such as Pritikin and The Ranch, Malibu—the latter the source of the unripe-foods recommendations.
Nutritional psychiatrists advise “paying attention to how eating different foods makes you feel —not just in the moment, but the next day,” writes Harvard nutrition specialist Eva Selub. “Try eating a ‘clean’ diet for two to three weeks—that means cutting out all processed foods and sugar. See how you feel. Then slowly introduce foods back into your diet, one by one, and see how you feel.”
One reason is that more general and widely accepted recommendations—such as eating fewer ultra-processed foods, less sugar, no gluten—don’t work for everyone: The advice to cut down on salt, for example, depends on personal salt sensitivity. Only about one-third of healthy people are salt-sensitive, according to an American Heart Association report, stating that “the effect of salt intake on blood pressure elevation is exaggerated [with salt sensitivity] higher in women than in men and, in both, increases with age.”
“Over recent years, evidence of the links between anxiety and inflammation has grown stronger,” according to MedicalNewsToday. The association of higher anxiety scores with a range of inflammation and coagulation factors has garnered support from studies showing higher levels of inflammation related to PTSD and depression. In addition, “anxiety disorders…may also be associated with increased risk of heart disease and metabolic disorders [that] involve low grade systemic inflammation.”
Blood sugar spikes can provoke changes in mood—with low blood sugar causing nervousness or anxiety along with irritability or impatience, although anxiety itself can also cause widely varying blood sugar levels. As a result, nutritionists rate different foods based on their glycemic index, the scale that measures how much a food or drink raises blood sugar levels. In addition, the microbiome may play as great a role as blood sugar in creating inflammation and thus increasing anxiety, which makes both targets for intervention by nutritional psychiatrists.
Among inflammatory foods associated with the Standard American Diet (SAD), “the two most metabolically challenging are refined sugars and processed vegetable oils [notably corn and soy oil], both of which can contribute to inflammation through myriad mechanisms,” write the Harvard researchers, who consider “lifestyle interventions for mental illness…a form of metabolic medicine.” High-fructose corn syrup, for example, which accounts for 10% of caloric intake in the U.S. “increases neuroinflammation and contributes to metabolic diseases.”
For anxiety, six nutritional interventions from the Harvard team include: avoiding artificial sweeteners and gluten; adding omega-3 fatty acids, turmeric and vitamin D; and following a ketogenic diet—eating normal protein, more fats and fewer carbs to help the body burn more fat for energy. Similar items appearing on a MedicalNews list of nine anti-anxiety food recommendations include fatty fish to increase omega-3s; and turmeric.
Other specific items on the MedicalNews list include pumpkin seeds (also bananas) for potassium because low potassium can elevate levels of the stress hormone cortisol; dark chocolate (and chamomile tea), rich in flavonoids that “might reduce inflammation and cell death” in the brain; green tea—for the amino acid theanine, recently studied for effects on mood disorders; and Brazil nuts, which can increase selenium to improve mood.
Eggs, good sources of vitamin D and protein as well as tryptophan—which indirectly boosts brain levels of serotonin “that helps regulate mood, sleep, memory and behavior” —are number two on the MedicalNews list. Also high on this list and many others naming specific healthy foods is yogurt, for calcium, potassium, and protein—and “most important,” according to the Consumer Reports column in the Washington Post, “live active-cultures and probiotics [that] tamp down chronic inflammation,” that are related to fermentation.
“Yogurt might be the easiest fermented food for Americans to add to their diets,” explains Harvard nutrition professor David Ludwig. While yogurt choices vary by amounts of calcium and fats, many people care most about protein content, which has higher levels in nonfat yogurt than in whole milk, even higher in Greek yogurt and highest in Icelandic yogurt known as skyr—which also ferments longer. Ludwig also encourages people to try pickled vegetables, such as kimchi; fermented soybeans, such as that in tempeh; and pickles labeled “naturally fermented.”
(To boost microbiome health, vegetable pickling should involve “natural fermentation” —not vinegar—using salty brine. In this process, salt releases beneficial bacteria in the vegetables, such as lactic acid. As opposed to the vinegar method, which often employs hot water to seal the vegetables, lacto-fermented pickles are uncooked and must be stored at low temperatures.)
Both green bananas and unripe brie appear on New York-based climate change advocate R.C.’s food prescription list, created by her nutritionist at The Ranch, Malibu—with the original goal of losing weight and, more recently, of reducing anxiety. Green bananas contain more than 50% starch, which helps control blood sugar and works as dietary fiber to create a feeling of fullness that can help limit calorie intake. (Ripening converts the starch to sugars, with fiber content falling to 1%.)
And while health benefits of unripe brie are harder to track down, dairy products including those high in fat, such as soft cheeses and even ice cream, have earned better reputations in recent years for creating feelings of fullness that help with weight management. For me, though, brie as well as skyr are appealing for their high protein content—and a relief for me to find favorite foods on healthy lists—while in general, I balk at dining from prescriptions and meal plans. Although the proposal of two clean weeks as a way to improve physical and mental health sounds manageable, I’m thinking of that only as a possibility—and not before the New Year.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
Since I last wrote about stem cell treatment for painful joints in 2017, the Arthritis Foundation has continued to warn against “unproven and likely ineffective stem cell therapies offered at the nation’s nearly 3,000 for profit clinics.” At the same time, the foundation reports that regenerative therapies, including stem cells (capable of reproducing identical or similar cells) are “the future of medicine…show promise for osteoarthritis and many other chronic diseases” —with researchers in “nearly every country…conducting clinical trials using stem cells to treat a vast array of conditions.”
STEM CELL injections were only one of several treatments DC lawyer F.J. chose after months with a painful ankle, along with cortisone shots and physical therapy—so that when the pain finally subsided, no one knew which treatment had helped, or if they had worked in combination, or whether the passage of time played any role. And while cortisone shots can stop pain instantly, the effects wear off —with some doctors suggesting regular shots every six months or so, while others warn about risk of tissue damage.
For excruciating knee pain, Virginia horse trainer T.D. chose stem cell treatment from a Northern Kentucky chiropractor, because of the shorter recovery time compared with surgical knee replacement. Stem cells reduced her pain, sometimes completely, and she was grateful to have had that option—although the effects began wearing off after about two years. For both patients, as at most U.S. stem cell clinics, insurance did not cover the $4,000 to $7,000 cost of implantation.
“The best-case scenario I’ve heard is that stem cell injections seem to help [patients’] knees for a few months,” UCDavis stem-cell biologist Paul Knoepfler told Bloomberg. The article cites an Emory University study that concluded stem cells were no better than steroids—for which costs are usually covered by insurance—at reducing knee pain and “many studies…including a large one by the Mayo Clinic are inconclusive about whether stem cell therapy helps ailing knees.” Often, too, “what’s being billed as stem cells…can be something called amniotic extract, or dead cells.”
The FDA—which “warns consumers about unproven and likely ineffective stem cell therapies offered around the country,” according to the Arthritis Foundation—has approved them only for the treatment of certain cancers and disorders of the blood and immune system.” Meanwhile, some clarity—for the vast array of anecdotal success stories, rumors of shortages and confusion about clinical trial outcomes and oversight of quality—can come from understanding the differences among the four types of stem cells.
Most questions concerning federal regulations and stem cell shortages, for example, refer to only one category—embryonic stem cells, which exist only in the first three to five days of embryonic development and are “pluripotent,” meaning they can turn into any of the 200 cell types in the body, such as lung and brain. According to the DVC Stem organization, federal regulations restrict research to embryos created for reproductive purposes and donated by the individuals seeking reproductive treatment.
Adult stem cells, a second category, are “induced pluripotent stem cells” (iPSCs),” created from autologous cells taken from the patient’s own organs and tissues (especially bone marrow and fat) that have been “genetically reprogrammed back to an embryonic state,” according to the Arthritis Foundation. Reprogramming adult cells “would avoid ethical concerns [of embryonic cells] while guaranteeing an almost unlimited supply…but iPSCs are still in preclinical trials amid concerns about their safety and the tedious reprogramming process.”
Finally come the two best-studied kinds of stem cells—also the ones most available for treatments today. First, cord cells—human umbilical cord mesenchymal stem cells (hUC-MSCs), which are self-regenerative pluripotent cells obtained from umbilical cords removed after birth—“have the ability to alleviate pain, enhance knee joint function and potentially postpone the need for surgical intervention,” according to results from 12 clinical studies in a Chinese research survey. The cells can “promote cartilage production [and, compared with stem cells from other sources, have] “stronger proliferation, differentiation and immune regulation abilities.”
For advanced osteoarthritis, these cells “coordinate cartilage regeneration” by secreting bioactive molecules related to cartilage repair and other activities, according to a Frontiers review by other Chinese researchers. But they conclude that “there remains no clear evidence that these hUC-MSCs have a considerable advantage”—compared to the final, most common category of stem cells that come from a patient’s own bone marrow (BM-MSCs). The article cites findings that “injection of autologous BM-MSCs is safe and effective in treating knee, ankle and hip joints,” along with a more than 11-year follow-up study demonstrating “their long-term safety and efficacy…for cartilage repair.”
At Minnesota’s Mayo Clinic, the primary U.S. center for stem cell research, the RECLAIM (recycled cartilage auto/allo implantation) study uses stem cells—both autologous from the patient’s own cells, and allogenic from other donors— to promote cartilage repair for both hip and knee joints. RECLAIM, however, accepts only patients without arthritis who have had traumatic or athletic injuries—and symptomatic cartilage defects must be “fresh,” meaning very recent.
My problems with joint pain and mobility have never been serious enough for me to try regenerative treatments—at least in the absence of insurance coverage or clearer evidence that they work well. What could change my mind are the ongoing, overwhelmingly positive anecdotes from people who are pleased with the results —though, in the end, most say they cannot be entirely sure how much credit to give their stem cell treatments. But five years after his stem cell injections, DC lawyer F.J. said his discomfort is “quite minor,” a lasting effect that could not result from cortisone shots alone.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
THAT HALF of all body parts is unnecessary “is a myth,” according to Harvard rheumatologist Robert Shmerling. Advising against unnecessary removals, Shmerling explains that “our understanding about so-called spare parts may change over time.” Already, those “parts” newly appreciated for roles in the immune system include the appendix and tonsils—also the thymus gland, recently seen as a hoped-for player in slowing the process of aging.
The tonsils, thymus gland and spleen—among “spare parts” listed by Shmerling — create links often likened to “a string of pearls” in the body’s lymphatic system. While injury or disease has been the most common cause of their removal, tonsillectomies used to be almost a rite of passage in early childhood; the spleen sacrificed if there was any risk of bleeding after injury; and the thymus eliminated as an unnecessary obstacle during chest surgery.
But the lymph system—and each of these parts—plays an important role by continuously cleansing the body, collecting byproducts of cellular activity and infection and transporting them for detoxification via lymph nodes and eventually the blood. Notably, lymph tissue located around the digestive tract helps protect this main entry point into the body against toxins and infection. A poorly functioning lymph system can cause fatigue and a feeling of heaviness in the abdomen —what the Chinese call “excessive damp.”
Joint pain, headaches, food sensitivities, cold and flu infections, including sinusitis, fatigue and depression may also be symptoms of disturbances in the lymphatic system — a high priority in Europe for both treatment and preventive health care. According to Marcelle Pick, OB/GYN nurse practitioner, author of Is it Me or My Hormones?: manual manipulations and movements for lymphatic drainage are considered routine treatments in European hospitals, especially before surgery “to improve healing by readying the system for recovery.”
Inactivity can seriously impair the flow of lymph fluid—because, unlike blood that is kept moving by the heart, the lymph system has no pump and relies on muscle contractions during deep breathing and physical activity to move fluids through the body. Lying on a slant board or otherwise hanging upside down can help. Estimating that 80 percent of women have sluggish lymphatic systems, Ann Louise Gittleman in her book The Fat Flush Plan suggests exercise on a mini-trampoline or any stretching or aerobic exercise; also drinking lots of water and eating raw fruit.
The thymus—meaning “soul” in Greek from the belief that the soul resides there—pumps out white blood cells called T-lymphocytes but is active only until puberty and then “withers away,” according to sciencenews. Afterwards it fills with fat, appearing “more like a fatty blob,” said Mass General hematologist-oncologist David Scadden. In research with colleagues on 1,146 patients whose thymus glands were removed during surgery—compared with a control group matched for age, sex and race but whose chest surgery did not include thymus removal—the thymectomy patients had nearly three times the risk of death and twice the risk of cancer.
Linking these results to loss of immune protection from newly formed T-cells, UCLA geneticist Steve Horvath and others studying the biology of aging looked at the possibility of restoring function in the aging thymus, according to MedicalNewsToday. The researchers based their hypothesis on the belief that “thymic involution leads to the depletion of critical immune cell populations and is linked to age-related increases in cancer incidence, infectious diseases…and all-cause mortality.”
In a trial called TRIIM (Thymus Regeneration, Immunorestoration, and Insulin Mitigation), the UCLA researchers tested a cocktail of hormones, steroids and the diabetes drug metformin with the goal of restoring youthful functioning of the thymus. In the original, small study of males ages 51 to 65, the cocktail reduced subjects’ biological age by two to three years. According to Forbes, “in most cases, their kidney functions improved, and some of the men’s hair became darker too.”
While a follow-up TRIIM-X study that includes women and a wider age range is underway, the organization PUR-FORM is testing slightly altered ingredients of the UCLA cocktail to affect biological age—also called “epigenetic age,” related to chemical modifications of DNA, in response to various environmental and lifestyle factors, as “a better predictor of age-related disease and mortality than chronological age,” according to PUR-FORM medical director Joseph Purita. “Our practice decided to enhance the TRIIM trial and design with what we feel will be [better] for thymus gland rescue.”
From Shmerling’s list, the seven “anatomic remnants” that might confer health benefits—in addition to tonsils, thymus gland and spleen—include adenoids, gallbladder and uterus. Finally, he adds the appendix—is shown in new research to play a possible “role in immune development and stores ‘good bacteria’ to repopulate the gut in case of future illness.” New appreciation for these remnants over the years has led to a steady decrease in their removal.
Years ago, I had several bouts of what was called “chronic appendicitis”—symptoms never severe enough to warrant treatment, even with antibiotics, the less invasive approach to appendicitis. The only spare part I have given up is tonsils—after years of childhood earaches that ended only after a second tonsillectomy to remove them completely.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
ON THE MORNING 60-something development professional C.M. was heading from Philadelphia to Boston for a child’s high school graduation, she woke with a sensation of spinning inside her head. She recognized it from prior experiences: vertigo. If she kept her head propped on pillows and remained still, it wasn’t too bad, but cars and airplanes, standing up and sitting down, would be unbearable.
The spinning that defines vertigo—that the head or the surrounding environment is spinning—is “the perception of motion when no movement is present, or the abnormal perception of motion in response to movement.” Lying on the back for a long time, such as in a dentist chair, can be a trigger. Vertigo is unpleasant and disorienting—and dangerous if you try to drive or climb a ladder. It’s not the same as dizziness—which usually lasts just seconds, while vertigo can persist—or fear of heights, although dizziness can accompany both vertigo and acrophobia.
The movement can also feel like floating or rocking, “intense [as] if you’re on a boat and the boat is rocking back and forth,” Connecticut otolaryngologist Francisco Benjamin Wycherly told the American Medical Association news site. The most common kind of vertigo is Benign Positional Vertigo (BPV)—or BPPV, with the added P for paroxysmal, meaning sudden recurrence or intensification of symptoms, such as spasms.
BPV is usually idiopathic, meaning without known cause—although it occurs more often in those over age 65 and twice as often in women as men; and may be linked to osteoporosis and family history. Vertigo can also start with a bacterial infection or Meniere’s disease—causing buildup of fluid in the inner ear; or it can begin in the brain with migraine or following head injury. Persistent vertigo can also be the result—or the cause—of mental health issues, such as depression and anxiety.
Sudden severe vertigo that makes it hard to stand or walk is one reason to seek emergency treatment. Also, hearing loss that accompanies the vertigo can indicate that infection is inflaming the inner ear, called labyrinthitis or sudden sensorineural hearing loss—and hearing may not recover without treatment, University of Iowa neurologist and otolaryngologist Deema Fattal told the AMA site. Another reason to seek emergency treatment: when neurological symptoms—clumsiness, hiccups, swallowing problems—accompany sudden onset vertigo.
The “head impulse test” for vertigo involves trying to hold the gaze on an object (like the doctor’s nose) while moving the head quickly from side to side. If the gaze shifts when moving the head to one side, that can help indicate which ear is affected—vertigo rarely infects both ears. Indicative of vertigo and thus an aid in diagnosis are unusual eye movements called nystagmus that occur with rapid movement: from sitting to lying down, or with the additional rapid movement of the head to one side and then down (over the side of the bed or other support) below the level of the body.
BPV arises from a disturbance in crystals in the ear that monitor the body’s movement. Displacement of the crystals—composed of calcium carbonate and called otolith crystals or otoconia, also debris and “ear rocks”— from the inner ear into the semicircular canals can alter sensitivity to positional changes. To break up the displaced crystals, the series of movements is similar to that used to diagnose BPV, called the Epley maneuver or canalith repositioning. The simple movement requires holding each position for 30 seconds after symptoms cease —but should be recommended and demonstrated at least initially by a physician.
Vertigo can disappear without treatment when the cause, such as a viral infection, clears. Or the body can adapt by relying more on the other senses for balance—either naturally or with the help of vestibular rehabilitation. Most cases of BPV resolve in a day or two, 80% end within a week; and 95% of patients recover fully.
Depending on the cause of vertigo, antihistamines or medications for seasickness—such as generic meclizine, called Antivert or Bonine—can help with dizziness as well as nausea. And ginger as an all-around nausea-suppressant is on the home remedy list, along with ginkgo biloba, also almonds (perhaps because of their high Vitamin A, B and E content). And because even mild dehydration can trigger BPV, drinking extra water can help prevent attacks. On the other hand, decreasing fluids via diuretics— and reducing salt —can help reduce the inflammation that accompanies vestibular vertigo and Meniere’s disease.
BPPV can recur, most commonly in people who sleep on the affected side. The best antidote can be adding a pillow under the head and/or using pillows or other props to prevent turning onto that side. Chronic sufferers should move their bodies, and their heads in particular, slowly when changing position, especially when standing or reaching overhead. But no one should just “live with” vertigo, according to Wyncherly, who described the “very sad” situation of a patient who lived 20 years with undiagnosed vertigo. He recommends starting with a primary care physician, or an ear. nose and throat doctor, who can make decisions and sometimes referrals for diagnosis and treatment.
I have not experienced vertigo but am very sympathetic to those affected as I am a chronic sufferer of all kinds of motion sickness—in boats and cars, watching 3-D films and the one time I tried a video game: just writing about vertigo can make me feel slightly woozy. And I became aware of widely varying approaches to vertigo treatment when a friend had extreme dizziness, diagnosed as Meniere’s disease and considered permanent—until she found physicians who helped rid of her symptoms entirely.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
FROM Metabolic syndrome to Post-Traumatic Stress Disorder and Ehlers-Danlos Syndrome, labels such as “syndrome” or “disorder” can elicit dismissive responses from medical professionals and even to gaslighting of patients—while bestowing the “disease” label can earn better attention and treatment. Lower-order labels—for both mental and physical symptoms—often result when diagnostic criteria for diseases are too restrictive or complex. But ChatGPT appears to be helping—with responses both to complicated symptoms and communication with the patients involved.
Metabolic syndrome, for example, is the cluster of conditions that increase risk for heart disease, stroke and type 2 diabetes—but that combination of risky symptoms receives less attention than the individual diseases, which include increased blood pressure, high blood sugar and excess body fat around the waist, according to the Mayo Clinic.
A diagnosis of PTSD, a different kind of problem, depends on unusually specific parameters—beginning with exposure to a “potentially life-threatening event…severe injury or sexual violence,” according to behavioral researchers studying “the frequency of clinically undetected PTSD” at Wayne State University and elsewhere. In addition, “individuals must experience intrusive symptoms related to the event, engage in persistent avoidance of stimuli associated with the event, and display [changes] in cognition, mood, arousal and reactivity…”
Because diagnostic requirements are complicated, physicians often miss or ignore associated medical conditions that could help with its diagnosis but are not listed in the Diagnostic and Statistical Manual ). The researchers focused on aboulomania—a “neurosis…characterized by pathological indecisiveness…that severely hampers [patients’] ability to function normally” —to “raise awareness both about the limitations of the DSM-5-TR [and the] importance of maintaining an open-minded approach when treating mental illnesses.”
“Is EDS real?” queries a diagnostic algorithm, according to a STAT post—noting frequent failures to diagnose the hypermobility that is related to EDS but remains in “medicine’s grey area.” Very loose joints may fail to receive the hypermobile EDS (hEDS) label because, unlike the 13 other EDS subtypes that are linked to specific genetic variants, hEDS has no known cause.
“Revenge of the Gaslit Patients,” headlines the STAT post—describing hEDS patients who “might look healthy, their tests might show no signs of disease, but they endure repeated joint dislocations, headaches and pain, as well as gastrointestinal issues, fatigue, and stretchy and fragile skin.” Recently discovered genetic links to the condition could help—but await months or even years of research to confirm.
“Syndromes [defined as] certain groups of symptoms that occur together” are the lowest ranking term in the hierarchy of diagnoses, according to verywellhealth. The next level, “’disorders’ …refers to “a group of symptoms that disrupt normal functions in the body or cause significant impairment;” while the highest level is “disease.” Pain in the joints, the example given, can receive a diagnosis of “arthritis disorder,” while additional testing that reveals immune system dysfunction leads to a label change to “rheumatoid arthritis,” which gets much more serious attention.
The greatest challenges can arise with diseases that are rare or have diagnoses based on recently discovered laboratory testing or genetic links—with endless examples in Lisa Sanders’s New York Times’s “Diagnosis” column. One woman, for example, waited 30 years for a new test that could diagnose her rare disease—a variety of congenital myasthenic syndrome—which came with the good news of a treatment: the common asthma drug albuterol.
Another woman waited 18 years for the discovery of an antibody that attacks a protein in the brain and spinal cord, the myelin oligodendrocyte glycoprotein (MOG) —and her “relief at having an answer was immediate,” writes Sanders—even though the altered treatment that improved her symptoms cannot cure the disease.
Large language models (LLMs), such as ChatGPT, are increasingly helpful to physicians and to patients—as New York gynecological surgeon Sara Farag told the healthcare news site fiercehealth: “The busier that our days get and the more information we have to sift through, the more useful that LLM’s [sic] can be.” And among the non-medical population, a Kaiser Foundation poll found “about one in six adults… use AI chatbots at least once a month to find health information or advice—while one in three trust” that AI chatbots are reliable.
More surprising, though, is the finding that “ChatGPT’s answers to patient questions were rated as more empathetic (and also of higher quality) than those written by actual doctors,” wrote Jonathan Reisman, internist and author of The Unseen Body: A Doctor’s Journey Through the Hidden Wonders of Human Anatomy, in last week’s New York Times. “The reason…in medicine—as in many other areas of life—being compassionate and considerate involves, to a surprising degree, following a prepared script.”
For me, having symptoms taken seriously—or even better, given a label at any level—has been helpful even in the absence of treatment. For example, it came as a relief to learn about my hypermobility, even if not hEDS— to understand that minor weakness in my back and knees may not be entirely my fault, caused by my failure to “stand up straight” as I was exhorted throughout my childhood, or to my ongoing failure to do much more frequent or strenuous exercise.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
THE SUPPLEMENT wars continue—intertwined with the diet wars—from the potential toxicity of turmeric to ever-changing recommendations on Vitamin D, to why not just drink apple cider vinegar every day. Meanwhile, what may be the biggest questions concern whether particular supplements contain the ingredients listed on the labels—or not; or worse, may be dangerous to the health.
Recently, so-called Ozempic dupes are the latest iteration of weight-loss supplements—notably those from Kourtney Kardashian’s company Lemme, gummies called GLP-1 Daily, touted to suppress cravings and lead to weight loss. According to Harvard Medical School diet expert Pieter Cohen, however, the studies Lemme cites to support the supplements are “not credible.”
“Increased mortality rates” were among the effects of large doses of beta-carotene, selenium and vitamins A, C and E in some randomized research studies, writes Anahad O’Connor in the Washington Post. Dangerous side effects likely occur when supplements use the same metabolic pathways as medications: for example, Vitamin C can interact with statins and estrogen. According to O’Connor, “dietary supplements account for about 20 percent of drug-induced liver injuries nationwide.”
Liver toxicity can be a direct result of drugs, such as acetaminophen, that are intrinsically toxic to the liver. But the alternative, idiosyncratic toxicity, varies with gender, age and immune status of different individuals and is not dose-dependent. Women are more prone to drug-induced liver injury, as are African Americans.
Turmeric—taken in concentrated supplement form for purported anti-inflammatory and antimicrobial properties, and notably for arthritis—has caused liver damage. Early blood tests in one study barely detected two grams of turmeric’s healthful ingredient, curcumin—until adding black pepper, included in many turmeric supplements, boosted its bioavailability, the amount reaching the bloodstream, by 2,000%, according to the Post.
“Based on what we’re seeing in our data, [turmeric] is one of the most common causes of dietary supplement liver injury,” NIH director of liver disease research Jay Hoofnagle told the Post. Consuming about half a teaspoon of ground turmeric daily led to elevated bilirubin, indicative of liver dysfunction, in a 66-year-old woman seen in a Baltimore ER. Baltimore internist Fadi Alghzawi recently reported an uptick in turmeric-related liver cases and advises avoiding turmeric supplements altogether.
On Vitamin D, updated 2024 guidelines from the Endocrine Society include the caveat that “the optimal dose . . . isn’t known.” The guidelines advise against routine testing for Vitamin D levels in healthy individuals—and oppose supplementation beyond the daily recommended intake for adults younger than 75 years old, in the absence of osteoporosis. The daily recommended intake is 600 Iu/d (international units/day) through age 70; and 800 for those over age 70.
“We have no data that there’s anything about [Vitamin D] screening that allows us to improve quality of life,” Maine internist and moderator on a recent Endocrine Society panel Clifford J. Rosen told Medscape. And Harvard internist and chair of the panel Marie Demay noted “the paucity of data regarding . . . optimal intake of vitamin D for preventing specific diseases”—but acknowledged that “there are certain populations that will likely benefit from [higher] levels.”
Finally, apple cider vinegar (ACV) may offer advantages similar to those of supplements—notably, Vitamin B and antioxidants—and “is generally harmless as long as you use it correctly,” according to WebMD. Potential health benefits include helping reduce blood sugar levels and aiding weight loss, and many people tout effects, such as quelling inflammation.
But “the Internet would have you believe apple cider vinegar is the new pixie dust due to its health benefits,” according to University of Chicago researchers. “ACV is not pixie dust, but it’s also not snake oil.”Among drawbacks, it may exacerbate acid reflux, and can erode teeth enamel although the effect can be allayed by drinking water afterwards.
In previous years, the medical community contended that healthy eating supplied sufficient daily vitamins —but based on a study last year, doctors now recommend a daily multivitamin to slow memory loss in patients age 60 and older. Multivitamins, however, carry the same risks of all supplements, that ingredients are not officially monitored.
Voluntary testing programs offered by two organizations offer certifications for purity and potency—and supplements that meet these standards earn listings on the sites and can display the programs’ logos: either the black and yellow “USP Verified” or the blue and white “NSF” (National Sanitation Foundation). Among highly rated multivitamins, however, Centrum products display no logo, while Nature Made has NSF boldly printed on its labels.
Discussing supplements with your doctor can be a good way to choose a reliable brand—although mine had none when she recommended a multivitamin based on last year’s study. I ended up choosing Centrum only because a friend gave me her supply; she had discovered the pills contained iron and didn’t want the risk of constipation.
Iron has also been a troublesome supplement for me. Years ago, my doctor urged me to take it for low ferritin, a protein that stores and releases iron to help replace what’s lost in the course of daily bodily functions, such as sweating and sloughing off skin cells. But for three years, the “gentle” iron she recommended–specifically to avoid the same risk of constipation—had no effect. Finally, a different doctor who is a high-school friend told me the only effective brand to increase ferritin is FeroSul. After taking it, my levels shot way up to normal by the next testing.
These and other confounding experiences have made me wary about adding any new supplements—despite the enthusiasm of friends for potions containing mushroom powders and anti-aging remedies, as well as for the multitude of gummies, lollipops and other formulations from Kourtney Kardashian’s Lemme.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
“WHAT about trying a fecal transplant?” one guest asked New York painter E.N. at a resort lunch last summer. By 2024, the topic of transferring donor stool samples (fecal microbiota transplantation, or FMT) to treat intestinal problems—currently approved only to treat dangerous, recurring infections of C.diff (clostridium difficile)—had become (slightly) more acceptable for mealtime conversations.
“The “ick” factor of getting a poop transplant doesn’t faze many of my patients who are desperate to vanquish their gut health woes,” writes Harvard gastroenterologist Trisha Pasricha in the Washington Post. Pasricha notes that, by transplanting healthy bacteria—that make up a healthy microbiome —via “healthy poop to an unhealthy gut, we can alleviate certain illnesses, but so far, our hopes have gotten ahead of the data.”
“The human microbiome is like a garden, where [many variables] affect whether you get weeds or beautiful flowers,” writes Pasricha. Because hormonal, dietary and neuronal factors affect the microbiome differently in each host, she said, “we still aren’t sure what combination . . . will give one individual weeds or flowers [the reason a 2019 meta-analysis of trials on patients with irritable bowel syndrome] “did not show a benefit of fecal transplant . . . there is no single microbial abnormality present in all patients.”
In addition to using FMT to treat C.diff—delivered in recently approved medications either orally or via colonoscopy—physicians have studied and prescribed it off-label for obesity, for several autoimmune GI conditions and for irritable bowel syndrome ( IBS), an array of GI complaints that can be hard to diagnose. Slate described one review of IBS research involving almost 500 patients that found FMT relieved some symptoms, but results were not statistically significant.
Even for C.diff, when the pandemic led to the suspension of FMT research at the University of Michigan, program director Krishna Rao treated patients with longer than normal courses of antibiotics and “leaned into holistic care (e.g. encouraging patients to eat fermented foods, which have anti-inflammatory effects),” according to the American Society of Microbiology. When 90% of these patients got better, Rau concluded that not all patients need FMT—but it’s impossible ahead of time to determine which ones do.
Three current targets of the NIH-based Human Microbiome Project—charged with establishing a database of microbial communities from 300 healthy individuals—are onset of type 2 diabetes and Irritable Bowel Disease, an autoimmune condition; and pre-term birth. For off-label uses, anything other than for C.diff, physicians obtain samples from stool banks, the largest being OpenBiome—while HumanMicrobes acts as donor network for those choosing the DIY route.
“The ultimate donor is probably something like a 2-to-18-year-old Michael Jordan,” according to HumanMicrobes; as well as someone less likely to have taken antibiotics. Before collecting and stool samples, OpenBiome screens donors so extensively, founder Majdi Osman told Slate, that qualifying is more difficult than getting into Harvard.
But even with careful screening, donor stool can contain unhealthy bacteria or unknown pathogens. Mpox (monkeypox), for example, “before the onset of the 2022 global outbreak . . . was circulating in the population—and stool banks and clinicians didn’t know about it,” according to the American Society of Microbiology. And improper screening for E.coli at a hospital-based stool bank may have caused the death of an immunocompromised 73-year-old man.
The greatest risks of FMT stem from the effects of the enormous influential gut microbiome—which can change from day to day—on everything from GI functioning to mood disorders. Conversely, risks also stem from frequent, outsized changes in the gut caused by food, hormones and brain activity—as well as medications: for example, using statins to lower LDL levels can make the gut more receptive to some bacteria, and less to others. Explains psychopharmacogeneticist Sony Tuteja at the University of Pennsylvania, “It could be bidirectional. The microbiome is affecting the drug, and the drug is affecting the microbiome.”
And differences in individuals’ microbiomes can alter, sometimes dangerously, the effects of prescription drugs: of 1,000 drugs screened in a 2018 study, nearly one-quarter had antibiotic effects in the gut despite not being sold as antibiotics. With medications such as those used to treat Parkinson’s disease, molecules in the gut can increase or decrease the amounts that reach the brain.
“It was possible to essentially transplant a mood disorder into rats,” according to Nature writer Neil Savage, on studies at APC Microbiome Ireland. “The ability of certain good bacteria to synthesize neurotransmitters . . . mood-regulators such as serotonin—may explain the link between low diversity of gut microbes and mental health conditions.”
A diverse diet is the number one recommendation of Netflix’s “Hack Your Health: The Secrets of Your Gut” —that is, consuming 20-30 fruits and vegetables each week. The second is to eat much higher levels of fiber than in the current American diet. “Your microbiome loves fiber,” writes Pastricha. Over years of eating too little fiber and taking too many antibiotics, she explains, “subsequent generations lost huge groups of microbes that could not be fully recovered.”
Supplemental psyllium is another component of Pastricha ‘s advice—starting with a low dose of 10 grams daily to as high as 30 grams, split between morning and evening doses—“that responds in real time to your bowel needs: it provides bulk to stool when you have diarrhea but can also retain water, which softens up your poop when you’re constipated. “
While most people—including painter E.N.—are unwilling to try FMT, others with persistent debilitating symptoms have gone the DIY route. D.C. area resident 66-year-old Alexandra, profiled by Slate, suffered from cystitis, candidiasis and irritable bowel syndrome, as well as frequent urinary tract infections and “terrible acid reflux.” Using preparations from HumanMicrobes, costing about $1,500, Alexandra started with a frozen stool sample that didn’t help much, and then tried capsules with “even worse” results.
“Finally…something miraculous happened and she got better,” according to Slate. “My body was distressed about taking all these new microbes,” Alexandra concluded, “but it got to the point where the microbes were established.” HumanMicrobes founder Michael Harrop acknowledges that many factors might have played a role in Alexandra’s improvement—including the placebo effect—but he also posed the question: “What if there is a miracle drug waiting for us in the right toilet?”
—Mary Carpenter regularly reports on topical subjects in health and medicine.
IMAGINE the terror of driving on a fast highway knowing that at any moment your eyes might jam shut —or facing a fully scheduled day with no idea when searing pain might force your retreat into a darkened room. The dramatic, unpredictable and different medical conditions— blepharospasm (benign essential blepharospasm or BEB) that can force the eyes shut; and migraine headaches that cause blinding pain—share surprising features. Notably, the symptoms of both can respond to Botox.
And Botox—now famous for smoothing wrinkles and later found to offer relief from migraines—had its first medical uses with issues affecting the eyes: blepharospasm (blepharo- is a prefix meaning eyelids), along with strabismus (crossed eyes). But the first research on botulinum toxin as a potential chemical weapon during World War II, according to the New York Times, found it “100 times more virulent than cyanide.”
The toxin “can cause a deadly reaction called botulism [if eaten] in spoiled food, because it blocks signals from your nerves and paralyzes your muscles,” according to WebMD. But when applied to the head and neck—and not digested by the stomach—the same effect on nerves appears to block neurotransmitters carrying signals from the brain—to prevent transmissions of pain from reaching the nerve endings.
Dubbed “pretty poison,” Botox medical treatments had the “unlikely [cosmetic] byproduct: brows as smooth as a child’s”—first applied to frown lines called “Elevens,” and then elsewhere around the face, according to the Times. Said late Canadian dermatologist Alastair Carruthers, first investigator of its wrinkle-blocking possibilities, “The worst complication of Botox treatment is reduced expressivity.”
But Carruthers believed that “we help people better express themselves…not looking angry/worried/stressed when they’re not angry/worried/stressed.” As noted in the Times obit, “movie directors complained that actors were losing their ability to emote [but] lawyers trumpeted it as an aid to retaining a poker face, a boon in negotiations.”
Besides responding to Botox treatment, BEB and migraine overlap in creating involuntary eye movements, called twitches or spasms. Twitches can occur in the early stages of a migraine headache, though they are more likely to accompany related conditions, such as retinal migraines, which cause temporary vision loss in one eye and can last from several minutes to months at a time; or cluster headaches, which create pain around the temple and eyes that radiates to the back of the head.
For Massachusetts-based event planner M.J., migraine headaches over 40 years caused missed work opportunities and precious family time—as well as daily fears of the next one coming. Botox gave M.J. some relief, as did various drug treatments—blood pressure medicine, antiseizure medicine and recently a new drug called Nurtec, famously touted by Lady Gaga. But M.J. said, “eventually [each drug] stops working very well” —while Botox continues to help.
For Maryland landscape designer G.L., “uncontrolled squinting, different from just squinting because of sunlight, screws up my whole face,” making it hard to concentrate on device screens for work and leading to worries about driving. Over more than a year, she visited a handful of specialists—including ophthalmologists and a neuro-ophthalmologist —who alternately prescribed light sensitivity (FL-41) sunglasses, erythromycin ointment for ocular rosacea, drops for dry eyes—and finally, a blepharospasm support group.
BEB “is a neurological disorder that causes spasms, or twitching, of the eyelid,” according to the National Institute of Neurological Disorder and Stroke (NINDS). But BEB sufferers believe “spasms” or even “intense squinting” describe their experience better than twitches. BEB symptoms include eye dryness and sensitivity to light, and “having a hard time keeping eyelids open, sometimes closed for long periods of time, which causes substantial visual disturbance or functional blindness.”
BEB is a type of dystonia or movement disorder that causes involuntary muscle contractions and is more likely to affect women between ages 50 and 70. According to MyClevelandClinic, “You blink more than most people…even when [not] having noticeable spasms.” Spasms occur in both eyes at the same time, synchronized spasms that are uncommon in other eye-twitching conditions—and in patterns sometimes discernible only by health-care providers. Calming can come from “sensory tricks…like humming, singing or touching your face.”
“Blepharospasm and its related disorders can feel overwhelming to learn about,” according to the website for the Benign Essential Blepharospasm Research Foundation, which offers videos that G.L. found useful. The site notes that the cause remains unknown, but dry eyes often precede or occur at the same time as blepharospasm and may trigger its onset “in susceptible persons.” The BEB site also warns that, over time “spasms may intensify…the eyelids may remain forcefully closed for several hours at a time.”
BEB can also make it difficult to close the eyes completely, which can interfere with sleep. Saying that neurotoxins were the only treatment she was aware of for BEB, B.L.’s neuro-ophthalmologist prescribed Xeomin, similar to Botox, which is supposed to last four to six months. “It helped a lot,” said G.L., though in less than two months, she felt symptoms “slowly creeping back.” Recent discoveries of different botulinum toxin strains can make it possible to alternate strains, allowing for effective results over longer periods of time.
Eating or chewing gum has helped G.L. reduce muscle contractions—especially when driving, but she has found “the most effective intervention is simply pressing against my forehead or the side of my temple.” Still, spasms come, off and on all day whenever she tries to concentrate —for example, focusing on an opponent who is about to serve in tennis, though “once the play starts, the uncontrolled squinting mostly resolves itself.”
Knowing about BEB, I intend to pay more attention to dry eyes when they occur. More importantly, though, I now have a better understanding of both conditions and of how much sufferers benefit from greater awareness among their friends—both about the symptoms of these debilitating conditions; and about why, during difficult periods, sufferers might need extra time in a darkened room or extra help with various tasks like driving.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
WITH AN upcoming wedding or funeral, I start worrying weeks ahead—about crying, sobbing tears that can arise for me with anything from emergency sirens (courageous rescuers) to movie theater ads (cars on lonely roads). But my lacrimal flow is at its worst at ceremonies, where common tips are useless: an ice cube in the hand or cold water to splash on the face are never available; and counting backwards or mentally reciting a poem, song or nursery rhyme—or even a mantra such as “I am a happy person”— takes too much attention away from the ceremony: I don’t want to miss it entirely.
Distractions that work better are “grounding” techniques, such as pinching yourself hard anywhere, or at acupressure points such as between the index finger and thumb; making a tight fist; fidgeting; and pushing the tongue against the top of the mouth. According to the dentistry site RDH, “the tongue’s position against the hard palate affects the parasympathetic system” —which reduces heart and respiratory rates to create calm as well as distraction.
“Emotional tears” may have evolved in humans to help us bond, according to Healthline. In contrast to basal tears that clean and lubricate the eyes, and reflex tears caused by irritants, like the compounds in onions or pollen— “emotional tears have more proteins, which makes them more viscous and more likely to stick to the skin and roll slowly down your face for other people to notice.”
And “crying causes your body to release oxytocin— the ‘love’ chemical you feel when you’re hugging someone,” writes Lauren Valko on the site HighlySenstiverRefuge. Quoting Harvard Health, Valko notes that endorphins also released along with tears are “the happiness hormone… actually a mild, natural opioid. In other words: crying actually helps fix those negative emotions.”
Anything that alters hormones—sleep, stress, medications—can affect how much you cry, according to Healthline. Testosterone may inhibit crying, “while prolactin that is higher in women may promote crying.” Women cry more often than men, although the numbers can vary from three to six times as often; and Americans—both men and women— cry more times per month than the global averages. Finally, temperament may affect crying behavior in both sexes —with extroverts more comfortable about their tears.
Another statistic —surprising, but helpful to anyone worried about inappropriate tears—is that one in 20 people cry every day at work, writes Valko. In addition, she describes “Highly Sensitive People” (HSP), a category that may include as many as one in three people who “feel and process…surroundings more deeply than non-HSPs [and] absorb emotions from those around them…makes us incredibly empathetic.”
While the category of HSPs is unofficial, researchers have used functional MRIs to examine brain activity in HSPs compared with that of other participants. When asked to look at photos of their partners and of strangers making happy or sad expressions, HSPs had more brain activation in areas associated with empathy and awareness; and in those involved with attention and taking action.
Crying can have benefits, notably relieving stress and removing chemicals that build up during stress. And, as in “getting it out of your system,” crying can release old hurts and prevent new ones from getting buried. Also, crying can provide useful feedback: “tearing up frequently could mean that something in your life needs attention,” according to PsychCentral. Common recommendations include taking up journaling, getting more sleep and noticing where crying happens most often: if around a family member, try drawing better boundaries; if at work, “perhaps it’s a sign to move on to another opportunity.”
“Helplessness and powerlessness” comprise one consistent trigger for adult crying—the other being “separation and loss,” Dutch clinical psychologist Ad Vingerhoets told the New York Times. But, the article advises, “if you think your emotions are regularly getting the best of you, chat with your doctor about it just in case—an underlying condition like depression or anxiety could be causing you to cry a lot.”
Besides depression, what can cause someone to feel worse after crying is experiencing shame as they cry, or trying to suppress tears, according to researchers at the University of South Florida in Tampa. Of two mental health diagnoses related to unstoppable tears, one is prolonged grief disorder, which involves unexpected crying outbursts that continue for a long time after a loss and become more intense and persistent over time; and the other is adjustment disorder, which causes exceptional difficulty coping with significant adverse events.
“Sudden uncontrollable emotional reactions, with or without crying outbursts,” may in rare cases indicate a condition called pseudobulbar affect (PBA), according to VeryWellHealth. Occurring most often in connection with head trauma, stroke and neurological diseases, such as Parkinson’s, the exaggerated emotions of PBA don’t match feelings or situations at the time, for example, crying during a funny movie; or laughing that suddenly turns to crying.
In preparation for an upcoming funeral, I am trying to concentrate on the benefits of crying, also on feeling less embarrassed by overabundant tears. But as I remember the failures of techniques tried at past ceremonies, I am also assembling my fallback aids—beta blockers and handkerchiefs, which I have in large supply.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
SYMPTOMS that stumped doctors treating Philadelphia artist C.J.— sudden, severe intestinal problems that kept him in bed for several weeks and, for almost six months, unable to work and needing to be near a bathroom—became easier to diagnose once he mentioned having traveled to Corsica about four months earlier.
Despite her medical training, Ann Arbor, Michigan occupational medicine physician Deborah Heaney had no clues to explain intense itching over her entire body, red blood spots spreading across her torso and diarrhea that left her severely dehydrated, according to AAMCNews from the Association of American Medical Colleges. Finally, the link of symptoms to a recent vacation on Curaçao led to the diagnosis of dengue fever.
“Our medical systems are not adequately equipped to diagnose tropical diseases, and in a warming climate, that’s a problem,” according to the New York Times headline for Heaney’s report. Such cases also highlight patients’ travel history as a glaring omission in medical records. Even when both incidence of infection and likelihood of serious symptoms are low, vector-borne diseases (VBDs) can be devastating and deadly: for 21 people who recently traveled to Cuba, oropouche, also called “sloth fever”— spread by midges and mosquitos —caused severe illness, infection linked to malformations in fetuses and several deaths.
And closer to home, diagnoses of unfamiliar VBDs—including dengue, West Nile and Rocky Mountain spotted fever — are occurring at unexpected times of the year and “expanding into areas of the country where people have little experience with them,” according to AAMSNews. Said medical biosafety researcher Susan McClelland at the University of Texas in Galveston, “Awareness is low because the incidence is low [but] that’s changing” —for reasons that include climate change.
For infectious disease specialist Anthony Fauci, West Nile virus—that “hit him like a truck,” he said, and led to hospitalization—came from a mosquito in his backyard. And in New York, according to NBCNewYork, trapping and testing in 50 locations found “the number of mosquitoes with West Nile. . . up across the board thus far in Summer 2024 throughout the five boroughs.”
“The high-risk season for West Nile virus is just getting underway,” WebMD reported at the end of August. While only about 20% of infected people develop symptoms—fever, headache, body aches, vomiting, diarrhea, and rash —“serious and potentially fatal illness affects about 1 in 150.”
In 2022, 1,247 reported arbovirus (arthropodborne virus) infections—most often spread by mosquitos and ticks —led to 968 hospitalizations and 103 deaths. In addition, just one mosquito, tick or other insect that bites someone with an active infection— whether acquired via travel or locally—can spread the disease. A single case of Triple E, eastern equine encephalitis, that killed one man in August caused such a scare that four Massachusetts towns imposed early curfews to avoid the deadly peak hours of dusk for virus-carrying mosquitos.
“It’s time to add travel history to routine information such as temperature and blood pressure collected in electronic medical records,” infectious disease researchers at the University of Texas Southwestern Medical Center wrote in 2020. “We have the infrastructure to do this easily with the electronic medical record, we just need to implement it in a way to make it useful to the care teams . . . we’ll also need to communicate what is called ‘situational awareness’ to ensure that providers know what geographic areas have infections so that they can act accordingly.”
An important reason to add travel history is that treatments vary widely among VBDs. “For example, while Lyme can be treated with antibiotics, the main medical response to dengue is supportive care to reduce certain symptoms, such as pain and so-called ‘break-bone fever,’” according to AAMCNews. “One common misstep for doctors is to pump dengue patients with fluids, because they seem to be suffering from the kind of dehydration that is common with many viral illnesses.”
“Most people who die of dengue die because of shock,”Puerto Rican pediatric infectious disease specialist Ines Esquilín-Rivera told AAMCNews. Hydration has to be administered especially carefully because dengue patients often suffer from capillary leak syndrome, in which fluids leak from small blood vessels, that can lead to low blood pressure and cause shock. Symptoms of dengue include muscle and joint pain along with fever, headache and nausea.
After extensive tests—ultrasound, stool exams and dozens of others—C.J.’s treatment included anti-parasitic drugs for suspected fasciolosis, which has showed “significant increase from the late 1990s to early 2000s,” according to a 2023 report from French researchers titled “Fasciolosis in the Mediterranean Island of Corsica (France).” “Among the re-emergent human parasitic infections, fasciolosis stands out as one of the most important snail-borne diseases” —with an incubation period of several days to a few months; and spread via contaminated water, either from drinking or eating vegetables washed or irrigated with contaminated water.
Reading about Fauci’s local West Nile infection has made me worry more about mosquitos. “Biting insects seem to be everywhere in the Washington region [and] the typical season runs from July through September,” reported the Washington Post at the end of August—also warning that “risk for serious disease…begins to increase at age 50.” The Post’s experts recommend staying indoors at dusk, wearing long sleeves and pants when outdoors, and treating bare skin and clothing with repellants such as DEET. For me, turning on a little Thermocell Radius Zone mosquito-repeller device has worked so far—but I remain vigilant and plan on adding counter measures if I see more than one bug flying around.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
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