IS the egg a near-perfect food, with lots of protein, low carbs and low risk of digestive issues? Or is it too high on the dangerous cholesterol list? And about cholesterol: What’s the latest on “good” HDL and “bad” LDL (high- and low-density lipoproteins) for heart and brain health; and for risk assessment—what about blood cholesterol vs. coronary artery calcium (CAC) testing? Finally, do statins enable worry-free cholesterol consumption—including eggs?
One large egg contains about six grams of protein (depending on body weight, most adults should eat about 150 grams/day), very few carbohydrates and “147 mg of choline, which supports memory and mood,” according to VeryWellFit. At about 80 calories, the egg contains five grams of fat, which include “good” polyunsaturated and monounsaturated fats that could help lower LDL cholesterol—along with “bad” saturated fats that The American Heart Association advises to limit to about 13 grams/day.
But one assessment of a two-egg breakfast, compared with an egg-free meal, found “no significant effects on blood cholesterol;” and another study on diabetics showed that eating 6-12 eggs/week “didn’t negatively affect total blood cholesterol levels [and instead] increased HDL,” according to Healthline. Eggs become more nutritious when they contain higher levels of “omega-3 fats” —when specified in the label, these hens have been fed flax seeds; while for eggs labeled “pasture-raised” and “free range,” the hens have eaten “greens, grubs and other natural foods.” (“Outdoor access” can mean nothing more than a little window for hens that are crowded indoors.)
Lowering blood levels of LDL cholesterol, however, can make a big difference in health—at least when measured in patients taking statin medications. In a 2019 meta-analysis that looked at more than 130,000 patients, in the group taking statins “for every 18 mg/dL drop in LDL, there was a 24% reduced risk of major coronary events, such as a heart attack, and a 16% lower risk of stroke,” according to HealthCentral.
The good reputation of HDL, meanwhile, became more complicated—in its links to dementia, as well as heart disease and cancer—with research that followed more than 184,000 adults over 17 years: an elevated risk for dementia occurred at HDL levels that were both below 41 mg/dl but also above 65 mg/dl. Explains study author, Boston University epidemiologist Maria Glymour, “The elevation in dementia risk with both high and low levels of HDL cholesterol was unexpected, but these increases are small, and their clinical significance is uncertain.”
“I’d say the HDL hypothesis is on the ropes right now,” James de Lemos, cardiologist at the University of Texas Southwestern Medical Center, told the New York Times. And in the 10 years since that study, some of the 200 or so subspecies of HDL proteins have shown no association or even association with increased risk of heart disease, while other HDL subspecies continue to prove “good” for the heart.
Testing for heart disease risk also became more complicated with the discovery that coronary artery calcium (CAC) plays an important role in heart disease risk. “Distribution of risk factors in [asymptomatic] individuals is heterogeneous and varies by the presence or absence of coronary artery calcium,” according to researchers at Emory and Johns Hopkins universities—challenging the earlier notion that high LDL levels are, independently, an important risk factor for heart disease and cardiac events.
A high LDL blood cholesterol score suggests the need for intervention—but alongside a zero CAC score, indicates low risk of coronary heart disease, according to MedicalNewsToday. CAC testing that shows high calcium levels in the arteries indicates risk of plaque buildup that may eventually cause a blockage—with risks higher when “estimated arterial age” scores are farthest from a person’s actual age: a score of 40 at age 65 is okay, as is 100 for age 73, while higher than 100 at any age suggests the need for intervention. Taking statins can alleviate some worries about consuming high-cholesterol foods, because these drugs “reduce the synthesis of LDL [cholesterol and help keep it] out of the arteries,” according to HealthCentral. But physicians warn that patients taking statins should still exercise and follow healthy diets, notably the Mediterranean regimen—because inflammation and other factors not addressed by statins continue to play an important role in risk of heart disease and in overall health.
For me, success in lowering LDL cholesterol levels when taking statins has been encouraging to my doctor. But I have been hesitant to take cholesterol numbers seriously ever since, right after a bout with Lyme disease, my LDL levels suddenly shot up more than 150 mg/dl—following decades of impressively low LDL and high HDL cholesterol scores. Eggs, meanwhile, are among my favorite foods—boiled ahead of time for quick and easy breakfasts, or for lunch with spoonfuls of mayonnaise, also rich in cholesterol, as egg salad.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
CONNECTICUT organic farmer L.P. struggled for decades to get a good night’s sleep until, in her early 70s, she engaged a “sleep consultant”—and started cognitive behavior therapy for insomnia (CBT-i). So far, determining the best timing for nighttime sleep, called “sleep consolidation,” has been the most helpful—along with a variety of familiar “sleep hygiene” measures, such as avoiding electronic screens in the hours before bedtime.
The goal of improved sleep—along with reducing pain and anxiety—is currently driving soaring levels of cannabis use among seniors, according to the New York Times. For people age 65 and older—“one of the fastest-growing populations of cannabis users in the United States”—the numbers rose from about .4% in 2007 to about 8% in 2022. Said Denver geriatric psychiatrist Aaron Greenstein, “People are just desperate.”
Numbers of “wisdom customers,” which refers to those 55 and older, have increased each year for grower and seller Trulieve, which has “the largest retail footprint for cannabis products in the United States,” according to the Times. A major drawback to cannabis use, however, is insufficient research and ongoing obstacles: cannabis remains federally illegal; and the wide variability that exists among different cannabis products as well as its effects on different individuals.
And what gives pause to many sleep sufferers about cannabis is the risk of potentially serious side effects, such as dizziness and panic attacks—as well as cannabinoid hyperemesis syndrome, which causes recurrent vomiting. According to the Times, California ER visits associated with cannabis use among older adults rose more than 1,800 percent from 360 visits in 2005 to 12,167 in 2019. Also, as with many medications, any beneficial effects can diminish over time.
For insomnia, CBT is “generally…the first treatment recommended,” according to the Mayo Clinic. “The cognitive part of CBT 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, for example, is to “remain passively awake”—by suppressing thoughts about falling asleep.
Sleep consolidation, also known as sleep restriction, begins with limiting the time spent in bed—with an initial goal based on hours of actual sleep previously recorded: for example, five hours of sleep out of seven or eight spent in bed. For the first few nights of consolidation, the allowed amount of sleep is insufficient, causing fatigue that slowly helps make it easier to fall asleep, to sleep better during the time allotted and eventually to sleep well for a longer time period.
Improvements in total sleep time and sleep efficiency by eight to ten percent were the findings of a 2015 meta-analysis of CBT-i involving 1162 patients, reported in the Annals of Internal Medicine—with the note: “psychological approaches are likely to produce sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches.”
“The long-term improvements seem to result from the patient learning how to support and promote the body’s natural sleep mechanism,” writes Jeffrey Rossman, “Life Management Director” at Canyon Ranch in Lenox, Mass., in the American Journal of Lifestyle Medicine. “Changing sleep patterns requires changing the negative thoughts and beliefs…like “I dread getting into bed because I won’t be able to get to sleep… and I’ll be a wreck tomorrow!”
“CBT-i produces results that are equivalent to sleep medication, with no side effects, fewer episodes of relapse, and a tendency for sleep to continue to improve long past the end of treatment,” Rossman observes. While sleep medication can be effective short-term, side effects can include episodes of amnesia, cognitive impairment and morning hangover—and in some patients, these can require increasingly higher doses and lead to dependence and tolerance.
Sleep hygiene, in addition to avoiding electronic screens and other bright lights before bed, includes refraining from eating and from drinking alcohol two to three hours before bedtime, and avoiding caffeine in the afternoon and evening. Other recommendations include exposure to bright outdoor light in the morning or early afternoon, and developing a relaxing evening routine.
In addition, CBT-i advocates relaxation training and biofeedback, which involves practicing “how to relax both your mind and your body,” according to Sleep Education. Various devices can help teach relaxation by signaling levels of muscle tension or brain wave frequency, which the user can learn to alter in ways that improve sleep.
Cognitive control and psychotherapy make up another component of CBT-i, to help “identify attitudes and beliefs that hinder your sleep,” according to the sleep education site. One suggestion is to set a “’worry time” in the afternoon or early evening [to] review the day and plan for tomorrow…You focus on getting all your worries out of your system.”
Another suggestion is to use guided imagery: “You imagine you are in a story…try to picture what things look, feel and sound like…try to make it as real as possible,” according to Sleep Education. Keeping your mind away from worries can also help prevent active efforts to sleep and allows the body to relax and eventually to sleep.
CBT-i also includes “stimulus control:” going to bed only when you feel very sleepy; and if you are not asleep after 20 minutes, get out of bed and do something relaxing. But maybe most important, according to Sleep Education, is using the bed “only for sleep and for sex,” and not doing anything else in bed, including watching TV and reading.
But reading before bed, for some people, “actually allows our brain to move from ‘doing’ mode to ‘just being’ mode,” according to Orlando sleep psychologist Sarah Silverman. If you associate reading with sleep, Silver advises to keep it up, with whatever books you are accustomed to choosing before bed. Other sleep experts advise against reading crime, thrillers and books that might be “emotionally distressing.”
To find behavioral sleep medicine specialists, available to meet in person or online, the Mayo clinic recommends checking sleepeducation.org/sleep-center, and behavioralsleep.org. And the site suggests most people need six to eight sessions—which can be covered by insurance.
Although doing much better, L.P. still struggles enough on some nights that she takes Seroquel, the sedative she relied on for years to help with sleep. While I don’t often have trouble sleeping, if I can predict a bad night—such as before early-morning travel plans—I take the antihistamine doxylamine, recommended for sleep. On weekends, I sometimes eat a low-dose cannabis candy because these seem to provide deeper sleep. And on the few nights when I slowly become aware that I’m struggling to get to sleep, I try to figure out what could be bothering me, and then work on sorting it out—or else I start going through lists, such as European countries or U.S. states.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
WIDESPREAD complaints of disabling fatigue and brain fog extend beyond those suffering from Long Covid, Paxlovid rebound and Covid Rebound, according to Census Bureau data reported in the New York Times. Since the beginning of the pandemic “there are more Americans who say they have serious cognitive problems—with remembering, concentrating or making decisions—than at any time in the last 15 years.”
“The number of working-age adults reporting “serious difficulty” thinking has climbed by an estimated one million people—attributed to lasting effects of the virus as well as “other effects of the pandemic…psychological distress,” according to the article. Federal Reserve economist Richard Deitz, however, attributes much of the increase to Long Covid: “These numbers don’t do this—they don’t just start increasing sharply like this.”
Meanwhile, “Failed Long COVID Research” headlines a Time column by epidemiologists Steven Phillips and Michelle Williams, who contend: “little has emerged [from well-funded Covid research] that directly impacts prevention or patient care.” Phillips and Williams urge pivoting resources to “health services research and…measures that directly impact the welfare of Long COVID sufferers: prevention, improved prognosis, access to empathetic care and quality of life issues.
Countering false beliefs, however, continues to be an important role for Covid public health research—for example, the abounding anecdotes about risks and benefits of Paxlovid treatment. In fact, Covid symptoms returned one to two weeks after taking Paxlovid for fewer than 6% of more than 10,000 patients, according to NBC News. In addition, research from Washington University and the St. Louis VA hospital found that those who took Paxlovid, among 282,000 eligible participants, had a 26% lower risk of Long Covid.
Paxlovid also appears to help clear lingering virus or viral proteins that cause symptoms in those with Long Covid—and patients in NIH’s RECOVER (Researching Covid to Enhance Recovery) Initiative, which is studying and treating symptoms of Long Covid, can obtain a prescription lasting up to 25 days. Penn Medicine Post-Covid Clinic Director Benjamin Abramoff told NBC, “I think there’s a lot of benefit for many of our patients who have significant Long Covid symptoms.”
Biomedical research also continues to unveil new potential avenues of treatment. Recent research on mice traces low levels of the neurotransmitter serotonin—seen in many Long Covid sufferers—to insufficient production in the gut. Pulling together “several drivers of [Long Covid] —the ongoing presence of viral material, blood clotting and chronic inflammation,” Stanford University neurologist Michelle Monje told NPR, “[the researchers] did a beautiful job showing the causality of these changes.”
Both burdensome and concerning for many are post-Covid infection symptoms that persist but don’t yet qualify as Long Covid—based on the CDC definition, of symptoms lasting more than four weeks. For the “murky middle” period, UCSF infectious disease expert Peter Chin-Hong told the New York Times, “researchers are not entirely sure why this happens. It could be because low levels of the virus are still lingering, or because the immune system is acting as if the virus is still there, even if it’s gone.”
“You’re left with this almost paralyzing exhaustion,” Chin-Hong said. “You’re just dragging yourself, and you’re trying to go to the gym and you can’t go.” Post-Covid symptoms might last longer depending on how severe they were during the acute phase—and those that had previously resolved can return during the week or so after a negative test.
“It’s not unusual for certain symptoms to stick around [following viral infections],” said Cleveland Clinic pulmonary specialist Joseph Khabbaza. Caused by ongoing inflammation, “people’s airways might swell, causing wheezing or coughing, or their sinus passages might puff up, causing congestion.”
But cognitive impairment—affecting 20 to 30 percent of people for several months after acute Covid infection—is a “hallmark of Long Covid,” according to St. Louis epidemiologist Ziyad Al-Aly. In addition to inflammation, visible effects include changes on M.R.I.s and neurovascular changes. Said U.T. San Antonio rehabilitation medicine chair Monica Verduzco-Guitierrez, “It’s not just fog, it’s a brain injury, basically.”
Older adults responding to the Census report had more complaints related to memory than younger adults, according to U.T. Health San Antonio neurologist Gabriel de Erausquin. In contrast, younger responders were “more likely to experience difficulty with attention and concentration and, in some cases, fatigue or pain so severe their thinking is affected.”
“Long Covid is a new name for an old syndrome,” Phillips and Williams point out, “…virtually indistinguishable from… post-infectious syndrome or myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).” And, as for chronic fatigue sufferers, the advice for those with Long Covid symptoms—notably fatigue and brain fog—is to seek treatment at a medical facility that specializes in post-infection recovery.
After two and a half years, Florida musician and avid court and water-sports enthusiast C.T. continues to struggle with Long Covid exhaustion—PEM, or post-exercise malaise. Luckier than many, C.T. is retired with sufficient funds to continue consulting doctors and pursuing an array of treatments—so far including a long list of prescribed medications and supplements, with some involving regular IV infusions, well as daily sessions of hyperbaric oxygen.
A probiotic formula that became part of his latest regimen aims to rebalance the gut to increase serotonin production. In a recent email, C.T. sounded modestly optimistic: “Some progress…higher lows and faster recoveries from setbacks”—though by the end of a tennis tournament, he could barely play. For me, especially knowing about C.T.’s experience, I plan to request Paxlovid at the first sign of a positive Covid test result.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
A scene from the film, Nyad, starring Annette Bening.
By Mary Carpenter
Note: This post contains spoilers.
NYAD, the Netflix biopic, portrays swimmer Diana Nyad striving to complete a continuous swim across more than 100 miles of open water (depending on currents, tides, wind, etc.) from Havana to Key West—for which her specialized training and diet regimens can both inspire and inform the recreational swimmer.
And in warm Caribbean waters, temperatures in the 80s are enough lower than the body’s norm to achieve health benefits touted for “cold-water” swims, in water under 57 degrees. And, recently popular, the “ice mile” refers officially to any swim, under supervision, in water below 41 degrees F. wearing only a swim suit, cap and goggles —with medical checks before and after highly recommended.
Especially inspiring for older swimmers, Nyad didn’t begin training for the Cuba-to-Florida challenge until her 60th birthday — after taking a 30-year break from long-distance swimming. For this nonstop, more than 50-hour swim, however, Nyad’s greatest strength may have been her mind.
“I think it was her belief in herself that she could do this,” Women’s Sports Foundation CEO Kathryn Olson told NBC News. For long swims, Nyad also created mental routines (which included counting to 100 in four languages and an 85-song playlist) that she ran through again and again, hour after hour.
Nyad’s training schedule for the winter and spring before her five Cuba-to-Florida swim attempts that took place in August began with land exercises: 100 burpees a day along with military-style push-ups and Pilates core strengtheners like the “teaser”—making a V-shaped formation with legs and upper body extending upwards in opposite directions.
After January, Nyad began to up her time spent swimming and trained less on land, although she still biked 100 miles one day a week. For the three or four months before a long swim, explains ESPN’s Natalie MacKenzie, “too much of virtually any form of cardio other than swimming builds the legs too much—counterproductive when you’re trying to be as buoyant as possible over…hours of swimming.”
Even while swimming, those aiming to go a long distance avoid strenuous kicking —though that also helps protect the heart. “Extreme endurance athletes have probably a five- or sixfold increase in the risk of atrial fibrillation,” University of Texas Southwestern Medical Center internist Benjamin Levine told Outside. For swimming—in contrast to ultramarathons that can overstress the joints—said Levine, “It’s the heart that’s going to be the limiting factor.”
Also, a measured slow pace can help keep swimmers’ exertion “completely aerobic,” explained swimmer Ross Edgley, who said the goal is to avoid “tapping into your lactic threshold” —the point when lactic acid starts accumulating in the muscles. Constantly adapting his technique to move with the least possible effort, Edgley notes: “I barely kick my legs at all, and it’s just very much a rotation in the upper body…I’m sort of floating efficiently.”
“Hardening” refers to adaptation both to cold water and to seasickness—with nausea and vomiting the most unpleasant and dangerous issues with long-distance open-water swimming, made worse by constantly swallowing salt water. In a 1979 effort, Nyad lost 29 pounds in less than 42 hours of swimming—with the weight loss, as well as her failure to complete the swim, later blamed on her swim diet: mostly cake and Coke.
“I was vomiting constantly,” Nyad told the Today Show—during the 50-plus hours of her Cuba-to-Florida swims, despite ongoing efforts to improve her nutrition formula. According to ESPN, “what works for a marathon runner or cyclist doesn’t necessarily work” for long-distance swimming, which requires spending dozens of hours in a prone position not ideal for digestion. Along with special liquid formulas to help replace lost fluids and electrolytes, Nyad consumed small banana pieces covered in peanut butter for protein and to help coat and protect her stomach.
During the months of training, Nyad consumed about 9,000 calories on non-swimming days and about 3,500 when swimming: “there simply aren’t enough hours to consume any more than that when you spend half the day in the ocean,” writes MacKenzie. But Nyad has said, “it’s not as fun as it sounds to eat that many calories.”
The warm Caribbean waters added the risk of encountering poisonous marine animals and sharks. Nyad refused to use the shark cage that helped previous swimmers on this route. But along with goggles and a swim cap, she wore a special mask to protect against stinging jellyfish —though it slowed her down by about .3 mph and forced her to swallow more seawater.
Health benefits of swimming include a 41% lower risk of death due to heart disease or stroke than non-swimmers—as well as a 28% lower risk of early death overall, writes Cleveland Clinic exercise physiologist Christopher Travers about a Swim England-commissioned study. Travers adds that, because swimming creates resistance but with low impact, it’s “one of the best exercise options for anyone with arthritis…helping to reduce symptoms.”
“Swimming makes your body use oxygen more efficiently,” Travers reports, which is related to improvements in lung strength and capacity. For those who prefer to start “small with something like water walking or water aerobics,” he suggests beginning in water up to the waist and walking slowly across the pool, swinging the arms and keeping the back straight and then moving into deeper water.
For swimmers in “very cold” water—below 57 degrees—the benefits accrue for “two of the biggest hallmarks of aging: high blood pressure and arthritis,” Hirofumi Tanaka, director of the University of Texas, Austin, Cardiovascular Aging Research Lab, told Why We Swim author Bonnie Tsui. For ice swimming, because of the hypothermia risk, athletes must be in good health and have trained in cold water —and they swim at high intensity for several minutes.
“We realized the effects of swimming actually surpassed the magnitude of the effects of walking or cycling,” Tanaka said. And for those with arthritis, “cool” water at 80 degrees or lower “stimulated mobility —without pain—and circulation,” and lowered blood pressure more than land-based exercise training.
Critics of the film Nyad point to the swimmer’s habitual revision of her stories over the years along with the inflations of her accomplishments. But for me, the film documents Diana Nyad’s unwavering determination —along with her intensive training and her mastery of the enormous distance of open water and number of hours involved in the swim from Havana to Key West. Also very impressive to me is the walk to shore following so many hours of swimming: to officially complete an unassisted swim, she had to reach the point where both ankles were out of the water —a long walk in Key West waters that are too shallow to give much support.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
The importance of group therapy continues to grow alongside wait lists to see individual therapists, a situation that began early in the Covid pandemic. So, ICYMI, we’re reposting Well-Being Editor Mary Carpenter’s story from last September.
ByMaryCarpenter
“I FOUND my voice” is how Virginia finance manager A.M. described her experiences—as we all saw happen over about five years—in a recent DC therapy group. Her first move was not merely speaking up when she felt shy or taking a controversial position, but exploding suddenly to take on a group member who’d regularly made hurtful comments to others without anyone ever confronting her. That day, A.M.’s voice broke in, angry and pointed but also thoughtful and articulate, after years of her near-silence. In the weeks to come, A.M. would come out with amusing comments and begin tackling issues that had plagued her for as long as we knew.
With anxiety and depression on the rise since the beginning of the Covid pandemic—reported by more than four of every 10 adults, about 43%, according to a recent census—and mental health professionals in short supply for individual therapy, more people are joining therapist-led groups. (Other kinds of groups include those led by peers.) What group therapy can offer, Nicole Cammack, psychologist and advisor for the mental health platform Sesh, told the Washington Post, is “broader perspective [for] solving life’s troubles.”
“Social anxiety, anger from others and fear of humiliation” are reasons people are reluctant to join therapy groups, writes Harvard psychiatrist Joseph Shay in his research paper titled “Terrified of Group Therapy.” But Shay concludes, “the research literature has established the definitive benefits of group therapy [such as] having opportunities to observe and change relationship patterns.”
“Psychologists say, in fact, that group members are almost always surprised by how rewarding the group experience can be,” posts psychotherapist Ben Johnson on the American Psychological Association website. Johnson points out that group therapy gives members the chance to receive feedback from many individuals and to address relationship concerns, such as asking for help and dealing with conflict.
And group therapy can be more effective than individual for mood disorders, such as depression and bipolar disorder, according to a recent meta-analysis by psychologists at Penn State and Brigham Young University. Contemporary therapies, such as C.B.T. (cognitive behavior therapy) and D.B.T. (dialectical behavior therapy), often incorporate therapy groups as do treatment programs for eating disorders and substance use.
Group therapy has been around since the early 20th century but burst onto the scene with the early 1960s “human potential movement” in the form of encounter groups —which “encourage strong emotional expression; the participants are not labeled patients; the experience is not labeled ‘therapy,’ but nonetheless the groups strive to increase inner awareness and to change behavior,” according to the report from a 1970 task force of the American Psychiatric Association.
“The number of encounter groups has proliferated to such a degree . . . the intensive group experience movement [is] one of the most rapidly growing social phenomena in the United States,” wrote the task force, chaired by Stanford University psychiatrist Irvin Yalom, considered by many the “father” of group therapy. Among 200 or so encounter groups in the Palo Alto, California, vicinity at the time, intensive “marathon” psychodrama groups met in concentrated stretches—such as up to 36 hours over weekends.
At Stanford summer school in 1969, I had friends who participated in these groups, which sounded terrifying when one described the dramatic emotional encounters designed to break people down, with the goal of making them more receptive to change. A few years later, though, a college course called “Encounter Groups” began with one that met every day for two weeks—which seemed safer, maybe because we were in college together. Nonetheless, some people got very angry, others cried, and I discovered a few things about myself.
But not nearly as much as during my five years in the DC group that included financier A.M. Most “therapy” groups are either “open” with new members joining at any time; or “closed” with everyone beginning at the same time and a specific meeting length, such as 12 weeks. Mine, on the other hand, varied in size from five to seven members with each of us starting at a different time when a slot opened up—after meeting several times beforehand with the psychologist group leader.
I joined after my life took several major turns and, after years of various one-on-one therapies, I thought a different format might help me navigate the future. Believing everyone else knew each other very well, I was on edge in early meetings but hesitant to pose personal questions of the others because these had enraged my mother. I never asked how long each had been a member, and only slowly found out that a few others were relatively new like me. Slowly I experimented with querying the members, and then talking about my own family background, my work and my sons, more honestly than I was used to. Slowly I felt a new acceptance among people I hadn’t known at all, which surprised me.
What also surprised me was afterwards when a work colleague I’d always thought had her life very together emailed that she had “LOVED group therapy.” Later she wrote: “(after avoiding even the idea of it) . . . it was such a non-threatening way to learn about myself without being defensive—I learned a lot through the back-and-forth among the other members of the group; it felt safe . . . I learned that people can disagree, even fight, and nobody dies!”
These were my thoughts exactly— also that A.M.’s explosion improved my group, and we all learned a lot. Although some of us had grumbled about the upsetting member, very circumspectly and briefly, no one had spoken up before. When A.M. started off, I felt a tension that was familiar in the presence of conflict. But then I began to appreciate her outburst and finally exuberant, as if the air were clearing, and we began to explore issues we’d all been having. And no one died.
—Mary Carpenter regularly reports on need-to-know topics in health and medicine.
This season’s bumper crop of acorns creates a small risk of traumatic brain injury (TBI) —it’s why we’re taking the opportunity to republish most of Mary Carpenter’s 2019 post on the topic.
“IT IS just a very heavy mast year,” writes Washington Post columnist John Kelly— referring to the “hailstorm..rifle-crack” sounds of abundant acorns falling from oak, hickory and pawpaw trees in the Eastern U.S. this autumn. (“Mast” is the collective term for acorns, and other fruits and nuts, and is also the label given years of abundant production, resulting from growing seasons one to two years earlier.)
“Trauma to the head…could be from an acorn falling from a tree…or a bullet or shrapnel penetrating the skull,” according to Practicalneurology. In rare cases, an acorn hitting the head can cause TBI similar to injuries during tackle sports, vehicular accidents and war. Although acorns have little mass, falling from a high tree can provide acceleration and thus the force — based on the formula F=ma—to split them open.
ACoRN (After Concussion, Return to Normality), by coincidence, is the acronym for the Scottish Brain Injury Trust’s advisory leaflet on handling concussion sustained during sports events: “If in doubt sit [sporting events] out.” Acorns littering the ground have also led to trips and falls—notably for anyone running on tennis courts and other hard surfaces.
ICYMI:
MILD CONCUSSIONS don’t get the respect they deserve—for how debilitating they can be, and for how many weeks, months or years the brain can take to recover completely. Four months after hitting her head on a pole while rushing to get off a Metro train, DC artist and teacher A.M. still struggled, at first mostly with headaches and facial pain focused in her jaw.
But A.M.’s eyes caused her the most trouble—in the presence of any light, indoors and outside. Reading was difficult, especially black print on white pages and even more, anything on an electronic screen. In addition to its bright lights, a screen also continually flickers, making the eyes work harder.
“Sensitivity to light is the worst,” she said, “because everything involves light.” Most of the time, even indoors, she wore two or three pairs of dark glasses. A.M. also had trouble with noise, both the uncontrolled ringing of tinnitus and the amplification of voices, including her own, which sounded like a recording blasted through a loud speaker inside her head. At the four-month mark, she received an official diagnosis of post-concussion syndrome with ocular-motor difficulties, a prescription for vision therapy and the prognosis that these could take months or even years to heal.
With a concussion, severity and recovery time are often unrelated to the original impact or its immediate effects, such as blacking out. It’s almost impossible to detect how far the initial damage has spread, and every concussion is unique.
“Imagine you have a mason jar that is full of thick liquid and just big enough to accommodate a peach,” writes Lori Fox about her girlfriend’s head injury. “If you shake the jar violently, the peach sustains multiple impact points. When you take the peach out, the bruised places are visible. If you cut into the bruise, you will see the damage spreads beyond the area around the impact sites.”
“I just saw someone the other day who had a dog toy thrown at their head by their toddler,” said clinical neuropsychologist Alicia Sufrinko at the University of Pittsburgh Sports Medicine Concussion Program. “The injury comes from the brain shifting inside the skull and affecting your nervous system.”
“Usually it’s only in retrospect that you can say how severe a concussion is,” according to Vanderbilt neurosurgeon Andrew Gregory. Bruising caused when the brain moves back and forth inside the skull often affects the frontal lobes. These are responsible for cognitive functions, also called “executive functions,” such as attention and completing tasks; planning and organization; inhibition and emotions. Head injury can also cause fatigue, irritability, anxiety and insomnia.
Most people, including physicians, are unaware that sufferers should avoid triggers such as bright lights, loud noises and physical or mental exertion until the symptoms are gone, Gregory pointed out. Said Sufrinko, “We give people a structured rehab program, and we follow up with them and make sure they get to 100 percent before we discharge them.”
Few physicians are also aware that, for symptoms that persist after three to four weeks, more aggressive interventions should begin, including vision therapy for eye problems, vestibular therapy for balance problems and cognitive therapy for difficulties with concentration and multi-tasking. As with a stroke, undamaged areas of the brain can take over tasks from the damaged areas but need therapy and practice to master those tasks.
What can help predict recovery time is the total number of specific early symptoms, such as sensitivity to noise or light, difficulty concentrating, insomnia and balance issues. Others that appear less relevant include amnesia, tinnitus, loss of consciousness and hyper-excitability. The strongest predictor of a lengthy recovery from a mild traumatic brain injury is painful headaches in the days immediately following the impact. And the one effect of head injury with an unquestionable prognosis is loss of smell, because impact can completely sever the brain connections involved, and their functions cannot be replaced.
As for mast years, a secondary fate for East Coast residents is “a substantial elevation of populations of seed-feeding animals,” writes Kelly. “But more animals that feed on seeds means more animals that feed on animals that feed on seeds…an increase in ticks, fleas and mites can lead to an increase in diseases transmitted by the blood sucking insects, such as Lyme disease.”
An acorn is what hits Chicken Little in the children’s story and makes her believe “the sky is falling.” The hen then convinces many animals to join her on a trip to tell the king, including the fox, who kills them all except the hen who escapes. But acorns also bring hope: one resident of a New York City high-rise, seeing an acorn lodged between paving stones outside the front door, believes that someday a giant oak might grow.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
OCTOBER is Breast Cancer Awareness Month (BCAM)—with each advocacy group proclaiming a different slogan, but with similar goals of women supporting each other and supporting research. From Breastcancer.org, the awareness month “aims to promote screening and prevention of the disease, which affects one in eight women in the United States every year and 2.3 million women worldwide.” Another group describes “this year’s theme [as] ‘No one should face breast cancer alone.’”
“For 2023, the slogan is “Pink Together, Stronger Forever,” from still another group. And one more: “Living Beyond Breast Cancer is sharing some of the ways people thrive with breast cancer and how your support today can help people impacted by breast cancer—all year long. This year’s Breast Cancer Awareness Month theme is Thrive365.”
BCAM began in 1985 with a week-long event and the participation of Betty Ford; the pink ribbon emerged as its official symbol in the early 1990s. Since then, according to a review by Irish researchers: “an international health campaign [has led to] “increased levels of online activity relating to breast cancer…consistently generated each October”—along with advances in detection and treatment.
Five-year survival rates for invasive breast cancer jumped from about 75% between 1975 and 1997, to above 90% between 2003 and 2009. “When caught in its earliest, localized stages, the 5-year relative survival rate is 99%,” according to the National Breast Cancer Foundation. “In 2023, an estimated 297,790 women and 2,800 men will be diagnosed with invasive breast cancer.”
“The most significant risk factors for breast cancer are being a woman and getting older,” according to the website of the National Breast Cancer Foundation. U.S. breast cancer rates began decreasing in 2000 but have increased by about .5% annually in recent years. After lung cancer, breast cancer is the leading cause of cancer-related deaths in U.S. women and is the leading cause for Black and Hispanic women. In addition, 85% of breast cancers occur in women with no family history — “due to genetic mutations that happen as a result of the aging process and life in general.”
For women in their 70s and older, there continues to be a “sometimes intense debate about whether it’s appropriate to screen these women for breast cancer,” according to the National Cancer Institute website. The “risk of overdiagnosis with routine screening mammography [is] substantial…and this overdiagnosis risk escalates with increasing age.” Overdiagnosis for these women refers to the discovery of a cancer that is expected to grow “very slowly or not at all—and would never cause problems during someone’s lifetime.”
For all ages, however, overdiagnosis additionally includes the risk of false-positive results—and “the anxiety that comes with follow-up tests or procedures,” according to Cancer.gov. As a result, the WISDOM (Women Informed to Screen Depending on Measures of Risk) trial is examining whether risk-based screening—at intervals based on individual risk from genes, family history and other factors—is as “safe, effective, and accepted as standard annual screening mammography.”
A woman’s risk of breast cancer nearly doubles if she has a first-degree relative (mother, sister, daughter) who has had this diagnosis. The risk of breast cancer rises from 13% of women in the general population to—for those with a BRCA gene variant—between 45 and 72% of women, who are expected to develop breast cancer by 70 to 80 years old. In screenings of unselected populations, 50% of those discovered to have BRCA variants reported no personal or family history to indicate increased cancer risk.
Screening populations with no family history is worthwhile for three conditions—Hereditary Breast and Ovarian Cancer Syndrome (cancers linked to the BRCA variants), Lynch Syndrome (the most common form of hereditary colorectal cancer) and Familial Hypercholesterolemia (very high cholesterol starting at an early age), according to the CDC. The reason: for these three, there is sufficient evidence that interventions can reduce morbidity and mortality.
In addition, at-home screening tests, such as the Color Extended test, can analyze genes related to eight types of cancer including breast—as well those related to cardiac disease and medication response. Such genetic screenings—also offered by 23andMe, Veritas and others—usually require an order from a physician, either one’s own or one provided by the company.
Also currently under study is 3-D mammography because, according to cancer.gov: “it isn’t known whether it is better than standard 2-D mammography for detecting cancer at a less advanced stage.” Also in question, whether 3-D screening is better for some kinds of breasts, such as those with very dense tissue.
Treatment for aggressive subtypes of breast cancer was the research focus of the 2019 Nobel Prize winners in Physiology or Medicine. Examining the role of decreased oxygen levels in cancer cells involved in metastasizing cancers, the researchers found that hypoxia can transform some cancer cells so that, much like embryonic stem cells, they can multiply indefinitely. Low oxygen levels also enable these cancer cells to hide and evade treatments with radiotherapy, chemotherapy and immunotherapy. At least two drugs now in clinical trials focus on reversing tumor hypoxia.
Recent advances also include the division of breast cancers into subtypes based on response to hormone treatment, including HR-positive cancers that contain estrogen and or progesterone receptors. Some women with one subtype of aggressive HR-positive cancer, for example, do not benefit when chemotherapy is added to hormone therapy. And treatment success with HR-positive cancer in a group of postmenopausal women has led to new hope for individualized, targeted therapies.
After 2000, cancer incidence rates in the United States that had increased for the previous two decades began to drop—by 7% from 2002 to 2003 alone. One theory traced the decrease to reduced use of hormone replacement therapy (HRT) after early results from a large 2002 study suggested a connection between HRT and increased breast cancer risk. Since then, however, critics have pointed to poor selection of study subjects and flawed results of the study.
Over time, raising public awareness has been essential to improving detection and treatment of breast cancer, along with decreasing the incidence and improving survival rates. One explanation is that inadequate attention has traditionally plagued medical issues related to women. But, too, directing focus onto critical health problems has often required public intervention—perhaps most for the AIDS crisis. Recently, the documentary film “All the Beauty and the Bloodshed” showed photographer Nan Goldin’s almost single-handed organization of public protests in art museums that galvanized an enormous public reaction, followed by increased legal and medical response, to the opioid crisis.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
“WOMEN are seven times more likely than men to be misdiagnosed and discharged in the middle of having a heart attack,” according to the Harvard Health blog. Differences in specific health issues—stroke, STDs, adult acne, sleep apnea, osteoporosisa and autoimmune diseases like rheumatoid arthritis (RA)—require women to keep informed, ask questions about treatment, as well as call for greater efforts by researchers and personal physicians.
Pain may be the most prominent problem area: “Women in pain are much more likely than men to receive prescriptions for sedatives, rather than pain medication, for their ailments,” according to the Harvard blog. And “one study even showed women who received coronary bypass surgery were only half as likely to be prescribed painkillers, as compared to men who had undergone the same procedure.” “70% of the people [chronic pain] impacts are women…80% of pain studies are conducted on male mice or human men.”
“Gender biases in our medical system can have serious and sometimes fatal repercussions,” writes the Harvard Health blog author. In her own experience, inattention by doctors to her pain led to endometriosis “strangling my large intestine and adhering my ovaries and fallopian tubes to my colon.”
Also notable, many women suffer unnecessarily from hormone-related conditions —since a flawed 2002 study on Hormone Replacement Therapy (HRT) led to a dramatic drop in HRT prescriptions, despite its well-established benefits, such as reduced risk of heart disease and several cancers, including breast and colon; and help with menopause-related issues, especially osteoporosis. (While the optimal time for starting HRT is ages 45-55, during menopause, many of the 16,608 women in the 2002 study were in their mid-60s—as well as overweight and already at risk for heart disease.)
“Our generation got screwed,” 60-something DC lawyer B.J. said, referring to doctors’ ongoing refusal to prescribe oral HRT for symptoms affected by hormones like estrogen, ranging from painful sex to brain fog. According to johnshopkinsmedicine, “Doctors are increasingly aware of how managing osteoporosis, urinary conditions…and diabetes in female patients may call for different approaches that take into account women’s physiological differences.” But for many women, “increasingly” is not fast enough.
For Pittsburgh-based health writer T.C, RA symptoms first diagnosed after her physician took her off HRT after 28 years began to resolve when another doctor re-prescribed HRT. Said T.C., “I am thrilled to report that within a month, my pain had almost vanished.” According to University College London rheumatologist Charles Raine, “declining estrogen and/or progesterone levels…appear to increase the risk and severity of RA.”
Research on the connection between hormone levels and autoimmunity is, however, contradictory and varies with the different conditions—for example, small studies show lupus symptoms diminish after menopause. Because arthritis and menopause “can cause similar symptoms”—fatigue, GI issues, bone loss and sleep problems—untangling cause and effect can be “challenging,” according to the Arthritis Foundation. A 2020 study of more than 1.3 million women found no association between RA and hormones that are affected by menopause—but found a small increase in RA with HRT.
“The medical concepts of most diseases are based on understandings of male physiology,” according to the Harvard blog. As a result, writes Forbes business council member Tlalit Bussi Tel Tzure, “when it comes to certain ‘gender-neutral’ diseases such as sleep apnea or heart attacks, women can go undiagnosed because they don’t have similar ‘textbook symptoms’ to men.” Women are less likely to receive an initial diagnosis of heart failure and are more likely to suffer long-term health problems related to medical conditions such as diabetes. Among the blog’s explanations of dysfunctional healthcare for women: “glaring disparity in research funding.”
“The first stop is awareness,” San Francisco VA medical center’s Calvin Chou contends on Duke Health. Chou describes implicit bias, especially among office-based physicians who “interact with our patients one by one without much outside observation.” Biases can lead, for example, to the greater likelihood of asking young male patients about substance use, or assumptions that female patients have an ample support system—in addition to “areas where disparities have been documented such as rates of cardiac consultations [that are lower for women].”
“The telltale heart attack sign of feeling like there’s an elephant sitting on your chest isn’t as common in women, [who] feel upper back pressure, jaw pain and are short of breath,” according to WebMD. “Or they may feel nauseated and dizzy instead. Though heart disease is the leading cause of death for both genders in the U.S., women are more likely to die after they have a heart attack.”
For stroke, common symptoms are sudden weakness on one side, loss of speech and balance, and confusion—but women can also have fainting, agitation, hallucinations, hiccups and other symptoms. STDs are less likely to cause symptoms in women, but can lead to chronic pelvic inflammatory disease that causes fertility issues, which is not the case for men. Also, women are more prone to adult acne than men, while osteoporosis is often missed in men, who are more likely to die folllowing a broken hip than women with osteoporosis who break their hip.
For sleep apneas, men often report “snoring, waking up gasping for air or snorting…[while] “fatigue, anxiety and depression…telltale signs of sleep apnea in females may not be as obvious,” according to the Eos Sleep Center in New York. The two times more likely diagnosis of men with sleep apnea “may be partially attributed to how women describe their symptoms…commonly mistaken for depression, hypertension, hypochondria…”
UTIs—which occur in women 30 times more often than in men, and are suspected to be more common in areas where water is polluted by E.coli—may be a good example of failure to direct health research dollars toward women’s issues. According to researchers in Berkeley, California and Guatemala: “No studies have measured whether [E.coli] presence in water may increase…the risk of UTIs in humans. Given the prevalence of drinking water supplies contaminated with E.Coli…efforts should be made [to do this research].”
—Mary Carpenter regularly reports on topical subjects in health and medicine.
RHEUMATOID ARTHRITIS (RA) is two to three times more likely to develop in women—linked both to sex hormones and to stress—and is the country’s leading cause of disability. For both RA and osteoarthritis (OA), inflammation plays a major role in symptoms, and both gender and genetics can create higher risk. Peak years for the onset of RA are the 40s and 50s, with a range into the 90s; while the risk for OA increases with age.
“As you get older, almost everyone gets some form of arthritis,” according to Mayo Clinic rheumatologist Eric Matteson. Of more than 100 different kinds of arthritis—including gout and crystal arthritis—OA and RA are the two most common. Also the most common systemic autoimmune disease, RA is an ideal target for research in autoimmunity as well as in rheumatic diseases —OA, RA and others that affect joints, muscles, tendons and bones.
For rheumatic diseases, regenerative therapies (using stem cells and gene editing to stimulate and support the body’s natural healing response) are a burgeoning source of treatment. Injections of platelet-rich plasma and implantation of healthy new cartilage have become familiar treatments for OA, particularly for knee joints.
“Regenerative medicine is rapidly expanding to include gene editing and gene therapies,” according to Arthritis.org. Researchers could one day replace damaged tissue with bone-marrow stem cells re-engineered to act like cartilage or with genes carried by a virus that are injected into tissue to create new cartilage.
“At least half the clinical trials in Mayo Clinic’s Center for Regenerative Biotherapeutics involve stem cells,” states the report. But it notes, “the key words are clinical trials. The FDA has approved stem cells for treating certain cancers and disorders of the blood and immune system [but] unproven and likely ineffective stem cell therapies [are] offered at the nation’s nearly 3,000 for-profit stem cell clinics.”
“Regenerative medicine is attracting so much attention that it is fundamentally changing the paradigm of treatment [especially] for patients with rheumatic diseases with poor prognoses,” writes Yokohama, Japan stem-cell regulation specialist Ryusuke Yoshimi. “On the other hand, regenerative medicine still has issues to be solved not only in terms of technology but also in terms of society. Regenerative medicine is being actively debated in many countries, including its efficacy and ethical issues.”
In RA research on autoimmunity, one focus is the cause and prevention of flares—the periodic, rapid heightening of symptoms. During flares, persistent increased inflammation damages joints as well as blood vessels, leading to high blood pressure along with a higher risk of stroke and heart attack. RA flare research may also help in treating MS and Lupus—all on the top 10 list of autoimmune diseases and all systemic.
(Non-systemic autoimmune diseases, by contrast, attack specific organs: the thyroid gland in patients with Graves disease, the beta cells of the endocrine pancreas in patients with type 1 diabetes, or the skin in patients with vitiligo.
About 20% of RA patients fail to respond to the three principal RA drugs. For the rest, early RA treatment can prevent the worst outcomes: in stage 3, the joints become bent and deformed, with fingers often crooked, causing nerve pain; and in stage 4, the joints are destroyed and become fused, unable to move.
Genetics play a role in only about 30% of cases of RA, based on twin studies; the remaining risk is “environmental” — infectious disease, smoking and stress. And initial onset of RA often follows a viral infection, also true for other systemic autoimmune diseases. (Strep throat can precede the onset of psoriasis.)
To treat the pain of both kinds of arthritis, NSAIDs, such as ibuprofen or regular doses of Alleve morning and night, reduce inflammation—though most autoimmune conditions require corticosteroids for the most severe symptoms. For both conditions, however, what used to be the accepted truth and even the official medical prescription—to relieve arthritis pain with rest— is now seen as not just wrong but harmful. The stiffness of RA can improve with movement; and for OA, inactivity can contribute to the deterioration of joints.
Arthritis is the target of many other myths. For example, that damp weather makes symptoms worse has no support. Nor is there any evidence that heat, as lovely as it feels, works better than ice—although using heat to help relax the muscles that move stiff joints might be more helpful in the morning, while ice can ease inflammation at night.
And particular foods—especially nightshade vegetables, such as tomatoes, potatoes and eggplant — don’t aggravate arthritis. Nor is there any proof for the benefits of popular alimentary treatments, including consuming a dozen gin-soaked raisins per day; drinking cider vinegar; eating grapefruit or raw vegetables or adding spices, such as turmeric or ginger to food.
What’s surprisingly not a myth is that having a relatively shorter index finger compared to the ring finger is a risk factor. This 2D:4D ratio raises the risk of developing arthritis in the knee and hip joints, independent of other risk factors and particularly among women. Another true risk factor: flat feet. And finally, that the annoying habit of cracking knuckles and joints can accelerate arthritis damage has not been sufficiently studied to rule out—which means it can continue to be used as a threat when begging practitioners to stop.
For me, an older family member whose RA had reached Stage 4, leaving his fingers fused in bent positions, managed to do almost everything he wanted: flying airplanes, playing golf and smoking cigarettes. The only hint of ongoing threat from pain and worsening disease was his fastidious efforts to avoid certain foods—asparagus, chocolate, red wine; and the occasional flares of gout that stopped all activities for days. And finally, with enormous effort, he stopped smoking.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
“ChatGPT . . . interacts in a conversational way,” according to the blog from its creator, OpenAI. “The dialogue format makes it possible for ChatGPT to answer followup questions, admit its mistakes, challenge incorrect premises, and reject inappropriate requests.” (ChatGPT-4 is the more expensive advanced version used in medical settings.)
DEBILITATING pain and other symptoms in 12-year-old Alex (last name withheld for privacy)—with no diagnosis after three years and visits to 17 doctors—sent Alex’s mother searching via ChatGPT. “No matter how many doctors . . . specialists would only address their individual areas of expertise,” according to Today; and from the mom: “Nobody will even give you a clue about what the diagnosis could be.”
At the heart of most medical mysteries is seeking a diagnosis, consulting one specialist after another before finding a doctor who can figure out the problem. That’s an obvious opportunity for ChatGPT-4 because it can access so much information, “can process our natural human language and generate a response,” according to the Lighthouse Guild. As with AI’s other uses in medicine—reading scans, educating medical students—the technology has risks and limitations and still requires physician involvement at almost every step.
In 2019, the difficulties of coordinating expertise from a range of specialists inspired the Netflix series Diagnosis, based on the New York Times column of the same name by Yale internist Lisa Sanders. The first episode described 10 years of debilitating symptoms, including fatigue, in the patient, Angel; the hypothesis, sent from a medical student in Turin, Italy, that advised metabolic gene testing; Angel’s trip to Italy for tests; and finally the diagnosis of a rare muscle-weakness syndrome, leading to successful treatment.
Muscle weakness was also the diagnosis for a new disease, given the name Mitchell syndrome for the 12-year old athlete who had won a coveted slot for consideration by NIH’s Undiagnosed Diseases Network (UDN). Started in 2013, the UDN has accepted 1,500 out of 4,500 applicants, succeeded in making diagnoses for 30% and in the process identified 50 new disorders.
“Why can’t I get a diagnosis?” was the desperate question DC area 5K runner Nancy Chiancone typed into her computer. For Chiancone, the Undiagnosed Diseases Program (within the UDN) found an answer in just five weeks. But the NIH program, inaccessible to so many patients, has recently lost funding.
Diagnosis is the number one “pro” of medical uses for AI technology, according to FutureLearn. The technology’s ability to analyze data “much faster than humans are able to, and often more accurately . . . can help medical professionals reach a diagnosis a lot more quickly.”
High on the list of “cons,” in addition to security risks, are risks of inaccuracies. If struggling to find an answer, ChatGPT can hallucinate, or fabricate—for example, listing research paper titles that sound real, along with authors who may have written about the topic, when these papers may not exist. Practitioners will need a time-consuming learning curve to recognize these errors.
Another example of unreliability, ChatGPT may come up with a different answer each time the same question is posed—because the technology produces “text from scratch by gleaning from its datasets and creating a new answer,” according to Cnet. In this way, chatbots are different from traditional search engines like Google, “which aim to elevate the most relevant links.”
In addition, AI fails to consider “social, historical, and economic factors [that] can also influence the specific care an individual needs,” according to FutureLearn. “While AI is more than capable of allocating treatment based on the diagnosis, it isn’t yet capable of considering other social variables that may influence a medical professional’s decision.”
Training poses additional challenges—both training of medical staff to use the technology and training of the “AI tools themselves . . . with curated data in order to perform properly,” according to the site. However, for a different kind of training, that of medical students, ChatGPT-4 has proved especially useful. As Beth Israel Deaconess internist Adam Rodman told the New York Times, “Doctors are terrible at teaching other doctors how we think.”
Experienced doctors often use pattern recognition to make a diagnosis, explained Rodman: “In medicine, it’s called an illness script: signs, symptoms and test results that doctors put together to tell a coherent story based on similar cases they know about or have seen themselves. If the illness script doesn’t help, doctors turn to other strategies, like assigning probabilities to various diagnoses that might fit. [And ChatGPT-4 can] create something that is remarkably similar to an illness script.”
AI can also perform “self-supervised learning.” According to Nature, with retinal scans used to detect eye disease—or risks for other health conditions, including heart failure and Parkinson’s disease—the AI tool RETFound can analyze millions of retinal images to teach itself to detect abnormalities in small vessels that are linked to disease.
For medical scans (X-rays, MRIs), ChatGPT-4 can improve “the accuracy and efficiency of radiological diagnoses by reducing interpretation variability and errors,” according to one review. Because medical scan readings are notoriously both dependent on individual radiologists’ expertise and susceptible to scheduling delays, ChatGPT’s “ability to analyze and interpret medical images in real time can help reduce interpretation variability and errors, improve workflow efficiency, and ultimately enhance patient outcomes.”
One study reported in the Journal of the American Medical Association (JAMA) found ChatGPT-4 “did better than most doctors on weekly diagnostic challenges [that had been] published in The New England Journal of Medicine,” Rodman said. But researchers at Mass General Brigham who assessed “an entire clinical encounter with a patient [from first evaluation to] final diagnosis” determined ChatGPT’s success rate at 71.7%, “at the level of someone who has just graduated from medical school, such as an intern or resident.”
That 71% success rate, based on comparisons with diagnoses made by the country’s top doctors, however, is a very different challenge than evaluations of patients who have no diagnosis at all. For the young patient Alex, Michigan pediatric neurosurgeon Holly Gilmer explained that his eventual diagnosis—tethered-cord syndrome, caused when spinal cord tissue has formed attachments to the spine— can be missed because young children have trouble describing their symptoms. But after Alex’s mother typed in every one of Alex’s medical evaluation reports, ChatGPT quickly found the right answer.
For me, a lifetime of reading medical mysteries—often endless tales of patients who suffer from terrible symptoms while frantically searching for a diagnosis—offered motivation to approach the complicated high-tech world of AI. After investigating uses of ChatGPT in medicine, I listened to a podcast of the Wired article “What OpenAI really wants,” and understood enough to find it fascinating—though also to worry how much AI will succeed in truly improving medical care for patients everywhere.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
2023 “has really has been the year of the ear, with hearing aids going over the counter and new research confirming how important hearing is for brain health,” according to the Washington Post. For some people, however, such as Lake Tahoe-based health editor L.D., her hearing aids don’t offer enough help for conversations in noisy rooms, or for watching TV or going to the movies without captions—leading her to begin considering cochlear implants (CIs).
L.D. started thinking about CIs after two friends reported remarkable improvement following their implantation surgeries despite the learning curve required for adjusting to the unfamiliar computer-generated sounds; and for one friend, dizziness lasting several months. The CI bypasses damaged portions of the ear to directly stimulate the auditory nerve, while hearing aids simply amplify sound— to improve detection after a lifetime of damage, often by loud noise over a lifetime.
CI application has “expanded…from the relatively small population of totally deaf individuals with little or no residual hearing, to the much larger population of people with cochlear hearing loss who have difficulties understanding speech with acoustic hearing aids in one or both ears,” writes speech pathologist Isabelle Boisvert at the University of Sydney. “Cochlear implantation is beneficial to the majority of adults of any age who have limited aided speech perception abilities.”
Older adults still have the lowest relative utilization rates of CIs, though in recent years “a shift has occurred, resulting in improved access,” according to otolaryngologists at the University of Colorado and the Mayo Clinic. Yet, “despite growing incidence among those with qualifying hearing loss, cochlear implants remain widely underutilized.”
The more than 120,000 CI devices implanted in American adults as of 2019, along with about 65,000 in children, represents low penetration of the U.S. market compared to that in other countries, according to CI manufacturers. Reasons include lack of understanding about how implants work along with concerns about what is involved in implanting and adjusting to the CI—as well as opposition from members of the deaf community.
But the biggest obstacle may be acquiring either clear information about how CIs might help or an accurate determination of insurance coverage eligibility — with both varying from one specialist or clinic to another. Writes Boisvert, “Access to cochlear implantation may be delayed for someone with poor speech perception scores but better hearing thresholds—even if functional hearing for communication could reasonably be improved with implantation.” “Functional” refers to real-life applications, such as participating in conversations.
Last year, Medicare increased its coverage, based on new research, to make CIs “available to millions of additional individuals with hearing loss,” according to the Washington University Department of Otolaryngology. The “expanded candidacy profile” includes individuals with scores on sentence recognition tests up to and including 60%—compared with 40% previously. Said department chair Craig Buchman, “The future for these individuals looks brighter than ever because of this new provision.”
Heralding the importance of functional hearing to brain health, a recent Washington Post headline read: “Hearing aids might cut cognitive-decline risk by nearly half.” In a large-scale study of nearly 1,000 adults ages 70 to 84 deemed at higher risk for dementia, “hearing intervention [hearing aids and counseling with an audiologist] had a significant impact on reducing cognitive decline effects of hearing loss.”
The extra effort required for people with hearing loss to understand what others are saying may help explain worse cognition in these people, Columbia University otolaryngologist Justin Golub told the Post. “The necessary brainpower leaves fewer cognitive resources to process what is heard.”
Alternatively, receiving less auditory input from the inner ear could diminish stimulation of the temporal lobe with “cascading influences on brain structure and function,” said Golub. A third possibility suggests that “people with hearing loss tend to be less social, and as a result have less cognitive stimulation.”
Early hearing loss tends to be imperceptible: unlike diminishing vision, which makes it difficult to read street signs, people are often unaware of sounds they cannot hear. But even mild hearing loss can create the feeling, as some describe it, of slowly becoming untethered from the world. The largest study to date, including more than 100,000 people over age 66, associated hearing loss with increased risk of depression, falls and dementia—but also showed that hearing aids lowered risks for all three.
Because implantation surgery might destroy residual natural hearing, losing that without getting any benefit from the implant is one risk of choosing a CI. Additional questions about CIs concern whether to get one implant or one in each ear; and the amount of time and money required for rehab—with concern about whether that will be also covered by insurance.
Despairing that she might never see another movie in the theater, however, L.D. recently encountered “closed captioning” via special eyeglasses, worn over existing eyewear, that display captions while the movie is playing. By contrast, “listening devices” offered at theaters and other performances are often unreliable. Still L.D. is planning an October eye clinic visit in the hope that she might qualify for a CI.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
“POSSIBLY the most remarkable thing about [Robert Oppenheimer’s] adolescence was the diagnosis he was given to explain his dark character: dementia praecox, i.e. schizophrenia,” according to El Pais. “He was always enormously generous as well as petty and arrogant; puny, in poor health and aggressive to the point of two attempted murders…”
After seeing the movie “Oppenheimer,” Minnesota-based neuroscientist N.A. asked several friends to explain schizophrenia. He also sought further clarification by reading three books: The Center Cannot Hold by Elyn Saks, Hidden Valley Road by Robert Kolkerand The Best Minds by Jonathan Rosen. N.A.’s conclusion: “I’m no further ahead in understanding the definition or classification of schizophrenia… but I now have examples and anecdotes.”
Examples and anecdotes are, in fact, the only way to explain schizophrenia—with infinite variations among individual sufferers. The disease usually begins with a psychotic break from reality that involves disordered thinking, such as delusions, auditory and visual hallucinations and paranoia. Even within one family, the six schizophrenic brothers in Hidden Valley Road have very different symptoms, treatments and outcomes—with each illuminating different aspects of this complicated and poorly understood disease.
For Elyn Saks in The Center Cannot Hold, and for Rosen’s close friend since childhood, Michael Lauder, in The Best Minds, their symptoms become increasingly disabling when both attend Yale Law School. Despite receiving surprisingly impressive, ongoing support from faculty and administrators, the two go on to have very different experiences with the disease.
Complicating the diagnosis and treatment of schizophrenia are delusions—notably anosognosia. Defined as “lack of insight,” the symptom “impairs the person’s ability to be aware they have an illness and explains why those with the disorder refuse medications or don’t seek treatment,” according to Colorado’s Gazette. “About 30 percent of people with schizophrenia…might show up at the ER and present as a homeless person who’s using drugs or alcohol”—and their release has led to death.
Another delusion, Capgras syndrome, creates the belief that friends and family look familiar but are actually imposters. As Oliver Sacks wrote in a 2012 New Yorker article, “An elderly woman got out of the taxi, and, galvanized into action, I ran toward her, shouting, “I know who you are—you are a replica of Augusta Bonnard! You look like her, you have her posture and movements, but you are not her… the logical though absurd conclusion that she was a ‘duplicate.’”
Sacks’s delusions emerged, however, not from disease but after extensive use of psychedelic drugs—demonstrating similarities but also vast differences in these experiences. As Sacks writes about his hallucinations: “My attention was caught by a spider on the kitchen wall. As I drew nearer to look at it, the spider called out, “Hello!” It did not seem at all strange to me that a spider should say hello… I said, “Hello, yourself,” and with this we started a conversation, mostly on rather technical matters of analytic philosophy.”
Also true of mind-altering drugs—as with schizophrenia—“anecdotal accounts are provided to give a better understanding,” according to Philadelphia osteopath Ashley Przywitowski. “Because hallucinogens and schizophrenia act on similar neurotransmitters and areas of the brain, the study of hallucinogens can allow for more insight into the cause of schizophrenia and allow for more effective treatment.”
But crucial differences make the “overall positive” mind alterations induced by hallucinogens unlike the debilitating experiences of schizophrenia. In the latter, paranoid delusions are the most frequent abnormalities of thought, along with confused thinking and an “overall depressed mood with a decline in functioning” —all of which can be frightening and lead to dangerous behavior —compared with “feelings of love and euphoria” of the psychedelic experience.
Another connection: Taking psychedelic drugs has led to episodes and eventually to a diagnosis of schizophrenia for about 20% of individuals, who may have had prior susceptibility to the disease, based on variables such as genetics and childhood trauma. Alternatively, explains The Best Minds author Rosen, about 25% of people diagnosed with schizophrenia recover completely in the first two years “because their correct diagnosis was short-term psychosis, which mimics schizophrenia.”
Along with such reports of recovery comes the most common question about schizophrenia: whether someone with this diagnosis can get better. Among the three books’ sufferers, only Elyn Saks ended up leading a fairly typical life —though in N.A.’s words “as a functional person, but not cured or in remission [who] manages with medication and psychotherapy, and a lot of both.”
As with schizophrenia, Rosen points out about antipsychotic medications used to treat it: no one knows exactly how they work and their effects “could differ wildly from person to person.” Since the early 1950s when the drug chlorpromazine (Thorazine) first showed positive effects, psychological vs. biological approaches to treatment have gone back and forth, according to a review article by Orlando and Boston psychiatrist Mark Ruffalo, with “renewed interest in psychotherapy for schizophrenia among some clinicians and researchers in the past two decades.”
The first psychotic break—mental detachment from reality—often predicts increasing disability for sufferers, a prognosis not much better than that portrayed more than 40 years ago in Susan Sheehan’s 1981 New Yorker series, “The Patient.” But now, as a caption in last week’s Washington Post article on the summer’s record-breaking temperatures notes: “schizophrenia may be the most dangerous preexisting condition in a rapidly warming world.”
For Robert Oppenheimer, most people dismiss the schizophrenia diagnosis—along with tales of his attempted murders. According to one view, when the physicist Max Born directed Oppenheimer toward theoretical physics—away from the mathematical and lab-based physics he had been struggling to perform well—that helped Oppenheimer focus his energy and led to his success, after which there was no cause for debilitating psychiatric diagnoses.
All three books fascinated me by weaving emotionally moving tales of sufferers into the history of research and dramatically changing views about schizophrenia. But what I most appreciated was the eloquent portrayals of the variability of the disease and experiences for these patients.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
MyLittleBird often includes links to products we write about. Our editorial choices are made independently; nonetheless, a purchase made through such a link can sometimes result in MyLittleBird receiving a commission on the sale. We are also an Amazon Associate.
“WINTER is coming” was the oft-repeated threat from Game of Thrones that opened MyLittleBird’s autumn 2022 article on viruses and vaccines. Again, like last fall, readers are asking for an update on vaccinations: which ones to get, when to get them and notably what to do about the vaccine against RSV (respiratory syncytial virus). In last winter’s “tripledemic” of Covid, flu and RSV, according to the New York Times, the “serious consequences of [RSV] were on full display…when the virus overwhelmed hospitals alongside the flu and Covid.”
The newest Covid vaccine—expected to be available in late September—should boost immunity against the Omicron variants that have dominated since last winter. With advice to get the new shot as soon as possible, Yale ER physician Megan Ranney notes: “Your strongest immunity will be in the two weeks to two months after you get your vaccines…while nearly all of us have immune systems that can recognize key parts of the virus now, even that memory of the infection fades over time.”
“The longer it has been since you’ve been infected or vaccinated, the more forgetful your immune system becomes,” Ranney explained. “Those B cells and T cells…they’re going to be a little slower to respond. That lag may give the virus enough of a window to get a foothold in our nasal passages or lungs, and we get sick [and then the immune system responds]. But for many, their immune system just doesn’t kick in as quickly or as vigorously as it should…immune function drops off naturally with age.”
After attending a party of 17 women in their 50s, 60s and 70s, Yoga instructor T.R. and nine other guests came down with Covid—with one admitting she had felt sick beforehand —an unusually high rate of contagion. “Covid-19 infections have started to rise again… it feels like people all over the country are testing positive,” according to CNN. And from the New York Times: “with a late summer wave of infections, hospitalizations increased 24% in the two-week period ending August 12, and wastewater monitoring shows a recent rise in Covid infections in the West and Northeast.”
For the flu vaccine—which can be received at the same time as the Covid shot—getting it later in September rather than sooner can help ensure that protection lasts through the winter flu season. While recommendations for flu specify getting the updated shot every fall, the Covid vaccine schedule remains undecided: for now, people can get boosters anywhere from three to six months after their previous shot.
The two RSV vaccines—which may end up on an every-two-year schedule—have proved 80% effective in clinical trials at “preventing lower respiratory symptoms such as cough and shortness of breath,” according to the New York Times. But rather than recommending the RSV shot to everyone 60 or 65 and older, the CDC’s current advice is that people talk to their doctor to weigh the benefits and risks.
The CDC “included this extra step in part because of the potential for…severe, albeit very rare, side effects,” American Academy of Family Physicians President Tochi Iroku-Malize told the New York Times. Of about 38,000 people who received one of the two RSV vaccines in clinical trials, 20 experienced atrial fibrillation and six had “neurological complications”—that included encephalomyelitis and Guillain-Barre syndrome.
In the absence of a clear recommendation from the CDC, reimbursement for the RSV vaccine is not automatic: Anyone on Medicare who does not have the optional Plan D prescription drug plan, as well as many people who have private insurance, must obtain a doctor’s prescription or risk being charged several hundred dollars for the shot. Iroku-Malize suggests that people with underlying health conditions may benefit most from receiving the RSV vaccine.
While RSV has infected almost everyone by age two. and is most worrisome in babies under six months, the National Foundation for Infectious Diseases calls RSV in adults aged 65 and older “a hidden annual epidemic.” In this age group, RSV causes 6,000 to 10,000 deaths annually—compared to 16,000 deaths linked to flu during the 2019-2020 season. Flu, RSV and Covid can have similar symptoms –- including sore throat, runny nose and cough, similar to those of a cold— but infection spreading to the lower respiratory tract, sometimes signaled by a “barking or wheezing cough,” can cause more serious illness.
Anyone worried about risks due to getting multiple vaccines, “routine adult vaccination… may be an effective strategy for dementia prevention,” write Chinese researchers on a multicenter study that found “all types of vaccinations were associated with a trend toward reduced dementia risk.” Their research “suggests that the immune system and infections play an important role in the development of dementia: bacterial, fungal and viral infections may cause neurotoxic inflammation and oxidative stress in the brain, which can lead to neurodegeneration.”
Once the CDC approves the new Covid vaccine, I’m ready to sign up. Also, in part for the chance at boosting brain health, I had been set to get the RSV vaccine—but now, with the risks in mind, I will confer with my doctor before deciding. For the more immediate quandary about highly infectious Covid, I have read the advice—to wear a mask when spending more than 10 minutes in an enclosed space with people closer than elbow-to-elbow—but am still pondering my options.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
“I’VE personally been ridiculed, heckled and coughed on for wearing my N95 [mask],” writes author Madeline Miller in a Washington Post essay titled “Long covid has derailed my life.” A “first-waver”— infected in February, 2020—Miller describes the stigma experienced over three years of debilitating fatigue with PEM, the Long Covid condition called post-exertional malaise that has made her “too tired to answer emails.”
For “contested diseases”—illnesses for which the existence and/or biomedical origin has been debated— stigma adds layers of suffering, according to a journalists’ Guide on how “to report on these “with accuracy and sensitivity.” With symptoms blamed on everything from the sufferer’s imagination to neuroses and lack of will power, the contested illnesses in recent news include post-partum depression and conditions related to obesity—along with the Guide author’s symptoms of ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome) similar to those of PEM.
“The United States has always been a terrible place to be sick and disabled,” writes Miller, author of the bestsellers Circe and The Song of Achilles. “Ableism is baked into our myths of bootstrapping and self-reliance.” Miller explains that, because “long-haulers who are reinfected usually get worse,” she always wears a mask—despite friends like one who acted personally insulted, demanding: “How long are you going to do this?”
“For new mothers, relief from an old stigma” headlined the print story by physician and Washington Post health writer Leana Wen. In response to the July FDA approval of the first drug that specifically treats postpartum depression, Wen confessed that it took “months before I finally sought help…stigma was at the core of what prevented me.”
“The [new] medication…reinforces the crucial message that post-partum depression must be treated like any other medical ailment,” writes Wen. Previously, one reason sufferers hesitated to talk openly about postpartum depression was that standard treatment involved a 60-hour, in-hospital IV infusion. (Most anti-depressants in pill form, in contrast, take two to six weeks to begin working.) Although the IV regimen is arduous while caring for a new baby, zuranalone has the significant drawback that women must stop breastfeeding for those two weeks.
Issues of personal responsibility and will power especially affect conditions of overweight and obesity. Contends Chevy Chase, Maryland, health writer M.K., “If you’re fat and fatness is a disease, you are by definition defective—and fatness is automatically stigmatized. While being fat increases the risk that you will get sick from other causes, it is not a sickness itself.” The AMA, on the other hand, in 2013, recognized obesity as “a disease state requiring treatment and prevention efforts…to improve research into the causes of obesity.”
In addition, twin and adoption studies show that genetic effects contribute as much as 70% of the variation in obesity, while physiologic changes that come with weight gain also play a role. And, though controversial, the “obesity paradox” refers to the finding that some people with related illnesses such as heart disease —along with a BMI in the obese or overweight range —have better short- and long-term health outcomes than those with a normal BMI, due at least in part to the physical fitness level of the individual.
“Obesity should be treated as a serious illness given its connection to other problems…an increased risk of cardiovascular disease,” specialists told the Post, after a new study showed reduced risk of heart attack for patients taking the new weight-loss drug Wegovy. The study highlights the need for insurance reimbursement for these new drugs when prescribed to treat obesity, rather than diabetes for which they are approved and reimbursed. Meanwhile, insurance covers bariatric surgery, which has been shown to reduce cardiovascular risk.
“Notions of health are highly context-dependent,” writes British bioethicist Jackie Leach Scully. Studies show that “whether people believe themselves to be ill varies with class, gender, ethnic group and less obvious factors such as proximity to support from family members…what counts as a disease also changes over historical time.” Scully notes that osteoporosis, following official recognition by the WHO as a disease in 1994, “switched from being an unavoidable part of normal ageing to a pathology.”
The consequences of recognizing osteoporosis as a disease impacted “sufferers’ sense of whether they are ‘normally old’ or ‘ill’ but more concretely…their ability to have treatment reimbursed,” explains Scully. “Another example is homosexuality, which has travelled in the opposite direction to osteoporosis, through medical territory and out the other side.”
For me, although the disease arthritis, which is evident on scans, causes my inflammation, people continue to remind me about changes in diet I should make to counter this process. On the other hand, I still find myself instinctively stigmatizing contested illnesses: reading about the debilitating fatigue of successful authors I admire such as Miller—and before her, Seabiscuit author Laura Hillenbrand—I was surprised to feel new respect for the seriousness of these conditions. Now, still trying to staunch my tendency to stigmatize, I am focusing on the crucial next step: sympathizing with sufferers of contested diseases.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
MyLittleBird often includes links to products we write about. Our editorial choices are made independently; nonetheless, a purchase made through such a link can sometimes result in MyLittleBird receiving a commission on the sale. We are also an Amazon Associate.
“YOU should consider taking a vitamin supplement” was advice I heard for the first time this spring from my internist—who had previously contended that diet could provide all the vitamins needed for good health. But new research supports the need for supplements, notably vitamin B12, she said; and other recent evidence also suggests taking added B3 and D.
The “common cause of B12 deficiency, especially in older people, is a lack of stomach acid, because stomach acid is needed to liberate vitamin B12 from food,” according to Harvard’s Nutrition Source newsletter. “An estimated 10-30% of adults over the age of 50 have difficulty absorbing vitamin B12 from food.” In addition, anyone taking antacids or other stomach acid suppressors for conditions such as GERD might need additional B12, although research has not shown increased prevalence of a deficiency in people taking these medications.
Low levels of B12, even without official “deficiency,” can contribute to brain fog, fatigue and weaker bone health—and extend to more serious complaints, including memory loss and pain. According to webmd, “When you’re in your 60s you should officially start getting blood tests to test for vitamin B12 deficiency. Around this age, you should be getting around 2.4 micrograms of B12 a day.”
Vitamin B3 is another recently recommended supplement, with evidence that it can improve energy metabolism in the brain that decreases with age—possibly contributing to cognitive changes associated with diseases such as Alzheimer’s (AD). Explained Delaware Center for Cognitive Aging Research director Christopher Martens: “If the brain cells can’t produce the energy they need to be able to function, then they can’t signal, and if nerve cells in the brain can’t signal effectively then cognition will be affected. Whether this is a cause of the disease or a symptom is unclear.”
Supplements of B3 in the form of nicotinamide riboside led to a “significant decrease in the levels of amyloid beta protein in neurons” associated with AD—compared to the effects in a placebo group — in research by Martens and his team. The brain converts B3 to the molecule NAD+—which is involved in creation of energy by the cells, and is also taken as an independent supplement.
“NAD+ can directly and indirectly influence many key cellular functions, including metabolic pathways, DNA repair, chromatin remodeling, cellular senescence and immune cell function,” according to Anthony Covarrubias and colleagues at UCSF. “These cellular processes and functions are critical for maintaining tissue and metabolic homeostasis and for healthy ageing.”
For vitamin D, the advice keeps changing, but evidence for upping daily intake appears stronger with every passing year —as does evidence for its many health benefits: roles in maintaining bone health as well as in disorders that include cancer, diabetes and depression. The body’s ability to synthesize vitamin D from sunshine, which is lower in those with darker skin, declines with age. From the same sun exposure, a 70-year-old may produce as little as one-quarter as much D as a 20-year-old; and more than three-quarters of hip-fracture patients have vitamin D deficiency.
Vitamin D deficiency rates in the U.S. are rising, with the most vulnerable living above the 40-degree latitude north of the equator (north of Philadelphia or Denver), where getting adequate levels from the sun, the best vitamin D source, becomes more difficult. Blood tests for vitamin D should be done in late winter to assess an individual’s lowest levels.
Vitamin D can act as both a vitamin and a hormone—with the general distinction that vitamins cannot be synthesized by the body, with exceptions such as D, and mainly affect metabolism; while hormones like estrogen and insulin are produced in the body and have primary roles in growth and development. Kaiser Permanente dermatologist and hair growth specialist Paradi Mirmirani told the New York Times: “We know that vitamin D acts more like a hormone in the hair [affecting changes in growth following menopause] than a vitamin.”
Diet may also need to change to ensure adequate vitamin intake—especially with age and even with the addition of supplements. “The only reliable food sources for B12 are animal products,” according to webmd. Though “vitamin B12 rich foods” include fortified cereals, primary sources most often listed are eggs, cheese, milk, trout, haddock, salmon, beef liver and cooked clams. Some foods, however, that are touted to contain high levels of B12 may in fact have little or none, for example: Brewer’s yeast—which only contains B12 if specifically fortified; and Nori, dried edible seaweed—because the amount of B12 varies so much among types of seaweed, with some containing none.
While I try not to believe too much in lucky signs, I received my doctor’s supplement advice only a week after a friend brought over two large containers of multivitamins for women over 50 (Centrum), saying she had discovered after buying the pills that they contained iron and had caused constipation—something I also wanted to avoid, but had no problem with these and now had a good supply to get me started.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
An old-fashioned solution to coping with back itch. / iStock
By Mary Carpenter
In her update to an earlier post on skin problems in hot weather, Mary discusses notalgia paresthetica (NP) – an intense and sometimes painful itching on the upper back—which occurs more often in summertime and more often to women; is often linked to stress and anxiety; and often goes unreported but suspected to be very common.
PACKING for a 10-day trip to Africa, D.C. ESL teacher B.A. felt intense itching between her shoulder blades. The diagnosis: notalgia paresthetica (NP), which dermatologists consider “very common” if often undiagnosed and have dubbed “the unreachable itch.” Laguna Beach, California, dermatologist Ally Alai describes NP as “commonly seen in middle-aged white females with a seasonal predilection for warmer summer months”—arising in response to ultraviolet radiation in sunlight.
In contrast, cases of notalgia paresthetica (NP) that are reported and added to official statistics most often occur in patients who have upper back or neck pain related to injury or underlying conditions such as a herniated disc. In these cases, bones or muscles trap and put pressure on nerves—placing NP in the category named by Alai: skin-itch-spine-syndrome (SISS). SISS may have inspired the invention of back-scratchers, fashioned in the past from tree branches, whale bone or a nearby wall for rubbing against.
NP involves both “localized pruritus” or itching; and “dysesthesia”—disruption in the experience of touch-based sensations, according to MyClevelandClinic. Dysesthesia can occur when the brain fills sensory gaps: In the absence of nerve receptors that detect moisture, for example, the human brain combines sensations of temperature and texture to create feelings of wetness.
Similarly, emotions, such as anxiety and depression, can contribute to itching that feels “every bit as real as…if there were an obvious cause [like nerve damage],” the site explains. Another example of the emotional component of itching: seeing someone scratch can make another person itch. Besides appearing more common both in middle-aged to older adults and in women, NP symptoms may last longer in those with a higher BMI.
“Pain’s creepy bedfellow” is how Harvard cardiologist Haider Warraich once described itching. The same receptors trigger both sensations; distraction can alleviate both sensations; and both sensations can arise or increase in the presence of mental health issues, including depression and obsessive-compulsive disorder.
Finally, capsaicin, the chili pepper extract that is applied topically, can help treat both pain and itching. More familiar as a general analgesic, capsaicin sends impulses to the brain that produce sensations of warming, tingling, itching, stinging or burning—and then diminishes these responses in a process called “defunctionalization.” In addition, pain relievers like lidocaine as well as corticosteroid creams can help relieve itching. (Nerve-related NP, on the other hand, may respond better to stronger drugs like gabapentin—or in some cases, to a neck massage.)
Of all causes of itching, the most common is contact dermatitis —which can start with any irritant— a wool sweater, prickly lawn grass. Irritant contact dermatitis is a nonallergic skin reaction to a substance that damages the skin’s outer protective layer and usually develops within minutes to hours after exposure. An allergen—poison ivy, the mango plant, nickel, formaldehyde—can provoke a similar reaction.
Whatever the initial cause of itching, scratching can result in rashes and bumps—which in turn cause more itching, more scratching and more reactions, until the layers of bumpy rash began to look serious. Repeated scratching can also cause the bumps to ooze, creating a good place for bacteria or fungi to grow and produce infection. Independently, fungi can also cause itching, as in athlete’s foot.
In very cold weather, itching can arise in exposed areas of skin. Among other common causes, eczema and psoriasis are both “atopic”—hypersensitivity reactions that occur in a part of the body not in contact with an allergen. Both are traced to a combination of genetic and environmental causes, such as pollen. Psoriasis causes itching that may be similar to that of eczema, often less intense but sometimes accompanied by a stinging or burning sensation that has been compared to that produced by fire ants.
Lichen sclerosis (LS), with symptoms that include itching along with white spots and pain, can be the result of an “overactive immune system.” When linked to previous trauma or infection, LS qualifies as an autoimmune disease in which the body’s immune system causes inflammation and damage in healthy tissue.
For B.A., her physician prescribed capsaicin as well as Zyrtec, an antihistamine often taken for allergic reactions. But what seemed to help most to relieve the itching, she said, was bouncing up and down on rutted roads in the safari vehicle—and maybe getting past the stressful anticipation of her trip. By the time she returned home from Africa, her NP seemed to have disappeared —although itching continued to recur.
For me, poison ivy has been the main nemesis, although I’ve had contact dermatitis set off by combinations of wooly clothes, dry skin and even absent-minded scratching. Cortisone cream has helped, and the poison ivy has sometimes required a course of prednisone—but the crucial component of treatment is often the most challenging: to stop scratching.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
Read anything good lately? We have, and that’s why we’re pumped to publish this occasional series inspired by our favorite recent reads. This week Mary’s inspiration was The Covenant of Water, by Abraham Verghese.
“YOUR hands are a super important part of how you interact with the world and do the activities you love,” states MyClevelandClinic. In The Covenant of Water, the hand injuries of two characters stop them from doing the work they love: in the case of a doctor, that is surgery—due to scarring after a fire; and for the other, an artist, leprosy slowly diminishes her abilities. Although leprosy is rare in the U.S., several of the most common hand conditions occur predominantly in women.
Base-of-thumb arthritis afflicts women 10 to 20 times more often than men—most frequently over age 50— although no one is sure why, according to Duke Health hand surgeon David Ruch. Although the thumb has an impressive range of motion, over time dexterity can wear away the bone-cushioning cartilage and result in pain as well as displacement of the thumb. What is also called thumb arthritis or CMC (for carpometacarpal joint) may respond to NSAIDS, splints and steroid injections, and surgical options may help prevent serious permanent impairment.
Trigger finger is also more likely to occur in women, also more commonly in women over age 50. Tendons along the front of the hand that slide in order to flex the fingers can thicken and catch—most commonly affecting the thumb and ring finger—and in advanced cases cause fingers to lock and need assistance to unbend. According to Cheltenham Hospital orthopedic surgeon Ewan Bigsby, when the triggering becomes “troublesome”— for some, producing a clicking sensation—cortisone injections may help, but surgery provides the best long-term solution.
Carpal tunnel syndrome (CTS) is a compressive neuropathy that also afflicts more women, in this case at three times the rate of men—with peak incidence between ages 45 and 54. Irritation of the wrist’s median nerve — most often linked to repetitive professional work, such as typing — can cause pins and needles, with discomfort often impeding sleep. Early symptoms, such as reduced feeling in the fingertips, can proceed to constant numbness of fingers and weakness in the hand, and ultimately damage the hand muscles, especially at the base of the thumb. Initial treatment can involve wrist splints worn at night, but surgery offers rapid improvement in symptoms and can allow the nerve to fully recover.
Ganglion cysts, sac-like structures often filled with liquid that can occur in almost anyone, develop along the tendons and joints of hands and wrists and can range in size from tiny nodules to an inch in diameter. Most cysts have no clear cause and are harmless, but they can restrict mobility and can cause pain if pressing on a nerve. Infection—often resulting from at-home attempts at removal, such as hitting the cyst with a hammer, closing it inside a heavy book and sticking it with a sharp object in the hope of popping it —can require surgery.
Essential Tremor (ET), which most often affects the hands, is the most common movement disorder—with Katharine Hepburn a famous sufferer. “To drink without using both hands” was the greatest wish of one man, who’d had ET since age 9. The condition can look like Parkinson’s disease (PD) but is not linked to dopamine depletion and causes handwriting that is large and tremulous, rather than the slow and very small scribbles of PD. For sufferers of both, tremors can be made worse by anxiety, stress, fatigue, physical exertion and fever.
Finally, Dupuytren’s contracture is slightly more likely to affect men; is the most common connective tissue disease; and is often inherited. Thickening of tissue in the palm or fingers —most likely first to affect the ring or fourth finger—can cause the hands to contract and fingers to bend inwards. Conservative treatment using splints at night can prevent worsening. And needle fasciotomy, using a needle to perforate thickened tissue, can offer relief but because the condition has a high rate of recurrence, surgery to remove diseased tissue is the most established treatment.
The disfigurements of Dupuytren’s contracture can be, though to a much lesser degree, similar to those caused by leprosy or Hansen’s disease: for a case described in JAMA, ring-shaped rashes led to numbness and tingling patches on the skin—and after four years, hands “slowly bending like a claw,” according to metro.co.uk. With leprosy, nerve damage leads to joint deformity, but loss of sensation can also make sufferers unaware of limb injuries, such as burning.
While uncommon in the U.S., leprosy has been on the rise, notably in Florida; and with 159 new cases reported in 2020, some experts consider the disease “endemic.” In the U.S., armadillos appear to be the common reason for local transmission, either consuming them or working in soil that has been contaminated. But leprosy, usually contracted via airborne droplets from an affected individual, is not highly transmissible: almost 95% of people exposed to the bacteria never develop the infection.
For my hands, I’ve had mild essential tremor since childhood. Then in my 30s, breaking a glass led to stitches and a persistent painful, red lump over one joint —the occasion for my first encounter with a “hand doctor,” who told me the tiny fragments of glass that remained would emerge on their own in a month or two. Decades later, after performing all of the ill-advised at-home treatments on a ganglion cyst at the end of one finger, I developed an infection that required surgery.
Over the years, I also developed CMC arthritis that caused my thumbs to appear lumpy and out of place: without surgery, a doctor warned, I might lose the opposable thumb function. Ligament reconstruction surgery—removing and replacing the damaged ligament using a piece of tendon from the wrist—on my left, nondominant hand made that thumb look less displaced and lumpy. But weakness that remained helped me decide to leave the right hand alone.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
MyLittleBird often includes links to products we write about. Our editorial choices are made independently; nonetheless, a purchase made through such a link can sometimes result in MyLittleBird receiving a commission on the sale. We are also an Amazon Associate.
Read anything good lately? We have, and that’s why we’re pumped to publish this occasional series inspired by our favorite recent reads. This week Mary’s inspiration was the Pulitzer Prize winning Trustby Hernan Diaz.
By Mary Carpenter
“CONVULSIVE therapy”—using chemicals to induce epileptic seizures—appears near the end of Diaz’s novel, one of this summer’s top book-group reads, a late-1930s treatment for one character’s depression. By the 1940s, seizures produced by chemicals—including insulin and the drug Metrazol—gave way to electrical stimulation (electroconvulsive therapy or ECT), now increasingly used as a “first-line” treatment in cases of severe depression.
Psychedelic drug therapy (notably MDMA) for depression related to PTSD is also receiving recent attention—from veterans speaking up about their experiences. In response, members of Congress have increased support—up from 91 votes in 2019 to 140 in 2021—for what they dubbed Alexandria Ocasio-Cortez’s “little shrooms bill” that proposes to lift federal prohibitions making it difficult to study psychedelic drugs, specifically referring to the psilocybin in “magic mushrooms.” In early July, a similar version, calling for clinical studies of psychedelics in military treatment facilities, made it into the National Defense Authorization Act.
Casting a dramatic recent spotlight on treatments for severe depression —in this case in-patient care and antidepressant drugs— is newly elected Pennsylvania Senator John Fetterman’s openness about taking more than six weeks’ leave from his new Senate job. Arriving at Walter Reed Hospital “gaunt, listless, barely able to function,” Fetterman told Time, “I didn’t think I could be fixed.”
“It was a powerful and a helpful thing that he did,” said Vermont Senator Peter Welch, who noted that “the COVID-19 pandemic and its aftermath triggered a widespread mental-health crisis that the nation is struggling to address.” In a recent survey of Americans, 18% said they have depression—a rate that has nearly doubled in the past decade—with fewer than 10% of sufferers receiving psychiatric treatment.
“Depression to the public connotes sadness [but] the cardinal feature of the medical illness of depression is slowed speech, movement, and a lack of drive or initiative,” explained Walter Reed inpatient Neuropsychiatry Director David Williamson. “[Fetterman] was very passive, very flat, very unemotional, almost mute, although he did talk. Just a lack of responsiveness and a flatness, a lack of that spark or passion you would expect to see in humans.”
“A medical condition rooted in brain chemistry” is how Williamson characterizes depression, although he was able to convince the Senator only after persuading him to read Understanding Depression, by Raymond DePaulo (currently out of print, audio is available). Said Williamson, Fetterman’s openness about his struggles has the power to help countless others.
“There can be a biological predisposition, but there is often a trigger, and we just don’t always know what that trigger is,” explained McLean Hospital Director of ECT Services Stephen Seiner. “Very often in patients who experience depression there may be a psychosocial stress that somehow sets off a cascade of neuronal connections in the brain that then leads to an episode of depression. Where most people would be able to bounce back from the stressor, patients who have a predisposition towards depression often continue to spiral down.”
Depressive episodes “characterized by persistently depressed mood or loss of interest in activities [cause] significant impairment in daily life,” according to CMS (Centers for Medicare and Medicaid). Of those with a diagnosis of major depressive disorder (MDD)— about 16 million U.S. adults in 2015—around 70% do not recover completely, which puts their illness in the category of “treatment-resistant depression” (TRD).
With psychedelic drugs, significant improvement can come after just one experience in a therapeutic setting. MDMA, or ecstasy, works specifically to block or extinguish “fear memory,” according to a recent study of 91 patients with severe PTSD. A major motivation to study psychedelic drugs, according to Veteran Affairs: “nearly 17 veterans dying by suicide each day.” The FDA appears “expected to approve MDMA for PTSD and psilocybin for depression within two years,” according to New York Times opinion writer Maia Szalavitz, writing about the psychedelic drug, ketamine. Szalavitz describes testimony by two survivors of the cult Nxivm, actress Catherine Oxenberg and her daughter India, about their “new foundation that plans to offer ketamine in a therapeutic setting to other female survivors of cult and sexual violence.”
“Plant medicines like psilocybin…give you exactly what you need, even if you don’t know what it is you need,” notes Veronica Duron, chief of staff to New Jersey Senator Corey Booker, co-sponsor of Senate legislation similar to the “little shrooms bill.” The subjective experience of tripping while taking psychedelics appears to be part of the therapeutic effect—and biochemical changes in the brain appear related to the same serotonin neurotransmitters targeted by antidepressants.
While psychedelics, antidepressants and talk therapy help many people with depression, these options “fall short” for an estimated 100,000 people a year in the United States who may respond better and more quickly to ECT, according to McLean’s Seiner. While no one is certain why ECT works, the observations that seizures reset brain functions—and that brain activity involves electrical signals passing through neurons—has led some to compare ECT to rebooting a computer.
For many, including Seiner, ECT should become the first-line treatment in severe cases of depression, especially when suicide is a possibility—although concern about side effects, including headaches, muscle aches and temporary memory loss, means many continue to use it only as a last resort. Based on a five-year review of ECT studies, however, Chinese researchers write that it “should be a first-line therapy for depression due to its profound effects in relieving desperation in certain situations.”
ECT is “the most valuable option in case of treatment resistance and severe and life-threatening mental conditions, especially depression and schizophrenia,” write German researchers based on their three-year analysis of ECT. They found “excellent remission rates of up to 75% even in treatment resistance, improving health-related quality of life [also] a significant anti-suicidal effect.”
In Trust, chemical seizures helped at first but ultimately killed the character. For me, however, two friends who underwent ECT for overwhelming, long-lasting depression said the side-effects, even memory loss, didn’t persist long enough to affect their conclusions—that ECT worked when nothing else had.
—Mary Carpenter regularly reports on topical subjects in health and medicine.
MyLittleBird often includes links to products we write about. Our editorial choices are made independently; nonetheless, a purchase made through such a link can sometimes result in MyLittleBird receiving a commission on the sale. We are also an Amazon Associate.
