My last post went over the anatomy of the spine, both the bony part, the spinal column &  the nerve part, the spinal cord, cauda equine and nerve roots. Now I’d like to focus on low back pain (LBP), while acknowledging that many of us (including both my wife and myself) have problems with the upper spine, AKA the cervical spine.

The most frequent problem seems to be that strange entity called degenerative disc disease (DDD).  When I’ve looked at a variety of sources on this condition, the feature that many  of us with DDD have in common, is age. The Cedars-Sinai webpage on DDD mentions a critical point: as we age nearly all of us will show at least a modicum of signs of waer and tear on our final discs, yet many will have no symptoms. So the term, DDD, conventionally is used to refer to those who have pain from their damaged discs.

I copied the illustration below from the webpage of Dr. Jeffrey Goldstein, a New York City orthopedic surgeon and back specialist. He emphasizes that disc degeneration is a normal part of aging, but it can cause damage to nerves or cause pain by bones rubbing on each other.

 As I mentioned briefly in my previous post, spinal discs are rubbery, so they can act like shock absorbers for the vertebrae. They also help the facet joints in allowing us to twist and turn; at the same time they are exposed to and resist tremendous forces. They have a tough outer layer and an elastic (more fluid) core.

They have minimal blood supply, so if they get damaged there’s no repair mechanism built in. Then, much as my medical history reveals, over a considerable period of time, the injured disk causes acute pain limiting back movement, then pain may occur off and on as the bone that was injured loses some of its stability and eventually the portion of the spine injured restabilizes and pain occurs less frequently.

By the time we are sixty, partially depending on our sports and daily motion, we’re quite likely to have disc degeneration, but, as noted above, we may or may not have back pain.

Sometimes, under various stresses, a disc pushes right through its outer membrane. We call this a ruptured or herniated disc. Roughly 90% of the time, if a disc herniation happens, it’s in the low back. And most of those who rupture a disc are age 30 to 50. As we age beyond 50, our discs dry out and are less likely to rupture.

On the other hand, we can develop arthritic changes in the vertebrae (see illustration above) that cause pain by pressing on nerve roots leaving the spinal column. This is termed spinal osteoarthritis and, although it may occur in the younger set because of trauma/injury (under age 45 this is more common in men), it’s typically seen and is more common in women over that age. There may be neck or back stiffness or pain, often lessened by lying down. It’s even more frequent in those who have excess poundage.

Facet joint disease is another form of this osteoarthritis (the term osteo refers to bone). It may be associated with inflammation of the facets and cause the back muscle to spasm with increased pain on any motion of the area.

Sometimes the space in which the spinal cord lies gets narrowed; this is called spinal stenosis and occurs mostly in the neck or low back regions. It may be a congenital condition (one you are born with), but much more commonly is caused by overgrowth of bone, a ruptured disc, tightening of the ligaments that help keep your vertebrae together or even by injuries or a tumor. It’s more commonly seen in those of us over 50 and, if severe can lead to complications (numbness, weakness, incontinence or even paralysis)

When I had an MRI and saw my neurosurgeon for the first time, I had all three conditions: a ruptured disc, facet disease and spinal stenosis.

I was fortunate in that, under light anesthesia, the surgical team did tests to determine exactly what levels of my spine needed fixing. Now I’m by no means a neurosurgeon or orthopedic back surgeon (My initial residency was in Internal Medicine), so I can’t tell you exactly what my doc did.

I have a scar like this

But as best I know, he poked in a protruding disc, reamed out a facet joint opening and expanded whatever was causing my spinal stenosis.

That led to considerable improvement of my symptoms and signs (back pain and leg numbness and weakness with some shrinkage of the muscle above and to the inside side of my right knee) But some of the symptoms came back after six years and I had a second operation.

Now all I have is fairly regular low-grade back soreness; I’d sure like to get rid of that too. So when I found that article online in medscape.com, with the title “Autologous Bone Marrow Grafts Promising for Low Back Pain,” I read it quite carefully.

It clearly is research at this stage and, as I mentioned, needs a large, prospective controlled trial, but researchers from Missouri reported a series of 24 consecutive patients (averaging 45 years old and with 17 men and 7 women) who had chronic LBP unresponsive to a number of therapy trials and all having lumbar disc disease. They took some of their own (AKA autologous) bone marrow from a hip, concentrated it and injected some into the lumbar disc affected and more just outside those discs.

This only took a short time (20 to 60 minutes) and most of the patients had considerable pain relief that lasted over a two-year followup period.

I’m eager to see more data on this new modality for treating chronic LBP.

It happens to many of us

The website of the NIH’s National Institute of Neurological Disorders and Stroke has a ten-page Low Back Pain Fact Sheet with the comment that Americans’ LBP is our most common job-related disability and, as a neurological affliction, trails only headache in frequency. Much of it resembles Dad’s three-iron comment; it’s often exercise or work-associated and lasts just a few days.

But some is chronic and overall the amount of money spent on LBP is staggering, $50 billion a year.

My wife has also had low back pain (LBP) problems and wrote a story for one of the Chicken Soup books with her title being, “How Pilates Saved me from Surgery.” That concerned her first episode of severe LBP eight years ago when an MRI showed disc disease in her lumbar area (below the ribs and above the sacrum). At that time she saw the same Denver neurosurgeon who has operated on me and he said, “It’s too soon for surgery. I’ll arrange for an injection by an anesthesiologist in Fort Collins (I played the D card, calling for her and saying  this is Doctor Springberg, and she got her shot the very next day).

She mentioned Pilates to the neurosurgeon and he approved her going to a class with some caveats. She told her instructor about her back problem and the health club’s experienced teacher said, “That’s no problem; there are some exercises I’ll modify for you and some you should not do at all.”

I had seen the online story of a woman who hadn’t had the same positive experience; she and others have cautioned that Pilates is not the answer for everyone, unless you have an instructor familiar with the limitations necessary for some students.

Lynnette has remained slender and exercised five or six days a week (Pilates on three days and a class called “Strong women, Strong Bones ” twice a week + stretches every day and one or two trips to the gym with me). Then she had a flareup over the last few months. She saw our favorite physical therapist, got new exercise and posture ideas and is back to low-grade soreness (two on a pain scale of one to ten). There’s no surgery in sight.

She also has a strong family history of chronic LBP; her mother had it for years and her sister has had two operations thus far and numerous injections of either steroids or pain medication.

My  first episode of acute LBP happened forty-four years ago when I was a clinical Nephrology fellow at Duke, was relatively inactive and had gained lots of weight (I was at 216 pounds and had wrestled at 155 in college). The NIH Fact Sheet says most acute LBP is mechanical in nature, happens most commonly to those aged 30 to 50 who have a sedentary lifestyle and may be overweight.

I certainly fit that picture back in 1969 except I was only 28; today I weighed 149.4 pounds.

Chronic LBP, defined as pain that persists for at least three months, is another matter. It has lots of causes, especially disk disease. That statement requires considerable background. Your spinal cord is a major part of the nervous system with literally millions of nerve fibers that transmit information to and from the brain and the arms, legs, organs, and trunk of your body. It’s fairly delicate so to protect it you have a series of barriers and cushions starting with the spinal column (AKA the spine), a series of bones called vertebrae. There are seven in the neck region (the cervical vertebrae) twelve in your upper back (thoracic area technically), five in the lumbar (low back) area, and then a set that are fused together (your sacrum and coccyx, AKA tail bone), making up a rough and slightly variable total of thirty.

a typical lumbar vertebra

Each one of the vertebrae has a body, the main area for weight bearing, and an off-round hole that the spinal cord passes through. Branches of the cord, AKA nerve roots, pass through other spaces in each vertebra; these are called foramina (the term comes from Latin and means a natural opening). The bony structures are separated by intervertebral discs , rubbery pads held in place by muscles and ligaments. The posterior part of the vertebrae has a portion termed the spinous process. That’s what you can feel when you touch somebody’s back and move your hands up and down.. It also has wing-like bony structures (transverse processes) on each side where back muscles attach. A particular vertebra is connected to the next vertebra up and downstream by facet joints, stabilizing links which allow twisting motions especially in the neck and low back (very limited in the chest area).

The spinal cord itself is cushioned by a fluid called the cerebrospinal fluid or CSF. It is produced in the skull and serves multiple purposes for the brain: buoyancy, allowing the brain to be densely packed without cutting off its own blood supply; protection from being jolted or hit; chemical stability by removing metabolic waste and allowing distribution of neuroendocrine chemicals (e.g., the nine hormones from the pituitary gland).

One more bit, then I’ll quit this prolonged anatomy lesson; The spinal cord ends higher in the back than the spinal column. At the bottom of the cord is a bundle of nerve roots that send messages to and from the legs and pelvic organs. These are called the cauda equina (Latin for horse’s tail). Rarely they can get compressed by a ruptured disc, tumor, infection, car crash, a significant fall, gunshot  or knife wound, fracture, or narrowing of the spinal canal.

When that happens, it’s a surgical emergency, called the cauda equina syndrome.

So your spine is a highly articulated, complex structure and lots can go wrong with it.

More on that in my next post.

A C-section is a real operation and not bloodless

So what’s a nephrologist doing writing about an Ob-Gyn topic? Well, to begin with I’ve delivered fifty babies, just none recently, so I’ve always had an Obstetrics interest. I was reading the latest edition of JAMA and saw an article in the “Clinical Crossroads” section titled “Elective Cesarean Delivery on Maternal Request.” That caught my attention so I started reading about C-sections versus vaginal deliveries. The CDC webpage on the subject said in 2010 there were 1,309, 182 C-section deliveries in the US versus 2,680,947 vaginal deliveries. So nearly a third of all American deliveries were via C-section.

That hasn’t changed significantly in the last few years; there’s a 2007 article “Recent trends in Cesarean Delivery in the United States” which documents the increase in the percentage of deliveries done by C-Section rising from 21% in 1994 to 26% in 2002, 30% in 2005 to the plateau from 2007 through the most recent data I could find, a mid-June 2012 report in the publication, Healthgrades.

The 2007 report has details on C-section rates versus age of the mother and, as I expected, the percentage of deliveries done by this method rises steadily as the mom’s age does. For those under age 20, the rate was 23%, for women over 40 it rose to 48%. All racial and ethnic groups experienced a similar increase from 1996 to 2007 and excluding American Indian and Alaskan Native women, all the other groups had C-section rates of 30% or higher.

State by state differences were considerable with four (Alaska, Idaho, New Mexico and Utah) staying under 25% and five others (Florida, Louisiana, Mississippi, New Jersey and West Virginia) topping the list at over 35%.

A 2010 paper from the World Health Organization looked at Cesarean rates in 134 countries. There were 54 in which the rate was less than 10%, 69 where it was greater than 15% and only 14 in the 10-15% zone WHO considered optimal.

That’s amazing when we consider the WHO figure versus those in the United States. In 2006 a C-section was the most frequently performed surgery in U.S. hospitals!

There are a host of recognized medical indications for doing a C-section, those may include a fetus in an unusual position (not head-down), a maternal condition that may be worsened by labor (e.g., heart disease), an unusually large baby, a fetus with a known health problem, maternal infection with genital herpes or HIV, some multiple pregnancies (conjoined twins, AKA Siamese twins) or a placenta that is blocking the cervix (placenta previa).

Beyond clinical reasons for having this surgical procedure, there’s maternal preference. The JAMA article was part of a series called “Conferences with Patients and Doctors,” and presents the case of a late 30s primip (woman having her first baby; technically it should mean one who has already had a baby) who requested a C-section; she happens to have worked since she was twenty as a paralegal in a firm that handles mostly medical malpractice claims, so her viewpoint is very likely to be skewed.

The term itself, cesarean delivery on maternal request, with its acronym CDMR, sprang from an NIH State-of-Science-Conference Statement dated March 27, 2006. An 18-member panel reviewed the pertinent literature and heard comments for 18 experts in appropriate fields. They concluded there was not sufficient evidence to fully evaluate the pros and cons of CDMR versus  vaginal delivery, but noted that the incidence of C-section without medical or obstetrical indications was increasing in the U.S.

At that time the authors thought a decision for CDMR had to be individualized and ethical principles must be adhered to. They also noted that CDMR should not be recommended for women who planned to have more than one child as there were increasing risks in each subsequent cesarean delivery.

The placenta is the thickened area on the top of the uterus

What are those risks? Besides a difficult C-section in subsequent deliveries, sometimes leading to hysterectomy, need for blood transfusion or other surgical complications, there are potential problems with the mother’s womb. The placenta, the structure that develops in the uterus during pregnancy to provide oxygen and nutrients to the fetus and remove its waste products, normally attaches to the lining of the uterus on the top or side of that organ.

A variety of issues can affect the placenta: increased maternal age is associated with a number of those as are high blood pressure, blood-clotting disorders, substance abuse or abdominal trauma.

Two placental abnormalities are more common with repeated C-sections and, in turn, may necessitate another Cesarean delivery or even a hysterectomy. Placenta previa means the structure has partially or even totally covered the cervix, instead of attaching to the top or side of the womb. This condition can lead to severe vaginal bleeding either prior to or at the time of delivery. The likelihood of placenta accreta also increases when placenta previa is present, especially when the mother has had repeated C-sections.

Normally the attachment of the placenta to the uterus, via small blood vessels termed chorionic villi, is relatively superficial, allowing easy separation of the structure after the baby is delivered. In placenta accrete, the viili penetrate deeper into the wall of the uterus, into a muscular layer called the myometrium.

When this happens, vaginal bleeding can happen during the third trimester of pregnancy, heavy bleeding can occur after the baby is delivered, the placenta can fail to separate from the uterine wall after the delivery and a C-section and surgical removal of the uterus may be required. The risk of placenta accreta is increased in areas of uterine scarring, often caused by a prior C-section.

The NIH Consensus Conference on the subject and the American Congress of Obstetricians and Gynecologists (ACOG) issued three recommendations for planning CDMR: It should not be done before a gestational age of 39 weeks has been accurately determined (allowing the fetus to have adequate lung development); It shouldn’t be motivated because of fear of inadequate pain management, and It should not be recommended for women who wish to have several more children.

ACOG and medical ethicists feel that women need to have informed discussions of these issues, but, in the end, the obstetrician can ethically agree to a C-section. They are not required to do one and if the patient and her physician cannot agree on the route of delivery, it is appropriate for the doctor to refer her to another obstetrician.

You won’t see this hospital in the countryside

But then I started to think of my time at Duke, 1966-1970, and its associated Veterans Administration hospital, the Durham VAH. That was clearly an urban setting , but sometimes, when I was on a VA rotation, we’d get a transfer from a different veterans’ care facility, one located in the country. Now, in 2013, I fully understand the VA system has been markedly upgraded; then, in the late ’60s, there appeared to be a quantum gap between the university-associated VA a few blocks from Duke’s main hospital and the one, as we said in our smug way as residents, “out in the boonies.”

In retrospect, that was also true of transfers from civilian rural hospitals to Duke University Medical Center itself. It had much less to do with the VA than it did with location.

Today nearly a fifth of our population lives in rural settings and 16 years ago our Congress set up a system to ensure that 20% would have access to hospital care. I’ve read parts of the legalese, 42 CRF 485, Subpart F, that was the origin of the system, termed the Critical Access Hospital Program. In essence it defined a series of small facilities (no more then 25 beds) located 35 miles or more from the next inpatient facility (shorter distances allowed for mountainous roads). By 2010 nearly 25% of our hospitals fit the CAH definition; with exemptions granted to the various states, only 20% of those CAHs meet the initial distance requirements. The program gives them reimbursement advantages while exempting them from national quality improvement programs.

That last section made no sense to me. If we tried to upgrade healthcare for the estimated 6o million of us that live in rural areas, why wouldn’t we insist that those small hospitals join in whatever country-wide care-improvement programs that the urban facilities were mandated to participate in?

I went to the references on that issue; one came out in JAMA in 2006 with the title “Relationship between Medicare’s hospital compare performance measures and mortality rates.

The JAMA article looked at large numbers (1.9 to 4.4 million) of patients admitted to the CAH hospitals and to non-CAH hospitals for three common major illnesses: heart attacks, congestive heart failure (the short definition per the Mayo Clinic is your heart can’t pump enough blood to keep up with your body’s needs) and pneumonia over a ten-year period. They specifically looked at death rates and concluded they were worsening in rural areas and improving in urban ones.

Then I thought about healthcare in rural China. I don’t want to live there, but I keep being impressed by some of the things that huge and highly populated country is doing. But I’ve been aware that of the 1.3 billion inhabitants, half live in rural settings and don’t share in the advantages that appear to be happening in urban areas.

Medicine comes to the farm and village

So I Googled “rural healthcare in China” and found two articles of interest. One from the Bulletin of the World Health Organization in 1993 and said the barefoot doctor initiative had been faltering, the rural cooperative medical system was falling apart, there was an increase in poor, uninsured elderly and the 1978 policy shift to “Fee for Service” had favored the urban workers.

I found a recent update from February, 2013, in the Wall Street Journal online.  I subscribe to the paper copy of the WSJ, but was originally asked to pay $21.99 a month more for digital access. Finally I was given a way to look at the article free, but in order to print it would have had to order 50 copies. So I took notes instead.

China spent $125 billion since that 1993 timeframe and now 95% of its people have healthcare insurance and I bet they don’t call it “XiCare.” There are still huge disparities between rural and urban medical care and Health Minister Chen Zhu says they are encouraging doctors who’ve recently retired to take a stint in the rural areas, offering free education to new physicians who are willing to work there and (I wonder about this one) planning to lower exam standards for those to “aim to work in villages.”

They clearly see a need to improve their insurance coverage rates for severe medical problems; at present a villager with a catastrophic illness still has to pay 30% of the bill.

So both countries have a way to go, but at least have looked at the issue of disparities in how we take care medically of those who live in the city and those who live in a village or on a farm. We’ve got ~ a fifth of our citizens (and non-citizens) living out there; China has a worse situation with half of its population in the countryside.

It will be of great interest and equal importance to see who solves the problem and how.

Maybe, just maybe, we can learn from each other.

This is not our typical meal.

After diner I looked at recipes from Martha Rose Shulman’s book, The very best of Recipes for Health. Shulman writes a healthy food column in the New York Times online version. I’ve looked at it frequently and we recently purchased her book. Lynnette made a Quinoa and Tomato Gratin yesterday and we immediately added it to our “Keeper List.” A lot of the recipes are vegetarian (about 1/3 of our main meals fit in that category), but she’s got some turkey and fish dishes.

What sparked this column was a Pure Study report in JAMA dated April 17, 2013. The title is lengthy: “The Prevalence of a Healthy lifestyle among Individuals with Cardiovascular Disease in High-, Middle-, and Low-Income Countries” In 2009 an article in the American Heart Journal described the PURE Study, the Prospective Urban Rural Epidemiology Study. The World Health Organization defines epidemiology  as the analysis of the distribution and determinants of health-related states or events (including disease), and the application of this knowledge to the control of diseases and other health problems.

The PURE Study began with a premise we’re all (hopefully) familiar with; over the past 50-60 years we’ve seen an epidemic of obesity, diabetes and cardiovascular disease in much of the world, especially in countries, like the United States, where many smoke, eat too much of the wrong foods and exercise too little

Let’s start with smoking in this country. The CDC published data online from a 2010 study that said over 19% of adult Americans smoked cigarettes. Over a fifth of those aged 18 to 64 were in this group, but only 9.5% of those over 65. Hispanics (12.5%) and Asian-Americans (9.2%) did better than whites or blacks, but over 30% of American Indians and Alaska Natives were smokers.

Smoking percentages went sharply down with more education: 45.2% of those with a GED smoked, 23.8% of those with a high school diploma, under 10% of people who had graduated from college and 6.3% of those with a postgraduate degree.

Similarly those living below the poverty level were more likely to be smoker (28.9%) than those with incomes at or above that level (18.3%).

There’s lots of data linking obesity, low-quality diets, and lack of exercise with cardiovascular disease including heart attacks and stroke. How one defines a low-quality diets varies around the world; living here, I thinks it’s lots of fast food and little emphasis on fruits and vegetables.

As a young physician I saw many patients who didn’t seem to get the message that their unhealthy lifestyle may well have contributed to their cardiovascular disease. When I was 53 my four-year-older brother died of a heart attack. Almost all of the rest of the family lived to 90 or longer, but he had smoked two to three packs of cigarette a day, gained fifty or so pounds and seldom exercised. If I had a heart attack or a stroke and survived, I’d look closely at my risk factors and try to do something about them.

The PURE study following over 150,000 adults (ages 35 to 70) in over 600 urban and rural settings in 17 different countries. This article discussed 7519 participants who had already had either a stroke or coronary artery disease and determined if they had stopped smoking, altered their eating habits and/or gotten more exercise.

The results were striking, but not at all amazing to me. Guess what proportion improved in all three arenas.

4.3%

Over fourteen percent of these post-cardiovascular-event adults didn’t take up any of the three logical behavior changes.

That made no sense to me. Could it be genetic pre-programming? Let’s look at data on one of the three behaviors.

A rodent exercise machine

The New York Times had a recent online article titled, “Why we’re motivated to Exercise or Not.” Scientists at the University of Missouri took ordinary lab rats and put running wheels in their cages; They bred the males and females who were the most active to each other and did the same to those who ran the least. They continued this over ten generations and ended up with two disparate groups: one ran ten times as much as the other.

They examined the physiques of the rodents to see if one group was fat or had poor muscle tone: no significant differences were found. Then they examined genes in the reward portion of the rats’ brains; the part that gives motivation to do things because they cause enjoyment. Lots of differences were noted here.

Does that mean those of us who exercise do so because we’re genetically predisposed to do so and the rest are doomed to be sluggards?

The lead investigator, Dr. Frank Booth, thinks it’s quite probable that humans have a genetic motivation to exercise or not. But he’s quoted as saying his results “are not meant to be an excuse not to exercise.”

And that’s without having the added incentive of having had a heart attack or a stroke.

What does it take to change our habits of a lifetime?

At my age, I’m not scheduling this.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Why does this make sense?

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

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

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

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

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

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

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

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

A sign for our times

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

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

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

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

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

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

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

Don’t handle these in any form, kids!

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

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

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

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

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

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

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

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

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

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

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

Let’s leave most of this salt sitting there.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Text messages should make sense.

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

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

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

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

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

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

The upper chambers receive blood and lower chambers pump it out

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

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

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

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

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

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

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

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

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

These come in handy

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

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

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

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

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

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

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

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

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

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