Better Treatment for Shoulder Replacement?

 

Working at a physical therapy clinic, I do see a great deal of injuries but there are still many that I have never seen before. One of these being a reverse shoulder arthroplasty, which involves the tearing of the rotator cuff tendon in the shoulder due to arthroplasty, which is basically a disease of the joint that leads to nerve damage and issues of individual joints (Rugg 2019: Barco 2017). This type of rotator cuff surgery has been utilized in recent years as a new way to treat this injury. For the surgery, the surgeon will remove the damaged bone and screw in a metal ball into the shoulder socket and then a plastic cup or opening for the ball is placed on the upper humerus. This is the reverse of what happens in a conventional shoulder replacement (Rugg 2019: Barco 2017: Kirzner 2018).  Especially people who have no arthritis in their joints now have a reliable option in what treatment they would like to undertake. There are different ways that a person can go about their treatment and it is important that further research is made to uncover what the best possible treatment is (Kirzner 2018).

This is especially important because while this type of surgery is very helpful there are also certain side effects or complications that can occur for some individuals. The most common complications for this kind of surgery are infection, nerve damage, fractures of other bones, and possibly misalignment of the ball and socket (Barco, 2017). However, these issues can all be reduced by having the surgeon managing tissue damage and paying close attention to how the new ball and socket interact with each other. Another way to reduce this, especially in congruence with physical therapy, is meaningful recovery and rehabilitation. It is not an easy surgery to recover from and it takes time to heal fully recover. If strengthening and improving flexibility are components of the treatment it should be a speedy and safe rehabilitation. This was a very interesting and informative operation that I look forward to learning more about as I continue my path of being a physical therapist. I do agree that more research does need to be conducted to produce the best treatment for individuals with this injury.

Kirzner, N., Paul, E., & Moaveni, A. (2018). Reverse shoulder arthroplasty vs BIO-RSA: clinical and radiographic     outcomes at short term follow-up. Journal of orthopaedic surgery and research, 13(1), 256.https://doi.org/10.1186/s13018-018-0955-2

Rugg, C. M., Coughlan, M. J., & Lansdown, D. A. (2019). Reverse Total Shoulder Arthroplasty: Biomechanics and Indications. Current reviews in musculoskeletal medicine, 12(4), 542–553. https://doi.org/10.1007/s12178-019-09586-y

Barco, R., Savvidou, O. D., Sperling, J. W., Sanchez-Sotelo, J., & Cofield, R. H. (2017). Complications in reverse shoulder arthroplasty. EFORT open reviews, 1(3), 72–80. https://doi.org/10.1302/2058-5241.1.160003

Altered Mental Status: a COVID-19 symptom?

    As COVID-19 continues to impact patients and healthcare across the world, research indicates new presenting clinical symptoms. We all know the symptoms for COVID-19: fever, cough, shortness of breath, sore throat, loss of taste/smell.  From my experience, it was never quite as straight-forward.

    I worked on a COVID-19 unit March-May. The patients were in critical conditions; most had little chance of survival on the ventilator, were waiting to be placed on mechanical ventilation, or were in hospice. I noticed rapid decreased mental status in my patients. Upon admission, patients were alert and oriented. As days went on, patients became confused, had vivid hallucinations, and some became combative. Some patients had only altered mental status with no other COVID-19 symptoms. This leads me to wonder how COVID-19 impacts the brain and nervous system.

In a study focusing on the neurological effects of COVID-19, 36% had neurological manifestations. Patients with more severe infection had more neurological manifestations (Mao, et. al, 2020). These neurological manifestations in the patients with severe infection were cerebrovascular disease, impaired consciousness, and skeletal muscle injury. 

A recent study from Neurological Sciences discusses two patients in their 60’s diagnosed with COVID-19, both requiring mechanical ventilation. Both patients were started on heparin after admission. Both patients had increased levels of C-reactive proteins, involved in inflammatory responses, and increased D-dimers, involved in degradation of fibrinogen (Díaz-Perez, et. al, 2020). After waking up, both patients had altered mental status. Brain MRI’s on both cases showed ischemic lesions and areas of hemorrhagic transformation (Díaz-Perez, et. al, 2020). Hemorrhagic transformation is secondary bleeding, often associated with ischemic infarction (Internet Stroke Center). Ischemic infarction is also referred to as the “silent stroke”; a brain injury likely caused by blood clot (American Stroke Association). Researchers conclude that altered mental status in COVID-19 patients may be due to multiple brain infarctions (Díaz-Perez, et. al, 2020). 

Why do we care? How do we ensure those who have survived COVID-19 don’t have detrimental health issues, and if they do, how do we provide resources to improve their quality of life? As healthcare providers, it’s vital that we care for each person as a whole, cura personalis; we can’t just treat the symptoms in order to do good (beneficence). We must ensure these patients survive, and their quality of life isn’t impacted. This can only be done by more in-depth research to ensure we do no harm (non-maleficence). 

 

Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683–690. doi:10.1001/jamaneurol.2020.1127

Díaz-Pérez, C., Ramos, C., López-Cruz, A. et al. Acutely altered mental status as the main clinical presentation of multiple strokes in critically ill patients with COVID-19. Neurol Sci 41, 2681–2684 (2020). https://doi-org.dml.regis.edu/10.1007/s10072-020-04679-w

“The Internet Stroke Center.” The Internet Stroke Center. An Independent Web Resource for Information about Stroke Care and Research., www.strokecenter.org/professionals/brain-anatomy/cerebral-embolism-formation/hemorrhagic-conversion/. 

“Ischemic Strokes (Clots).” Www.stroke.org, www.stroke.org/en/about-stroke/types-of-stroke/ischemic-stroke-clots. 

Get a Vaccine, Prevent Cancer

  As a medical assistant in a primary care office and vaccine for children coordinator, a big part of my job was to push for vaccines for our patients. Of the many vaccines, there is one in particular that is difficult to discuss with individuals, the HPV vaccine. This is a vaccine, depending on one’s age, given in a two-dose series (under the age of 15) or three-dose series (at or over the age of 15) to protect against Human Papilloma Virus which is the most common sexually transmitted disease (White, 2014). There are low and high risk strains associated with HPV. The low risk strains are mild, patients generally do not even know they have this, and it will resolve with time. However, high risk strains are known to cause cancer and/or genital warts in the expressed area. This means that contracting high-risk HPV strains can greatly increase our risk of anogenital, vaginal, penile, and oropharyngeal cancers (White, 2014). HPV infection is responsible for half a million cases of cancer and more than 250,000 deaths every year (White, 2014).

As a vaccine coordinator, it is easy for me to say get this vaccine and prevent the spread of the infection, prevent cancers, and genital warts, however there are also many arguments against the HPV vaccine. Many patient’s receiving the vaccine are young, around the age of 11-15 and so it is difficult to discuss a sexually transmitted disease with these teenagers and their parents. Most children do not want to discuss sexual activity with their parents, shocker! I would always try to foster this open discussion with the parent involved, but it’s a little easier to put it in the context of future protection. This vaccine will help protect the child when they are an adult and when they are sexually active. I also had to warn patients about how painful the vaccine is and then monitor response to the vaccine as it is known to cause dizziness and syncope (White, 2014). This is a big put off to many patients and parents as they simply don’t want the side effects. Religion is also something that comes into play. If one is to be celibate until marriage and experience sex for the first time with their one and only partner, then what is the point of getting this vaccine? It’s difficult to have the discussion of religion with children and their parents. Maybe their children do not become part of the religion or maybe they don’t follow celibacy, against their parent’s wishes.

I find the HPV argument interesting on either side. It ultimately comes down to beneficence versus autonomy. As a provider, you of course want to protect your patient against cancer, but you also want the decision to be up to them. Where do you stand? What will you say as a provider to your patient? 

Reference:

White MD. Pros, cons, and ethics of HPV vaccine in teens—Why such controversy? Transl Androl Urol 2014;3(4):429-434. doi: 10.3978/j.issn.2223-4683.2014.11.02

Ethics and Tradition in a New Pandemic Age

    

     It would seem to some that the COVID-19 pandemic came out of thin air. Sadly, this is far from the truth, and the vaccine that the masses are clinging to is merely a bandaid to what is to come if we maintain our current course (Pocock et al 2020). We have broken the tip of the iceberg, first with the outbreak of SARS in 2003, followed by variously named MERS, avian, and swine flus and now the global pandemic of COVID-19. All have a common denominator, humanity's cruel and destructive nature of every other species that inhibit the world we share. The intense abuse of animals is not a new idea; however, we are yet to recognize the connection of our demise and their infinite torture. 

    To be clear, the abuse of animals is widespread. Factory farms are a global phenomena. 

A common example of breaches in animal welfare are the wet markets throughout Asian, primarily China. To a common American the idea of caging and consuming some of our worlds’ most exotic creatures is barbaric; however, do not be quick to judge and take a longer look at our consumption and treatment of livestock. We must attempt to understand the deeper complexities of why such markets exist. China has a deeply rooted culture and tradition surrounding the wet markets and they will not be going anywhere anytime soon (Zhu et al. 2020). Yet it still stands, there is still an outstanding connection between the slaughter of wildlife and global pandemics (Zhu et al. 2020). 

     

    Hyper-globalization and the systematic butchering of wildlife has only increased the odds of global exposure to deadly diseases (Aguirre et al. 2020). Likewise, the continual encroachment of human life on dwindling wildlife reserves exponentially increases the potential for novel disease transfer (Aguirre et al. 2020). Animal ethics is synonymous with human ethics, we must begin to see clearly our connection to the world we continue to destroy. 

References

Aguirre, A. A., Catherina, R., Frye, H., & Shelley, L. (2020). Illicit Wildlife Trade, Wet Markets, and COVID‐19: Preventing Future Pandemics. World Medical & Health Policy, 12(3), 256–265. https://doi-org.dml.regis.edu/10.1002/wmh3.348

Pocock, L. (2020). Pandemics and a New Age of Reason. Middle East Journal of Business, 15(2), 3–35. https://doi-org.dml.regis.edu/10.5742MEJB.2020.93826 

Zhu, A., & Zhu, G. (2020). Understanding China’s wildlife markets: Trade and tradition in an age of pandemic. World Development, 136, 105108. https://doi-org.dml.regis.edu/10.1016/j.worlddev.2020.105108

Charcoal Toothpaste and Its Effectiveness

 

Toothpaste is in all of our lives, and we use it on a daily basis to maintain a healthy oral hygiene. Since this is the case it is probably important that we pick the best and most effective toothpaste to use, one that will brighten our smile, freshen our breath, and keep the cavities away. That being said, charcoal toothpaste brands have been on the rise in popularity, touting all of these benefits and claiming to be superior to the boring old school toothpaste we all use. I myself once thought about giving it a shot but decided otherwise before doing any research. First off, the most important component of any toothpaste is Fluoride. Fluoride acts as a shield for our teeth and can affect the metabolism of bacteria. This is primarily done by inhibiting enzyme functions bacteria need in order to grow and replicate (Marquis, 1995). As long as a toothpaste contains Fluoride, which most do, it will do its job.

Its also important to know that the mechanical force of brushing our teeth is what cleans them, from that point on Fluoride acts to keep them clean for a time. Charcoal toothpaste does both of these things, however research has shown that beyond what basic toothpaste can do, there is no evidence that charcoal toothpaste whitens teeth (Franco et al., 2020). Its also important to avoid a toothpaste that is too abrasive which can cause a loss of enamel over time and charcoal infused toothpaste is known to be one of the most abrasive. At the end of the day, all of us as consumers would not want to be paying extra for toothpaste that is not necessary.

References:

Franco MC, Uehara J, Meroni BM, Zuttion GS, Cenci MS. The Effect of a Charcoal-based Powder for Enamel Dental Bleaching. Oper Dent. 2020 Apr 3. doi: 10.2341/19-122-L. Epub ahead of print. PMID: 32243248.

Marquis RE. Antimicrobial actions of fluoride for oral bacteria. Can J Microbiol. 1995 Nov;41(11):955-64. doi: 10.1139/m95-133. PMID: 7497353.

Out of Depression and Into a K-Hole

    While working in an emergency department (ED), I was surprised by the variety of uses for ketamine, including pain management, procedural sedation, analgesia, and calming the all-too-frequent agitated patient. When given a higher dose, typically for procedural sedation, patients are said to fall into a "k-hole". Ketamine has many advantages in emergency medicine as it is fast and short acting, is an alternative to opioids, can be given in multiple routes (intravenous, intramuscular, intranasal, and oral), and preserves airway patency (Sheikh, S., Hendry, P., 2017). More recently, researchers have been exploring other uses for ketamine including treatment for depression and suicidality.

    I was exposed to a diverse patient population and wide variety of complaints working in an ED in the Denver Metro Area. There was no shortage of individuals who presented for mental health issues, whether it be for an anxiety attack, suicidal thoughts, or a suicide attempt. Patients who are placed on an “M1”, a psychiatric hold for 72 hours, receive a psychiatric evaluation and are sometimes admitted to the hospital. There has been no scientific evidence showing that inpatient psychiatric hospitalization decreases the chances of these individuals completing a suicide attempt in the future (Scott, J., 2020).

    In a randomized, double-blind, placebo-controlled, proof-of-concept trial completed at the University of Alabama, researchers studied 18 depressed patients with acute suicidal ideation who required hospitalization. Nine individuals received a single dose of of IV ketamine, and nine in the placebo group received a bolus of saline. Ninety minutes after infusion, 33% of the placebo group achieved remission of suicidal ideation, compared to 88% of the ketamine group. These effects seemed to linger for roughly three days (Domany Y., Shelton RC., McCullumsmith CB., 2020). These results support further study of ketamine for depression and suicidality, and potentially other disorders such as PTSD or anxiety.

References:

Domany Y, Shelton RC, McCullumsmith CB. Ketamine for acute suicidal ideation. An emergency department intervention: A randomized, double-blind, placebo-controlled, proof-of-concept trial. Depression & Anxiety (1091-4269). 2020;37(3):224-233. doi:10.1002/da.22975.

Scott, J., 2020. Ketamine For Depression And Suicidality. [podcast] Emergency Medical Minute. Available at: <https://emergencymedicalminute.com/podcast-584-ketamine-for-depression-and-suicidality/> [Accessed 27 September 2020].

Sheikh, S., Hendry, P. (2017). Why Emergency Departments Love Ketamine [PowerPoint presentation]. Pain Week, Las Vegas. https://rsds.org/wp-content/uploads/2017/10/EMD-04-Why-EDs-Love-Ketamine-Hendry-and-Sheikh-9.4.16-HW.pdf

Circadian Phase Shift in Pre-School Aged Children

In the summer of 2019, I worked as an undergraduate research assistant in the CU Sleep and Development Lab where we studied how light exposure at night shifts circadian rhythm in pre-school aged children. There is a lot of research on the effects of light exposure in adults, but there is limited research on the effects in children. In adults, one study found that light exposure during the biological night, as short as 15-seconds, created significant phase delays (Rahman, et al., 2017). A phase delay means that a person secretes melatonin later than normal as a response to an environmental cue (light).

 

So, who cares, and why study this in children? Well, it is also known that circadian timing plays a very important role in almost all physiological functions, and a disturbance in circadian timing may lead to cognitive impairment, mood disturbances, and cardiometabolic disorders (Zee, Attarian, Videnovic, 2013). Further, it also known that children have distinct physiological differences compared to adults such as wider pupils and a clearer lens of the eye. This led us to believe that children would be more sensitive to light exposure. Thus, the birth of our lab. There is still a year left on the grant, but preliminary data we collected during the summer of 2019 suggests that pre-school aged children are extremely sensitive to light exposure. We were seeing phase delays in children at light intensities as low as 1 lux. For reference, the brightness of 1 lux is defined as the brightness of 1 candle from 1 meter away, so this is very dim.  

 

Now, the main application of this research is related to the large amount of screen time we see today in children. Whether it is television, cell phones, or video games, screen time is a huge part of American culture. As healthcare providers, it is important that we are up to date with the most recent literature to provide the best advice to our patients (beneficence: do the most good for our patients). Parents need to be aware that there are health risks to screen time after bed, and now it is up to them if they desire to find another way to coax their kids to bed besides the highly effective method of screen time (autonomy: make their own decision for their kids after they are given all the information).

 

References

 

Rahman, S. A., St Hilaire, M. A., Chang, A. M., Santhi, N., Duffy, J. F., Kronauer, R. E., Czeisler, C. A., Lockley, S. W., & Klerman, E. B. (2017). Circadian phase resetting by a single short-duration light exposure. JCI insight, 2(7), e89494. https://doi.org/10.1172/jci.insight.89494

 

Zee, P. C., Attarian, H., & Videnovic, A. (2013). Circadian rhythm abnormalities. Continuum (Minneapolis, Minn.), 19(1 Sleep Disorders), 132–147. https://doi.org/10.1212/01.CON.0000427209.21177.aa

Exercise in a Bottle?

     Would you try taking an enzyme pill to improve your productivity instead of waking up early for a morning sweat session? We know that exercise improves cardiovascular health, memory, learning and cognition, but we don't fully understand the mechanisms that underlie brain benefits of exercise (Allendorfer, 2018). The National Institutes of Health is even funding a $170 million dollar initiative called the Molecular Transducers of Physical Activity Consortium to answer these kinds of questions (Molecular Transducers of Physical Activity in Humans, n.d.). But is it possible that many of the cognitive benefits of exercise can be traced back to just one enzyme? 

    A study published in July in Science asked this very question (Horowitz et al. 2020). The researchers aimed to see whether blood transfusions could transfer the cognitive benefits of exercise to sedentary mice. To test their research question, they gave one group of mice wheels to run multiple miles a day on, and kept other mice relatively still. They gave the sedentary mice eight blood transfusions a week for three weeks from the active mice, and then tested them all memory and learning skills. They found that sedentary mice who received blood transfusions had double the number of neurons in the hippocampus as a control group, and performed similarly to the active mice on memory and learning tasks. The main blood composition difference between the two groups of mice was an enzyme called glycosylphosphatidylinositol specific phospholipase D1 (Gpld1). This was the likely agent for the cognitive benefits of exercise. To see if analogies could be drawn between mice and humans, they looked at the Fitbit activity of older adults and compared it to their blood Gpld1 concentration. They found that the most active adults had the highest concentration of Gpld1, suggesting that the enzyme might function similarly in humans. 

    Given the physiological relevance of Gpld1 to humans, there are some pretty cool clinical implications. Wouldn't it be incredible if fragile, elderly, or physically disabled patients could take this enzyme and improve brain function? Although Saul Villeda, the principle researcher of this study, cautions against getting too excited about "exercise in a bottle" anytime soon, he is enthusiastic that this research could become the basis for a new therapy for patients who cannot exercise (Scientists Discover Enzyme that could result in a Drug Substitute for Exercise, 2020).

References

Allendorfer, J. B., & Bamman, M. M. (2018) Getting the Brain into Shape: Exercise in Neurological Disorders. Clinical Therapeutics, 40(1), 6-7. 

Horowitz A. M., Fan, X., Bieri, G., Smith, L. K., Sanchez-Diaz, C. I., Schroer, A. B., Gontier G., Casaletto, K. B., Kramer, J. H., Williams, K. E., & Villeda, S. A., (2020). Blood factors transfer beneficial effects of exervise on neurogenesis and cognition to the aged brain. Science, 369(6500),167-173.

Molecular Transducers of Physical Activity in Humans. (n.d.). Retrieved September 24, 2020, from https://commonfund.nih.gov/moleculartransducers

Scientists Discover Enzyme that Could Result in a Drug Substitute for Exercise. (July 9, 2020). NPR.Org. Retrieved September 24, 2020 from, https://www.npr.org/2020/09/09/889502165/scientists-discover-enzyme-that-could-result-in-a-drug-substitute-for-exercise

Are You (or Your Water Preference, Rather) Basic?

    I was not surprised to see my friend pull out a bottle of water when we reached the peak of our hike this past weekend, but I was surprised to see the pH was labeled in large print as being above 9! Drinking enough water is important for countless reasons, but should we start paying attention to the type of water we ingest? Is the new artificial alkaline water fad potentially dangerous? Supposedly the theory behind the benefit of drinking alkaline water is that it counter-balances extra acid in the body. Pepsin is the major digestive enzyme in our stomach and is also the protein responsible for producing acid reflux. Therefore, there are potential benefits for someone who experiences frequent episodes of acid reflux to inactivate pepsin by drinking alkaline water (Koufman J., Johnston, N, 2012). I was unable to find human subject experiments relevant to potential medicinal use of alkaline water otherwise. Either way, it seemed dangerous to attempt to overcome the body’s homeostatic mechanisms, especially on the top of a mountain! However, there is much controversy regarding the risks and benefits of drinking artificial alkaline water. 

    Those who argue against intaking artificial water with an unnatural pH explain our body’s buffering system. Our body tries to maintain a pH around 7.4, and homeostatic mechanisms are at risk of being disrupted from drinking an excess of basic water. Without conscious thought, if our blood does become too acidic, we increase our respiratory rate to exhale more carbon dioxide and our renal system kicks in to excrete the excess acid in our urine (Patel, 2020).

    Those who argue for drinking alkaline water point out the benefits of reducing acidity in our body. An acidic environment can be created from several environmental factors, internal stresses, and diet. Alkaline water may balance out the acidic environment to protect our organ systems (Chycki, Kurylas, Maszczyk, Golas, & Zajac, 2018). Alkaline water also contains a larger abundance of magnesium and calcium to maintain the integrity of bones (Magro et al., 2016).

What type of water will you pack next time you take a hike?

References:

Chycki, J., Kurylas, A., Maszczyk, A., Golas, A., & Zajac, A. (2018, November 19). Alkaline water improves exercise-induced metabolic acidosis and enhances anaerobic exercise performance in combat sport athletes. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6242303/

Magro, M., Corain, L., Ferro, S., Baratella, D., Bonaiuto, E., Terzo, M., . . . Vianello, F. (2016). Alkaline Water and Longevity: A Murine Study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4906185/

N;, K. (2012). Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease. https://pubmed.ncbi.nlm.nih.gov/22844861/

Patel, S. (2020, June 24). Respiratory Acidosis. https://www.ncbi.nlm.nih.gov/books/NBK482430/ 

A New Approach to Migraines

If you’ve ever experienced a migraine you know how debilitating they can be. Now imagine suffering from episodic migraines and having up to 14 migraine days a month or having chronic migraines and having at least 15 migraine days a month. That’s what I was going through during my junior year of undergrad. I was having up to 13 migraine days a month and my quality of life took a large hit. I started missing class on a semi-regular basis since my migraines were both light and sound sensitive. Most days I could hardly leave my room because my migraines were so debilitating. I’m sure many of you have seen the TV commercials for medications such as Emgality or Aimovig, and if you have seen these commercials you know that they do not provide information as to how these medications work.

 

I have been using the migraine medication Ajovy for 15 months now and I can tell you that this medication has significantly improved my quality of life. The medications Emgality, Aimovig, and Ajovy all work in similar ways. The patient gives themself a subcutaneous injection monthly or quarterly depending on the specific medication and severity of their migraines. All of these medications are monoclonal antibodies against the calcitonin gene-related peptide (CGRP) itself or its receptor (González-Hernández et. al., 2020). Monoclonal antibodies are broken down by renal proteolysis into short peptides and amino acids (González-Hernández et. al., 2020). This breakdown does not result in any toxic intermediates meaning that the liver will not be damaged in any way (González-Hernández et. al., 2020). It has been found that the pathophysiology of a migraine consists of a critical neurophysiology state that results in a low plasma concentration of serotonin, and a high plasma concentration of CGRP (González-Hernández et. al., 2020). The release of CGRP results in vasodilation and sensitization of nociceptive pathways (González-Hernández et. al., 2020). Being able to prevent this release is the goal of antimigraine medications. Ajovy and Emgality work by scavenging the circulating CGRP molecules whereas Aimovig works against the receptor itself (González-Hernández et. al., 2020). The most common adverse reaction is an injection site rash (Ajovy-pi.pdf. n.d.). Both monthly and quarterly injections of Ajovy have shown statistically significant improvement when compared to a placebo (Ajovy-pi.pdf, n.d.). Overall, these medications have been shown to be very effective and have very minimal side effects.

 

References: 

Ajovy-pi.pdf. (n.d.). Retrieved September 18, 2020, from https://www.ajovy.com/globalassets/ajovy/ajovy-pi.pdf 

 

González-Hernández, A., Marichal-Cancino, B. A., Gracía-Boll, E., & Villalón, C. M. (2020). The locus of Action of CGRPergic Monoclonal Antibodies Against Migraine: Peripheral Over Central Mechanisms. CNS & Neurological Disorders – Drug Targets, 19. http://doi.org/10.2174/1871527319666200618144637

Why COVID-19 Is Ruining Our Eyes

I am not going to sit here and write about the pandemic, there are plenty of articles available to read about that. What I do want to talk about is the ongoing myopia epidemic and the unknown “myopia boom” we might experience during this digital time. 

Myopia is the inability to see things clearly far away and occurs when the eye is elongated, so the image is focused in front of the retina. It was expected that half of the population will become myopic by 2050. Data from the American Optometric Association revealed that one in four parents had a child with myopia in 2018, an increase of 25 percent from just 40 years ago. (Greenway, 2020). Although no one knows precisely why the eyes become elongated, some researchers believe that bringing something closer to view, like a tablet or phone, may cause this. 

This pandemic has caused many people to work and learn from home, increasing the time spent in front of screens. The internet has made it more convenient for people to still continue their days as normal, but what are the consequences? I believe children will face the biggest consequences, since their eyes are still growing. Myopia has already become a huge problem that Taiwan and Singapore have incorporated more outdoor activities into school time to reduce the onset of myopia. (Wong, Tsai, et. al., 2020). 

Blue light filter glasses have become the rage so help reduce eye fatigue, but there is no definitive evidence that they actually work. If you are experiencing eye-fatigue or headaches from long periods of screen time, I highly recommend the 20/20/20 rule. Every 20 minutes, you should be looking at something else 20 feet away for 20 seconds. 

Only time will tell what the effects of this pandemic will have on myopia, but I hope this brings light to be aware about your eye health.

References

Greenway, H. K. (2020, August 17). How to protect children's eyes during remote learning. The New York Times. Retrieved from https://www.nytimes.com/2020/08/17/parenting/kids-eyesight-distance-learning-coronavirus.html

Wong, C. W., Tsai, A., Jonas, J. B., Ohno-Matsui, K., Chen, J., Ang, M., & Ting, D. (2020). Digital Screen Time During COVID-19 Pandemic: Risk for a Further Myopia Boom?. American journal of ophthalmology, S0002-9394(20)30392-5. Advance online publication. https://doi.org/10.1016/j.ajo.2020.07.034

Appendectomies, are we doing them wrong?

    You're working in the emergency department, and a 24-year-old male comes in complaining of right lower quadrant abdominal pain that he has been experiencing for the past 4 hours. He is in obvious discomfort and complains of associated nausea and vomiting. Upon exam, you palpate the man's abdomen and find that he has exquisite tenderness with rebound to his right lower quadrant. As a good clinician, you run some labs and order a CT-abdomen. You think to yourself, "slam-dunk appendicitis." As you predicted, the radiology read confirms your diagnosis of acute appendicitis. As trained, you get a general surgery consult, who agrees to admit your patient for an appendectomy the following morning. You congratulate yourself and wish that all your cases were this straightforward. You did everything correct, right?

    The standard treatment of appendicitis in the US has been for a long time the emergent appendectomy. The reasons behind the urgent surgical removal of the appendix are to avoid complications such as the appendix rupturing and causing a sometimes deadly infection of the abdomen called peritonitis (Bhangu et al., 2015). Most American clinicians feel that surgical intervention is necessary to treat acute appendicitis, and to practice otherwise is negligent and dangerous. However, several European studies have investigated whether antibiotics are more effective and safer in treating appendicitis. A study in Finland found that about 80% of appendicitis cases are uncomplicated and do not require surgical intervention (WebMD, 2020). The study found that they could successfully treat 186 of 256 (about 73%) patients with antibiotic therapy alone (Salminen et al., 2015). Obviously, antibiotic treatment for appendicitis is not a perfect treatment. However, if the treatment is successful, patients would have fewer medical bills, shorter recovery time, and no scarring. Additionally, the patient would not have to be burdened with the postoperative complications associated with appendectomies estimated to be at 9% (Bettina, 2020). If you or your family member were the patient, would you like to choose between antibiotics or an appendectomy? Why do you think that nonsurgical approaches are favored in some European countries? I think that it is essential that the medical practices in other countries are taken into consideration as they may be beneficial to the patient's best interest in the US.

References: 

Appendicitis Can Often Be Treated With Antibiotics. (n.d.). WebMD. Retrieved September 19, 2020, from https://www.webmd.com/digestive-disorders/news/20150616/appendicitis-can-often-be-treated-with-antibiotics

Bettina, K. (2017). Clinical Value of Postoperative C-reactive Protein in the Detection of Complications After Open and Laparoscopic Appendectomy (Clinical Trial Registration No. NCT03119740). clinicaltrials.gov. https://clinicaltrials.gov/ct2/show/NCT03119740

Bhangu, A., Søreide, K., Di Saverio, S., Assarsson, J. H., & Drake, F. T. (2015). Acute appendicitis: Modern understanding of pathogenesis, diagnosis, and management. The Lancet, 386(10000), 1278–1287. https://doi.org/10.1016/S0140-6736(15)00275-5

Salminen, P., Paajanen, H., Rautio, T., Nordström, P., Aarnio, M., Rantanen, T., Tuominen, R., Hurme, S., Virtanen, J., Mecklin, J.-P., Sand, J., Jartti, A., Rinta-Kiikka, I., & Grönroos, J. M. (2015). Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA, 313(23), 2340–2348. https://doi.org/10.1001/jama.2015.6154

Going Vegetarian… Worth All The Hype?

These days, there are many diets making their way around crowds- keto, paleo, vegan, and so many more! Vegetarian diets are becoming more popularized with new foods such as the Impossible burger or seitan, tofu, and tempeh. But, is it worth the hype? According to Tuso et al. (2013), Plant based diets are shown to be more cost effective and can lower BMI, blood pressure, and cholesterol levels while also reducing heart disease rates. Tuso et al.’s (2013) study makes a strong claim that physicians should recommend vegetarian diets to patients who are at risk of diabetes, obesity, blood pressure, and cardiovascular disease. 

A 63-year-old man was used as a case study in  Tuso et al.’s (2013) review. He was a hypertension patient diagnosed with type 2 diabetes. He was noted to be on several medications with varying dosages and then was advised to go vegetarian. His diet consisted of non-starchy vegetables, less refined food, beans, nuts and seeds. After 16 weeks, significant improvement was noted. So much so, that the physician was able to wean the patient off medication he thrived on earlier, with the exception of diabetes medication. 

According to Medawar et al. (2019), plant-based diets were also found to improve gut microbiome. The same study found that individuals following a vegetarian diet tended to have better bacteria floras due to protein fermentation processes. One main concern with plant-based diets is the lack of Vitamin B12. However, this vitamin can be found in milk, eggs, mushrooms, and certain fortified cereals. A vegan diet has higher concern for this lack of nutrients; however, the vegetarian diet is more well rounded. 

So… Is it worth all the hype? You decide!

Medawar, E., Huhn, S., Villringer, A., & Veronica Witte, A. (2019). The effects of plant-based diets on the body and the brain: a systematic review. Translational Psychiatry, 9(1). https://doi.org/10.1038/s41398-019-0552-0

Tuso, P. (2013). Nutritional Update for Physicians: Plant-Based Diets. The Permanente Journal, 17(2), 61–66. https://doi.org/10.7812/tpp/12-085

So Matcha Better

Are you stressed? Tired? Drinking three cups of vanilla soy latte a day to get you by? If you answered “yes” to all these questions, then you may want to consider switching from coffee to matcha tea. Matcha tea is comprised of many helpful agents including L-Theanine. It also contains caffeine, albeit less than what you would find in coffee. According to Monobe et al. (2019), L-Theanine, which is not found in coffee, has been seen to be most helpful for lowering stress as well as increasing alertness and concentration. It is also a major component of how we process caffeine. With coffee, you may have immediate effects of caffeine which can often lead to jitters, increased heart rate, or even the post-coffee crash (Bennington, 2018). This may cause additional discomfort and difficulties in focusing. With matcha tea, these effects are counteracted due to L-Theanine as it provides a slower, more long-lasting pathway for caffeine (Monobe et al., 2019). Although containing smaller amounts of caffeine, you can stay alert longer without experiencing the discomfort you would feel with coffee. This combination of L-Theanine and caffeine has deemed itself worthy of providing people with a better, healthier alternative than coffee. 

References

Bennington, K. (2018, Dec. 30). L-Theanine & Caffeine: Boost Your Morning Coffee and Never Go Back. https://isum.com/l-theanine-caffeine/

Monobe, M., Nomura, S., Ema, K., & Horie, H. (2019). Influence of continued ingestion of matcha on emotional behaviors after social stress in mice. Bioscience, biotechnology, and biochemistry, 83(11), 2121–2127. https://doi.org/10.1080/09168451.2019.1637713

The Ketogenic Diet as a Treatment for Epilepsy

My experience working on a pediatric and adult neurology unit has allowed me to take care of patients suffering from epilepsy. Many of these patients were admitted to the hospital to trial the ketogenic diet as an alternative treatment for their drug-resistant epilepsy. About one-third of epilepsy patients do not respond well to anti-epileptic drug treatment and recent research has shown that the ketogenic diet has decreased seizure frequency and improved cognitive function (Ułamek-Kozioł, Czuczwar, Januszewski, & Pluta, 2019). This diet is high in fats and low in carbohydrates, which allows the body to metabolize ketone bodies rather than glucose for energy. Ketone bodies are substances that are synthesized in the liver during times of fasting and starvation. It is suspected that decreased glucose consumption may affect the potassium channels on neurons, resulting in a hyperpolarization of the membrane. A hyperpolarization of neuron cells means that potassium ions (K+) are being pumped out of the cells. This prevents excessive neuronal firing and subsequently increases seizure threshold (Ułamek-Kozioł, et al., 2019). An increased seizure threshold means that it is less likely for a seizure to occur.

Further research must be conducted to evaluate the therapeutic efficacy of the ketogenic diet for epilepsy patients. This is because the mechanisms in which the ketogenic diet effects brain function are largely unknown and can have different targets within the body. With respect to anti-epileptic therapies both drug and diet changes, the ketogenic diet should be considered as a first-line treatment because it is less invasive and has shown various improvements in seizure frequency and cognitive function. When evaluating the four main biomedical ethical values, this topic considers patient autonomy and beneficence. Patients suffering from epilepsy should be provided with education regarding available treatments and the risks and benefits of each treatment. This allows patients to exercise their autonomy by choosing which treatment could potentially work best for them. Additionally, implementing the ketogenic diet as a therapy for epilepsy also involves beneficence. Medical professionals that provide patients with this treatment option are doing good by the patient because they are offering a less invasive and economically sustainable treatment option as opposed to drug therapy.   

Ułamek-Kozioł, M., Czuczwar, S. J., Januszewski, S., & Pluta, R. (2019, October 18). Ketogenic Diet and Epilepsy. Retrieved September 08, 2020, from https://www.mdpi.com/2072-6643/11/10/2510/htm

Rocky Flats Nuclear Plant

Rocky Flats Plant was a nuclear weapons plant that was located 16 miles northwest of downtown Denver. Workers used plutonium to build nuclear weapon triggers from 1952-1989. In 1969 a fire broke out at the plant confirming for the first time, that radioactive materials had escaped off-site. The fire quickly spread as many of the fire alarms had been removed to make room for more production. This facility was lacking in ethical values, specifically beneficence and non-maleficence. The plant was producing nuclear weapons which brings harm to both the workers and the public. Removing the fire alarms risks the lives of other people. By 1989, manufacturing of plutonium stopped. 

My grandfather was a chemical operator at Rocky Flats for 26 years. In 2007 he was diagnosed with multiple myeloma in his hip bone, ribs, and spine. He underwent chemotherapy and eventually developed pneumonia while in the hospital that led to his death in 2008. Studies have suggested that there is an increased likelihood of developing multiple myeloma for those who have been exposed to ionizing radiation such as plutonium (Center for Environmental Health Studies, n.d.). Another study looked specifically at mortality rate of workers from three nuclear plants including Rocky Flats and found that multiple myeloma was the only cancer found to show a statistically significant correlation with radiation exposure (Gilbert, E.S. et al., 1989).

Multiple myeloma is a malignancy of plasma cells. This results in overproduction of light and heavy chain monoclonal immunoglobulins. Multiple myeloma tends to present with bone destruction, hypercalcemia, anemia, renal damage, and increase susceptibility to infection. The pathogenesis of multiple myeloma is poorly understood; however, it appears to reflect a chromosomal abnormality with many translocations involving chromosomes 12 and 14 (Alexander, D., 2007). As unstable radioactive isotopes decay, they release energy that can cause damage to a cell’s DNA which fuels mutations that can eventually lead to cancer (Ghose, T., 2017). Unfortunately, studies on multiple myeloma and plutonium are limited and the mechanisms are not well understood.

 

References:

Alexander, D., Mink, P., Adami, H., Cole, P., Mandel, J., Oken, M., & Trichopoulos, D. (2007, April 02). Multiple myeloma: A review of the epidemiologic literature. Retrieved September 06, 2020, from https://onlinelibrary.wiley.com/doi/full/10.1002/ijc.22718

Center for Environmental Health Studies. (n.d.). Multiple Myeloma (MM) and Exposure to Ionizing Radiation ... Retrieved September 6, 2020, from http://www2.clarku.edu/mtafund/prodlib/jsi/Multiple Myeloma_and_Exposure_to_Ionizing_Radiation.pdf

Ghose, T. (2017, May 10). Hanford Disaster: What Happens to Someone Who's Exposed to Plutonium? Retrieved September 06, 2020, from https://www.livescience.com/59042-how-does-plutonium-damage-the-body.html

Gilbert, E. S., Fry, S. A., Wiggs, L. D., Voelz, G. L., Cragle, D. L., & Petersen, G. R. (1989). Analyses of Combined Mortality Data on Workers at the Hanford Site, Oak Ridge National Laboratory, and Rocky Flats Nuclear Weapons Plant. Radiation Research, 120(1), 19. doi:10.2307/3577633

Hairy Mouth

This past year I was working at a dental office that specialized in full mouth prosthetics as I was working for a prosthodontist. While seating a patient one day to remove their implants for a repair, I was caught completely off guard. Inside of the patients mouth around the area where they received a graft, hair was growing. Yes, you read that correctly. After the patient left, I immediately did research on how this could be possible. Turns out, the patient had undergone oral reconstructive surgery due to an accident. For this procedure the surgeon will typically use skin from another part of the body that grows hair as the graft. For many patients who receive this treatment, hair growing inside the mouth tends to be common as the hair follicles in the skin are still intact. Fascinating right?

 

So…what does one do was my next question? As it turns out, a collective study was done regarding treatment to stop the hair growth. Bains (2017), collected data based on cases that removed intraoral hair. As one can imagine, the options are limited. In most cases it was found that using a laser known as neodymium-doped yttrium aluminum garnet (Nd:YAG) was found to be the most successful at stopping the hair growth. Intraoral hair growth can cause physiological stress as it can lead to difficulty in speech and swallowing. While oral reconstruction surgery is crucial to many patients, in the future I hope that medical professionals can address with full autonomy the possible outcomes of their treatment. While having hair in the mouth is a minimal side effect of life altering dental construction surgery, it should none the less be addressed.

 

Bains, P., & Mahajan, A. (2017). Hair in the Mouth: A Rare Presentation. International journal of trichology, 9(1), 43–44. https://doi.org/10.4103/ijt.ijt_97_16