By Cecile Bibawy

Since the publication of my book Loving Her Mind: Piecing Together the Shards of Hope, many people have shared with me their realization of the importance of opening up about their struggle upon discovering they are not alone. You can never tell your story in one go. Tell it a chapter at a time. Patients might significantly benefit from doctors and medical practitioners opening a “chapter” of a struggle they can share to open the communication about what might be going on. Alternatively, another’s story can be shared, like mine and the millions who struggle with mental illness.

Keep the Secrets on the Playground
 
If we stir up conversations about mental health and hardship, the secrets will lose their power, and those struggling will seek help. The only secrets left will be those whispered by the children on the playground.

When we were children playing in the yards and swinging on the swings and climbing the monkey bars, we told secrets. It was thrilling to share secrets with my friend because it was information that was just for the two of us. As I grew, the secrets I kept were no longer from my friend but from my mother. Nostalgia grossly lacking, the information, just between the two of us, was sinister and downright impossible.
 
When I was twelve or thirteen, my mother began telling me that certain relatives and classmates (my best friends) were psychopaths - evil agents of the devil who were out to get her. They were a threat to our family and we needed to stay far away from them. I was not permitted to tell anyone about these criminals because that would tip them off to the fact that she was aware of their evil and heighten the danger. I kept quiet.
 
For six years, I told no one about my mother. Even after I finally realized at 16 that my friends and uncles were not evil and discovered that my mother suffered from schizophrenia, I didn’t speak about it. Because of the incessant verbal violence, paranoia, distrust, anger, and fear at home, and the isolation from friends and family, I wished throughout high school that an aunt or uncle or family friend would arrive to save my siblings and me from our misery.

When no one came, I began to silently satisfy myself with the idea of the county’s children’s services to whisk us away to a better life. Maybe then I’d have friends. Maybe I wouldn’t be so awkward. But that never happened. We were alone.
 
I don’t know if any of my schoolteachers, doctors, or Sunday school teachers knew about my mother. If they did, the subject was never discussed with me. I was fortunate that anytime I wanted, I could talk to my father about what was going on. But he was in survival mode the whole time that I was growing up and processing the monumental effects of my mother’s brain disease on me and the family. As her caregiver, he concentrated all efforts on maintaining her treatment, keeping her medicated, making sure our basic needs were met, and going to church.
 
Resources were scarce - or we didn’t know of them. If there were support groups, counseling, or hotlines, we had no connections. I was never encouraged to talk about the silent monster called schizophrenia that roamed our home and infiltrated our lives in every imaginable way. And I was never asked.

In college, where I slowly started to open up to one or two trusted friends, new fears loomed. What if they don’t believe me? What if they laugh or scorn my words? What if they say I’m exaggerating or turn and run the other way? These fears were based on actual occurrences. So I remained quiet about my mother, my childhood, and mental illness and avoided bringing anyone to the house. My secrets were safe.
 
Our biggest secret - that we had mental illness in our family - practically wiped out the possibility of discovering resources for support.
 
My parents placed a high importance on the opinions of the doctor. I doubt my mother’s psychiatrists gave my dad suggestions or resources for our family, like communication tools and coping strategies. If the family doctor or pediatrician had known what was going on, any information from them would have been taken seriously. This would have helped tremendously.
 
It's a scary thing to talk about a personal encounter with mental illness - a thing marred with the unjust stains of blame, isolation, guilt, and shame. When we begin to tell our story, the walls shatter, the stigma dissipates, and hope is realized. We realize that we are not alone. We find someone kneeling beside us in our not-so-dark place helping us pick up the broken pieces. We all must tell our stories.

About the author: Cecile Bibawy spreads truth about mental illness, encourages people to tell their story for healing and stigma slaying, and promotes health of mind, body, and spirit. She homeschools her children with her husband in Sunbury, Ohio, and teaches fitness classes. Cecile is a speaker, teacher, and author. Connect with her at cecilebibawy.com, Facebook, Instagram (@sincerelycecile) and her favorite coffee shops. Loving Her Mind: Piecing Together the Shards of Hope is available for purchase at Amazon and Barnes & Noble.

By Kathleen O’Shea, Professor of English at Monroe Community College in Rochester, New York

At 55, my headache specialist, who had been a constant for me for 16 years--always there to help, encouraging me that if one medication or treatment didn’t work, we’d find another-- had retired, and I found myself in an intractable migraine cycle, which had already lasted for two months. I felt desperate, as there were/are few headache specialists in my area (Rochester, NY.), and they were over-booked already. I was lost, floundering, in pain, trying to keep working (teaching) at my best, but knowing something had to shift.

I decided to do what I’d always done when in pain (physical or psychological), and that was to turn to literature, since it invites the reader in to know he/she is not alone. In fact, I decided shortly after that, others needed to benefit from what I already knew: imaginative literature can give voice and insight into life experiences that find no outlet in any other way. The subjective and imaginative experiences that we often find difficult to describe, at least in ways that aren’t clinical and objective, are shared beautifully through poetry, fiction, plays, and non-fiction. 
 
Literature taps another kind of resource for migraineurs and those seeking more understanding--the written testimony of essayists, fiction writers, poets, and dramatists, all who give eloquent, often passionate and harrowing accounts of multiple features of migraine that go beyond the pain of the fierce headache itself. 
 
The multiple sensations and symptoms of migraine, which capture the consuming pain, exhaustion, confusion, nausea, cognitive problems, and overwhelming fatigue and isolation that often accompany the disease, differs from patient to patient in some ways, but one of the predominant frustrations migraineurs share is a feeling that no one knows what migraine disease really feels like.

The migraine experience is often invisible because the symptoms, unlike a physical trauma, are often not apparent to a casual observer; the stigma remains. The migraineur attempts to function in his or her life and often becomes good at masking all of the other symptoms in order to achieve some measure of outward normalcy. People have trouble understanding how excessive yawning, confusion, irritability, crying, cognitive blanks, and heightened sensory awareness (smells, light) can all be attributed to a simple “headache.” 
 
I knew, at this point, I needed to dig deeply to discover some of the best literature that could reach migraineurs in a number of ways: I chose the themes of the experience of migraine, the invisibility of migraine, the stigma that it’s just a headache,  the reality that  coping with this disease is a full-time, life-long job, and what migraineurs experience when it’s gone.
 
In exploring these familiar themes migraineurs share, I developed a passion for learning about the disease, and, insofar as possible, “mastering” the condition through a self-understanding that I can share with readers. As a professor of literature, I have access to and have identified a large body of material on this subject that spans some four hundred years, from and 18th century poem to recently published novels, plays, and poetry.

Professionals in the field of migraine testify that there is a “hunger” for information on the subject, and while the internet and blogs can be useful, what they offer is often piecemeal and sometimes contradictory. I wrote So Much More than a Headache: Understanding Migraine through Literature, which provides an organized and sustained resource that is different in kind from other sources. Through contact with professional writers, migraineurs will find affirmation that they don’t experience this disease alone. Family, friends, and co-workers will better understand and empathize with the people they care about and work with.

Medical professionals and other groups trying to understand migraine will find in this anthology texts that can become invaluable starting points for discussion of the disease and the patients suffering with it.

Finally, while I still suffer chronic migraine, I feel I am giving something to others. I have greatly benefited from researching and writing the book, and I hope to get it into the hands of whose who really need it.

The 6 “Be's” of a good primary care visit
By Sully Cardona MD

In the fast paced age we are living in today, it is common for physician visits to feel rushed. It can be hard to develop a good patient-doctor relationship. Patients have been sharing their dissatisfaction via patient surveys. I have been a family medicine physician for about 5 years at a local community health center. Here are some tips to get the most out of your primary care visits.

Be prepared: Write down your list of concerns: It’s easy to forget and be flustered when you’re face to face with your doctor. Do you need refills? If you don’t know the names and dosages of all the medicines you are taking, bring a list or your physical bottles. Are you having side effects from any of the medications? Is there a skin mole you’re concerned about? Or do you need tips on achieving a healthy weight?

Be understanding: Most appointment slots are scheduled for 15 minutes. That means that your doctor might not be able to get to all of your concerns. Be flexible and schedule more follow-up appointments to discuss your concerns. If you have several chronic medical conditions (such as diabetes or high blood pressure), be prepared for the doctor to spend the majority of the visit on these. Sometimes patients feel unheard when the doctor wants to spend more time focusing on their chronic medical conditions than their immediate concerns. Having a good relationship with your physician will help create trust and lead to more satisfying encounters.

Be on time: If your appointment time is at 10 AM, that means you should be checked in and waiting to be called inside by 10 AM. Most practices have a 10-15 minute grace period, but remember that if every patient shows up 15 mins late, your appointment will be pushed back accordingly as your doctor tries to catch up.
Be Flexible: as primary care doctors we literally have no idea what our day is going to look like. Since I’m a family medicine physician, I could have several easy, healthy, well child check-ups or I could have to disclose a new cancer diagnosis. Sometimes our electronic system stops working. There is nothing that stresses us out more than running behind, so please believe us when we say we work very hard to prevent this. If I have a new devastating diagnosis, I would want my doctor to take the time to answer my questions and offer some comfort.

Be proactive: Insurance is hard. Period. They change their coverage at the drop of a hat. They require pre-authorizations from one month to another. While we may be the only “face” you see in your medical encounter, please be aware that we have nothing to do with your insurance decisions. I encourage my patients to be proactive and call their insurance companies to find out what is covered, how much their copay will be etc.

Be healthy: Your doctor is going to tell you that you need to follow a healthy diet and exercise, sleep 7-8 hrs a night, and actively engage in stress-reducing activities. A lot of patients' health issues come from the lack of the above. Remember you might only see your doctor for 15 minutes several times a year, so it is up to you to take ownership of your health in between.

About the author: Sully Cardona MD is a board certified family medicine physician working in a community based health center for the last 5 years. Her interests include preventative care, family planning, procedures and lifestyle counseling. She is interested in helping patients become more proactive in their health. She earned a B.A in Chemistry from the University of Chicago, her M.D  from the University of Illinois and completed her residency training at the Northwestern McGaw Family Medicine Residency Program. She is bilingual, fully fluent in Spanish. She likes to travel and play with her 2 younf daughters. 

Invoke your spirit of volunteerism and add fun ways to stay mentally sharp as you age
By
Sylvanus A. Ayeni, M.D.

While the actions of volunteers by and large do benefit the recipient(s), volunteerism also fosters wellness and wellbeing of the volunteer. Most of us, at some stage in our lives during and beyond adolescence, would probably think about the idea of volunteering for a good cause. The spirit of volunteerism, I believe is innate in all human beings, though it may be dormant in some people for varying lengths of time throughout their lives. There has been a plethora of research into various aspects of volunteerism. These aspects include motivation and its driving forces, commitment, altruism, the opportunity for social interactions and possible health benefits.

About the author:
Sylvanus Ayeni is a retired neurosurgeon in the USA.  He is President and Founder of Pan Africa Children Advocacy Watch, PACAW Inc. a non-profit organization involved in the education of children in Africa.  He has been involved in development issues in Sub-Saharan Africa in the education and healthcare sectors for many years.

By Dana Corriel MD
Board Game Benefits
Board games are fun, first and foremost. My words are always met with pleasure when the words, “Let’s play!” escape my lips. The announcement is usually followed by the loudly happy rummaging through the chest of games, and a big, wide smile appears as they finally find the winner- the chosen one.
But board games have health benefits, too.
The following are eight ways in which board games teach our children valuable life lessons:
1 They make us happy
Engaging in a game stirs up our inner competition, and pushes us to strive towards a goal. This releases endorphins and gives us something that occupies our time, and which serves a purpose (to win the game, and have fun while getting there)
2 They teach children how to lose
It sucks to lose. But what’s worse is winning to a sore loser. When we win fair and square, we want to enjoy that moment, and not have to explain our win, or console others. Children who play regularly, and are challenged, learn that it’s ok to be on the losing end sometimes. And let’s face it, losing serves as a motivating drive to get even better and that’s a lesson that’s ultra important for our kids.
3 They help children expand their planning skills
Games almost always require thinking ahead. Children must form these thoughts in their heads, plan their moves out, and then proceed. It’s a necessary part of their lives, as they get older and we, as parents and their initial decision-makers, take a step back.

By Dr. Michael Letham, BDS
For some, the thought of a dental visit can be a terrifying, anxiety-inducing experience.
While most dental procedures aren’t painful, dental practices are still plagued by fear-inducing stigmas. According to a British Dental Foundation survey, 36% of individuals who did not regularly visit their dentist said that fear was the main reason.
However, the introduction of advanced dental technology is changing all that. These modern technological solutions are tackling traditional dental problems — specifically, patient behaviors.
Integrating such advanced digital technology is allowing dentists to improve diagnoses, proposed treatments, and communications with patients.
The following are five ways that technology is improving dentistry for the better.
1. Creating a “pain-free” experience
Technology is doing more than addressing inefficiencies and clearing lines of communication. The democratization of technology has afforded patients a more comfortable experience given the circumstances.
Computerized tools like dental lasers and The Wand simplify complex procedures, providing patients a more “pain-free experience.”
The Wand, for example, supplies a less invasive process for delivering anesthesia. Rather than delivering anesthesia too quickly or with too much force, The Wand employs anesthesia in a slow, gentle, and methodical manner, making injections painless.
Laser dentistry also diminishes previously painful procedures. As a less invasive precision tool, dental lasers do not require the use of dental drills, resulting in minimal discomfort and less pain. Further, gingival procedures such as periodontal therapy can be done in one dental visit.

2. Enhancing patient communication 
While reasons exist for dental anxieties and phobias, many patients report the feeling of helplessness and loss of control as a root problem. Adopting digital technology addresses such common concerns.
Digital allows dental practices to increase case acceptance by diagnosing conditions with greater accuracy. Digital x-rays, digital records, and 2-D and 3-D images provide patients with clearer views of dental problems, easing concerns.
While anxiety may persist, new technologies are creating clearer lines of communication between dentists and patients, helping fear to subside in many patients.

3. Refining dental pain relief 
Technological advancements transformed the in-office experience, creating relatively “pain-free” procedures. But what about pre- and post-operative treatment?
In the past, provisions for immediate pain relief for pre- and post-operative patients were limited to over-the-counter pain medication or applying ice. Pain and discomfort would linger for days or even weeks.
The severity of the issue would determine patient behavior, furthering negative perceptions. Digital technology now presents solutions for patients requiring pain relief before and after treatment.
Laser dentistry eliminates the need for scalpels, reducing post-operative pain.
Further, post-op recovery is expedited and pain and discomfort minimized with the assistance of a PRF (platelet-rich fibrin) procedure, a “healing biomaterial” that stimulates bone and soft tissue growth.
Laser therapy is also employed as part of the pre-treatment process.
Cold low level laser therapy provides fast, effective pain relief for patients experiencing severe pain and discomfort. Restoring a patient’s physical comfort before treatment or surgery occurs helps to regain the patient’s trust, fostering a more positive dental experience.

4. Improving dental education
Patient education is a major aspect of a patient’s behavior towards dentistry.
Imparting knowledge on causes and issues regarding dental diseases promotes wellness and prevention. However, it takes more than just a conversation to impress the importance of dental education.
Imaging technology encourages patients to be more involved with their oral health, particularly when it comes to pediatric patients.
More accurate diagnoses through the use of Cone Beam and Intraoral Imaging ensure patients are well-informed about what procedures and treatments must be carried out. The use of 3-D models and patient education videos can motivate patients to assume responsibility for their oral healthcare. 
Encouraging further discussions creates for an informed patient. And an informed patient is more likely to have positive associations with a dental practice than an uninformed one.

5. Reducing treatment timeframes
Part of a patient’s negative perception of dentistry lies in the requirement of multiple dental visits and long wait times for treatment.
Traditionally, cosmetic procedures and dental treatments such as dental crowns required multiple appointments. But with the introduction of new technologies like 3-D printing and CEREC technology, patients are offered single-visit restorations.
For patients, this means less drilling, fewer injections, a more accelerated healing timeline, and more importantly, fewer interruptions from their schedule for dental care.
Addressing patient inefficiencies
The exciting growth of digital technology within the industry is leading to greater amounts of leading-edge dental treatment.
The incorporation of digital-based solutions is enabling better collaboration between dentists and their patients. Patients are then rewarded with quicker and more immediate, detailed information regarding their dental health.
Easier access, lower costs, and less invasive procedures are improving quality of care, ensuring patients receive the best care and changing patient behaviors for the better.
AUTHOR BIO
Dr. Michael Letham is the owner and dentist at 24/7 Dental and Bayside Smiles. He graduated from Sydney University in 2000 with Honours, receiving the R Morse Withycombe Prize for Proficiency in Clinical Periodontics (gum treatment). Striving to provide a modern, holistic approach to dental care that is tailored to each individual's requirements, Mike's focus is on being thorough and meticulous whilst being caring and compassionate.

Hiding Veggies in Your Kid’s Food: A Pediatrician’s Perspective, By Laura Whitney MD

 “She just won’t eat anything except peanut butter and jelly!” Pediatricians hear this line or similar words many times each day. When a child is a picky eater, feeding and nutrition become significant sources of concern for parents. Picky eating in toddlers and preschoolers is a common phase, and most children will eventually outgrow their pickiness.  Interestingly, many also manage to maintain appropriate growth and a healthy nutritional status despite acceptance of a limited variety of foods. Parental perceptions of poor nutritional balance in the choosy child’s diet have given rise to the popular practice of sneaking more healthful foods into apparently child-friendly dishes. On the surface, this may seem like a good strategy: surreptitiously adding veggies to readily accepted foods (zucchini muffins, anyone?) may accomplish the immediate goal of increasing a child’s vegetable consumption. However, it is not a magic antidote to picky eating in otherwise healthy children, and, in the end, it may actually be counterproductive in fostering healthy eating habits.

 “More Macaroni, Please:” A Missed Opportunity to Try Something New
 
Some children seem to want the same thing to eat, meal after meal, day after day, often for weeks at a time.  These “food jags,” are a common occurrence during toddlerhood.  As the child’s rate of growth slows dramatically after the first year, there is a natural decrease in appetite.  Developmental tasks such as emerging independence, learning about cause and effect, and attention seeking may also impact mealtime behavior. For these reasons, a child’s interest in new foods may wane, or she may become resistant to trying new foods at all.  
When a child will accept little besides macaroni, tossing in some cauliflower without mentioning it may seem like a good idea. The parent may feel good that the child has consumed a few extra vitamins and nutrients, but the accomplishment stops there. The child has received the familiar food (macaroni), but she has missed the opportunity to explore the novel food (cauliflower). A better strategy would be to offer the usual favorite with sides of steamed cauliflower and bites of watermelon. This allows for easy identification of each item on the plate, and, with repeated attempts (8-10 tries for most toddlers), the child may eventually accept the new food.

“You Added WHAT to My Smoothie?” Why Dishonesty May Not Be the Best Policy
 
Another problem with adding that handful of kale into the berry smoothie on the sly is that children are incredibly observant. Toddlers and preschoolers watch their caregivers constantly, absorbing nonverbal cues very effectively at a young age. Hiding vegetables inside of snacks in lieu of offering them in readily identifiable ways sends the message that the parent agrees they are not enjoyable to eat on their own. Worse yet, a persnickety preschooler may discover one day that a food she does not prefer has been added to her shake. This experience may cause her to be suspicious of other mealtime offerings in the future. As with the macaroni example, the child may have consumed a vegetable in the smoothie, but she has not gained an appreciation for eating the vegetable. In addition, she may actually be dissuaded from trying new foods that are not specifically recognizable to her.
In this case, a better approach would be to make the kale a part of routine smoothie preparation and not a “secret ingredient.” The parent should explain enthusiastically that the kale makes the smoothie even better, perhaps allowing the child to add it herself after she has poured the dishes of berries into the blender. Later, the kale could be served differently, such as in a salad, along with a reminder to the child that it is the same kale that made the smoothie so delicious. The kale then becomes familiar to the child despite the novel presentation.

 Achieving a Better Balance
 
Teaching children to be healthy eaters is a process that unfolds over the course of many years. New foods provide interesting colors, tastes, textures, and smells that really can make a meal into an experience for all the senses. It is important to keep in mind that this can be overwhelming for a small child. Parents may need to introduce a food many times before a child will accept it. In the meantime, mixing some veggies in with the child’s usual favorite may seem like the best way to increase the nutritional content of the meal, but it should not be used as a stand-alone solution for picky eating. When it comes to feeding young children, sneaky tactics will likely create setbacks, while positivity, patience, and perseverance will pay off in the end.
Dr. Whitney is a general pediatrician with The Children’s Medical Center, PA in Greenville, SC. Her interests include toddler feeding issues and helping children develop healthy habits.

by Katrina Ubell MD
As doctors, we take great pride in having full control over ourselves. In order to act professionally and make our clinical experiences all about the patient and his or her issues, we’re able to stuff down any negative emotions we might be experiencing.

Sure, there is the occasional surgeon who flings instruments at the OR walls out of frustration, but in general, that behavior is few and far between.
 
I became an expert at the skill of stuffing my emotions out of necessity after I delivered a full-term stillborn baby about 5 years into my pediatric practice. The grief was overwhelming and I had constant reminders about what I had lost when I saw pregnant mothers and my newly born patients in my office.
 
A physical therapist friend who had suffered multiple miscarriages gave me the advice to always try to make the interaction about the patient. If they offered condolences, politely accept them and then start asking questions about their child and family, turning the attention back on them. I kept this advice in mind for many months after my loss.
 
We doctors live a human existence just like our patients. We experience the same range of emotions, such as grief, frustration, anger, disappointment, joy, and pride. It’s important for us to learn to manage these emotions in an effective way, that serves us and our patients, in order for us to provide the highest quality of care possible while maintaining our mental health.
 
After my baby was born still, I knew I would need the help of a trained professional if I ever planned to return to my practice. I had my first meeting with a psychologist 2 days after I left the hospital empty-handed.
 
It was a wonderful decision to work with a psychologist for a number of reasons. Everyone in my life was devastated by our loss, so she was a neutral, unaffected party. She was able to hold space for me to say anything I needed to say. She reassured me that how I felt was completely normal. She challenged me to leave my house and integrate back into my normal life. After working with her for a couple months, I was able to return to my practice.
 
But sometimes doctors aren’t in need of a trained psychologist, therapist, or psychiatrist. Sometimes we are already functioning at a very high level, yet still have a sticking point in our lives. It might be struggling with our marriage relationship, feeling stressed about our nonexistent work-life balance, feeling burned out, or being unable to permanently lose weight.
 
In these cases, a certified life coach can be just what doctors need to work through this rough area in their lives. A life coach is someone who is trained to help their clients evaluate and work through the mental components of their struggle. For instance, if the problem is overeating in order to deal with stress which results in being overweight, the coach would work with the client to identify the thoughts and emotions that drive the action of overeating. Then he or she would help the client to identify new ways of thinking about their life that ultimately give them the result that they want, which is freedom from overeating.

How to tell if you need a life coach or a psychologist
 
When people ask me how they would know whether they should see a psychologist or a life coach, I boil it down to very simple terms. If you are having a hard time functioning at a normal level for any reason, whether it be depression, anxiety, an adjustment reaction, or most certainly suicidal ideations, then you should consult with a psychologist and psychiatrist.
 
But if you’re already functioning at a normal level yet want to evolve yourself to the next level or want to sort through some difficult areas of your life, a life coach can be the perfect choice. Most coaching is done on the phone or via email, so you don’t have to carve out any additional travel time. What is also very appealing to doctors is the fact that you can find a coach who lives somewhere else in the country, so you never risk running into your coach at the grocery store.
 
Certification for life coaching is highly unregulated. Coming from the extremely regulated profession of medicine, it can be difficult to know how to find the right coach for you. First, look for someone who specializes in your problem. While I have the skills to coach anybody on any topic, I would not be as effective a coach to a man working in corporate America as a coach who works with that niche every day.
 
Second, peruse the coach’s website and read their blog. Does the tone and content resonate with you? Do you feel like this person would “get” you? If you’re not in agreement with their free online content, it’s probably not a good match.
 
Third, all coaches offer some sort of free call, usually anywhere from 15 to 60 minutes, to let you get to know the coach and decide if he or she can help you before making any financial commitments. These calls can have a variety of names such as a mini session or a discovery call. Definitely take the coach candidates up on this offer. It’s free so you have nothing to lose!
 
The work I’ve personally done with the life coach I hired has completely changed my life. My only regret is that I didn’t learn about coaching sooner. Because of the great results I’ve had, I decided to leave my practice to become a life coach for other physicians. It’s been a wonderful transition and I get just as much value out of helping other doctors as I did in my pediatric practice.

About the author: Katrina Ubell, MD is a board-certified pediatrician and a life and weight loss coach. She earned a B.S. in Biomedical Engineering from Johns Hopkins University and an M.D. from the University of Michigan. She completed her pediatric residency at Children’s Hospital of Wisconsin and worked in a private pediatric practice for 10 years. She then retired from her practice to become a life and weight loss coach for other women physicians. She is married to a physician and they have three children. She can be found at www.katrinaubellmd.com.

By Ari Magill MD

Alzheimer’s disease looms as a great specter on the elderly, robbing them of fundamental qualities we associate with the human condition. The ailment was first described by Bavarian-born German psychiatrist and neuropathologist, Aloysius “Alois” Alzheimer, in the early 1900s. Because of how the name of the disease sounds and because it is associated with advancing age, the malady has been colloquially referred to as “old timers’ disease.” While not inevitable with aging, Alzheimer’s disease is an epidemic ever increasing in size and scope with the aging of the population. The disease delivers a powerful blow to the economy in terms of lost wealth and productivity, not to mention stinging social consequences, including loss of intangibles such as well-being, creativity, and personhood.

Research and treatment strategies thus far have focused on directly attacking the neuropathology, as originally described by Dr. Alzheimer, with the bulk of the energy and resources focusing on abnormal “promiscuous” buildup of a protein called beta-amyloid leading to the formation of neurotoxic plaques. Beta-amyloid plaques are thought to instigate the malfunction and death of neurons by triggering neurons to accrue tangles of another protein known as tau within the interior of the cell. Dysfunction of blood flow and inflammation within the brain also play key roles, but the exact way they enter into the disease process equation is difficult to tease out. This war-on-amyloid approach has not been successful up to now in terms of translating bench research into effective disease-modifying therapy for human beings.

Two lines of research stand out in this author’s opinion for boldness and thinking outside the box. They represent a fresh way of looking at the disease, and it starts with a basic question as most brilliant ideas do. The question is: “what is the normal function of beta-amyloid in human beings?” This question has long plagued researchers and the question was largely swept under the rug, with the idea that beta-amyloid must represent some form of molecular garbage.

In the past decade, there have been studies showing beta amyloid has blood-vessel promoting (angiogenic) properties. Having more blood vessels seems like a good thing for the brain on initial inspection, but the excessive branching and buildup of cerebral microvessels induced by amyloid are dysfunctional and result in impaired cerebral blood flow that blocks removal of toxic amyloid. In this light, Alzheimer’s disease can be viewed as a disease of abnormal microvascular proliferation, similar to diabetic retinal disease, but involving the substance of the brain instead of the retina. The end result of this hyper-vascularity is build-up of beta-amyloid “gunk” in the brain with beta-amyloid buildup preventing its own removal. Another negative consequence of deranged angiogenesis is a breakdown of the blood-brain barrier, the semi-permeable wall that stands between potential pathogens and toxins in the blood and the fluid between cells within the brain, called the interstitial fluid. Breakdown of the blood brain barrier has been shown to precede well-recognized Alzheimer’s pathology, including the buildup of amyloid plaques.

Beta-amyloid might promote branching and aberrant growth of microvessels, but is that its primary function? A novel idea by a group of researchers at Harvard led by Kumar et al. is opening up a whole new way of thinking about beta amyloid, one in which beta-amyloid acts as an antibiotic generated by cells within our own brains to fight infection.

This concept was hinted at by prior studies linking Alzheimer’s risk and Alzheimer’s pathology to herpes simplex virus I, the same virus that causes cold sores. The implication was that Alzheimer’s disease might develop from reactivated herpes virus infection, a concept that has not been well received in the medical science community. There was some suggested evidence on a cellular and tissue level to legitimize the idea. Although not rigorously studied, microbes, including bacteria, fungi, and viruses, appear to be more frequently found in the brains of the elderly, and with even greater regularity within brains afflicted by Alzheimer’s disease. Also, herpes simplex virus I can trigger a well-characterized brain infection, called HSV encephalitis, with a predilection for similar areas of the brain to those affected in Alzheimer’s disease, including the hippocampal nuclei that serve as memory centers in the brain.

The new research from Harvard shows that beta-amyloid protein binds to sugar molecules located on the cell walls of microbial pathogens. The protein is composed of tentacle-like structures that clump bacteria together and ensnare them like insects in a spider’s web. Specifically the Harvard researchers exposed the brains of experimental mice genetically engineered to express Alzheimer’s-like pathology to Salmonella Typhimurium. Exposure to the bacterium stimulated the generation and expansion of beta amyloid plaques overnight around areas of bacterial inoculation, where the bacterium served as a focal point and nidus for surrounding protein scaffold.

The role of aging in the disease process of Alzheimer’s disease comes into play given that there is a natural breakdown of the blood-brain barrier with advancing age. This allows more microbial pathogens and pathogenic proteins access to the brain that would stimulate beta-amyloid production. Combined with the angiogenic properties of beta amyloid, we can see how a self-perpetuating chain reaction would ensue since beta amyloid buildup further erodes the blood brain barrier and hinders its own clearance. There are plans to compare the brains of patients with Alzheimer’s to control brains looking to find genetic evidence of pathogenic species in Alzheimer’s-infected brains not found in control brains using next-generation gene sequencing technology. In addition, amyloid plaques themselves will be evaluated for the presence of microbial pathogens.

The ultimate goal of course is effective treatments for this devastating illness. Antimicrobial agents including antibiotics as well as agents that remove pathogens, such as drugs that bolster the immune system, might fit the bill by limiting the stimulus for beta-amyloid production. Another avenue would be anti-antigenic chemotherapeutic agents to enhance the integrity of the blood brain barrier.

About the author:
Ari Magill, M.D. earned his BS in Zoology from University of Texas in Austin, TX, graduated with an MD from UT Southwest Medical School in Dallas, TX. Dr. Magill completed Neurology residency at the University of Arizona in Tucson, AZ, completed Movement Disorder Neurology Fellowship at University of Colorado Anschutz Medical Center in Aurora, CO. Dr. Magill will be starting work in private practice as a neurohospitalist at NW Hospital in Tucson, AZ.
Dr. Magill is an avid science fiction reader and enjoys writing.
Dr. Magill is currently developing interactive case scenarios for a CD to accompany a textbook for advanced EMTs for Williamstown Communications, a medical education company.

A Pediatrician Responds to Excuses for Avoiding HPV Vaccine by Laura Whitney MD

Vaccine visits for babies generally run very smoothly. Everyone expects the baby will need some shots, and most families accept the recommended vaccine schedule.
The adolescent well check, by contrast, seems fraught with controversy. The patient can clearly communicate that she does not want a shot. Since many schools mandate Tdap (tetanus with whooping cough) but do not require meningococcal, HPV (human papilloma virus), or influenza vaccines, parents have the impression that the other vaccines are not as necessary. Finally, parents and adolescents alike have talked to their friends about their vaccine experiences or looked up immunizations on the internet. The result is often a prolonged discussion which ends with the family making a la carte vaccine selections.
Nowhere is this more evident than with the HPV vaccine. From a scientific standpoint, there is very little controversy. The vaccine is not a live vaccine, meaning it will not produce an infection of any kind. It is very effective in creating immunity to the HPV virus, a virus known to cause cancer. Finally, the vaccine has an excellent safety profile.

The CDC recommendation is that all boys and girls aged 11-12 receive the three-dose series for complete coverage. Catch-up regimens are recommended for all girls up to age 26 and all boys up to age 21. The CDC’s recommendations are supported by the Advisory Committee on Immunization Practices as well as the American Academies of Pediatrics, Family Practitioners, Obstetrics and Gynecology.
A safe, effective vaccine that prevents cancer? Why, then, do families hesitate? Here are the top reasons I hear in the office:
It’s too new.
 
The truth is, the vaccine has been recommended since 2006. Over the last decade, 86 million doses of the vaccine have been given. These large numbers equal a vast amount of experience with the HPV vaccine. It’s really not that new anymore.
 
My child isn’t sexually active, and we teach abstinence.
 
Abstinence at a young age is ideal for numerous reasons. However, most teens do not tell their parents before they decide to have sex. I have yet to have a teen call and request the three-dose HPV vaccine series, given over 6 months, before he becomes sexually active. With nearly 100% lifetime risk of HPV infection for sexually active individuals, even those who wait for a committed relationship are at risk.
 
We’ve heard bad things about the vaccine.
 
Although people like to complain when something goes wrong, it is important to remember that people who have had a “normal” experience, neither extremely good nor extremely bad, are not likely to comment. Whether online in testimonials or in person at the ball game, those with grievances wish to air them, but complaints do not constitute scientific fact. Parents should check with the pediatrician for appropriate sources of information regarding vaccines and use the vaccine visit as a chance to get questions answered.
 
We don’t feel it is necessary.
 
79 million people in the US are currently infected with HPV, and 14 million new infections occur each year. If an adolescent will ever have sex in his or her lifetime, the risk of HPV infection is real, and it approaches 100%.
 
In those with HPV infection, there are approximately 27,000 new cases of HPV-associated cancer each year. That is roughly one every 20 minutes. HPV does not just cause cancer of the genitals, either: it is a leading cause of oral and throat cancers. HPV cancers at minimum generate need for medical procedures such as surgery or chemotherapy, but the cancers and treatments can also cause infertility or even death. The HPV vaccine could prevent almost all of these cancers. There is minimal risk and much to gain by getting vaccinated.

But I have a son. Do guys really need the HPV vaccine?
 
Yes. Throat cancers can affect males and females. 72% of these are linked to HPV. HPV also causes 63% of penile cancers and 91% of anal cancers. Protecting sons is just as critical as protecting daughters.
 
I have heard the vaccine is not that effective.
                 
The HPV vaccine is actually very effective. When studied, immunity rates approach 100% for covered strains of the HPV virus. Since the HPV vaccine was recommended 2006, there has been a dramatic decrease in the rates of vaccine-covered HPV infections in teenage girls. This means fewer teens will have complications associated with HPV infection as well.
 
I feel my child is too young for the vaccine.
 
The best way to prevent any HPV infection is to give the vaccine before exposure occurs, keeping in mind that the parent may not be notified when the adolescent becomes sexually active. (It is still appropriate to vaccinate teens who have already been sexually active as they may not have been exposed to all covered strains of HPV.) Also, while the vaccine is proven to be effective at all indicated ages, the immune system is very receptive to new information at ages 11 and 12, so the vaccine will produce the highest level of immunity then.
 
All adolescents should receive HPV vaccination: it is time to stop the excuses and protect our kids. If there are more questions, please refer to the list of resources below, or see your pediatrician for more information.
 
CDC: Frequently Asked Questions About HPV Vaccine Safety

CDC: Human Papilloma Virus (HPV)

CDC: Human Papilloma Virus (HPV) Questions and Answers

Dr. Whitney is a general pediatrician with The Children’s Medical Center, PA in Greenville, SC. Her interests include toddler feeding issues and helping children develop healthy habits. Other articles by Dr. Whitney include Hiding Veggies in Your Kids' Food: A Pediatrician's Perspective and Tips for Getting the Most Out of Your Pediatrician Visit