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

How to Prevent Holiday Weight Gain by Barbara Toman

We are so busy taking care of everyone else and having the perfect preparations that a huge blind spot is that we forget to care for ourselves.  When we are not present in our bodies and caught up in the whirlwind of the holiday rush, we tend to eat those extra treats that temporarily make us feel good and gives us quick energy, but the downside is that we eventually crash and feel worse off.  So, I have defined some tips to help keep you sane, healthy and eliminate weight gain during this holiday season, so you are not saying to yourself on December 31st, “What have I done? I over ate and I am not feeling so great.”  You can avoid the food and emotional hangover that comes with poor planning or reckless abandon during the holiday.
 
 
TIP 1-Plan your meals- When we eat at regular intervals, we keep our blood sugar levels stable, which helps keep our weight and mood in check.  Think about a time when you had too much sugar, white flour and/or processed/ fried foods.  You tended to eat more because the receptors in the stomach did not get the message of feeling full.  Not to mention the brain sends a chemical message to the pancreas to secrete insulin.  When insulin is too high or not effective anymore due to poor diet, sugar cannot get into the cells to be utilized for energy, so the excess sugar gets stored as fat around the middle and you tend to look like Santa Claus.  A good spacing for mealtime is; breakfast, then 4 hours later lunch then 5 hours later, dinner.  Try not eating after 7:00pm, or, if you have to eat late, make sure you keep it light and easy to digest.  Our bodies are designed to start to wind down for bed and not digest heavy meals after 7:00pm.

TIP 2-Eat nutrient dense/colorful foods-Nothing will keep you fuller than eating real food; the food that is closer to nature.  I never had a client say, “Wow, I finished a big bag of carrots and still feel hungry.”  I have had people say,” I started eating chips, cookies, etc. and I just couldn’t stop.”  Foods that are closer to nature:  i.e. fruits and vegetables ,help keep us feeling full because the simple reason is that we ARE full.  Fruits and vegetables contain fiber and water that help satiate and keep us full.  Fruits and vegetables take more time to chew and digest, plus they do not contribute to a huge spike in blood sugar levels. 
 
TIP 3-Sleep/Rest for a normal metabolism.  Your body secretes hormones at night that actually aid in weight loss.  The two main hormones are; Ghrelin that works with the brain to signal hunger.  If you go on a calorie-restricted diet, Ghrelin is elevated and makes it very difficult to lose weight since excess Ghrelin signals the brain that you are always hungry.  Leptin is released from fats cells; the more fat cells you have, the more Leptin is released.  Leptin signals the brain to have your body eat less and burn calories, but too much body fat causes Leptin resistance so your body never gets the right signal to eat less. 
 
TIP 4-Schedule exercise-What is the best exercise?  The one you will do!  This is a great time to schedule social time with friends you have not seen in a while.  What better way to connect with friends this holiday season, than to call and invite to go on a 4-5 miles hike or join you in a Zumba class? You can partner your work out time with a great invitation to meet with friends.  Who says you need to make every social event about food. Exercise will increase the good hormones like endorphins that will help you feel happy. 
 
The holidays are to be enjoyed and food does not have to be the focus.  Remember with these few simple tips, you will be well on your way to a healthy, happy new year.
 
 
Barbara Toman, owner of BodyWise, LLC is a LEAN Certified Health Coach and a Licensed Massage Therapist. www.bodywisellc.com

Tips for Getting the Most Out of Your Pediatrician Visit, By Laura K. Whitney MD

Be On Time
Most offices schedule patients for a set appointment length, such as 10 or 15 minutes, beginning at the given appointment time and including time for paperwork, initial evaluation by a nurse, and time with the doctor. When you arrive after your appointment time, some of the allotted time has already passed. This means the doctor may have less time to deal with your concerns, and if the visit cannot be completed in the scheduled time, the next patient will have to wait longer for his appointment.

Be Organized
Know the names and dosages of all your child’s medications, including over-the-counter medications and vitamins or supplements. If the primary caregiver cannot be present, make sure the adult bringing the child to the doctor has all the details of the child’s medical history and current symptoms. It is most helpful to send a written list of all pertinent information, along with any questions you would like answered. Do not rely on medical files already at the office as it takes considerable time to review old records. Missing details could hinder the diagnosis and treatment of any current problems. The majority of the visit should be spent addressing the issues of the day, not reconstructing what happened in the past.

Be Honest
Providing complete information to your doctor is essential. Without it, the correct diagnosis may be delayed or missed altogether. Your pediatrician is not sitting in judgment: if she has been in practice for a while, be assured she has heard it all. Do not omit any medications or other treatments you have given the child, and if your child has seen a specialist or other provider, be sure to mention it. Report all symptoms accurately and answer questions truthfully, even if the answer is embarrassing. You may ask to speak with the pediatrician independently of the child if you wish to convey sensitive information, or a teen may request to talk with the doctor while his parents wait outside.

Be Present, Even for Teen Visits
It is appropriate for teens to have time alone with the pediatrician, so they can open up about issues they would rather not discuss in front of a parent. However, teens may not know all the details of their personal medical histories or those of their families. They may not clearly communicate parental concerns to the doctor, or they may fail to report the results of the visit to the parent. Also, while teens are legally allowed to receive certain medical treatments without parental permission, these generally don’t include routine vaccinations, which are given at some teen well checks. For these reasons, an adult should be present with the teen at the beginning of the visit and remain in the waiting room until the visit is complete.

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.

How to keep your kidneys happy and healthy, By Dr. Rich Feldenberg

When things run smoothly, we tend to forget the importance of all the moving parts that make up our lives. Our kidneys are certainly no exception. We don’t think about how much they are doing for us each day until something goes wrong. The kidneys have the important task of keeping our internal environment constant. They maintain the precise chemical composition of the blood, and through their intricate architecture of filters and tubules, they regulate the right amount of water in the circulation and remove waste products from the blood. They also produce several important hormones, one of which keeps us from becoming anemic and another which activates vitamin D.

When our kidneys are working well, we don’t notice all the help they’re giving us, but when your kidneys become sick then it becomes obvious how important they are to maintaining a healthy life. Kidney failure can result in massive swelling from fluid retention, dangerous shift in your blood’s mineral balance, and the accumulation of toxins in the body. These problems can be fatal, and in some cases dialysis or kidney transplant is necessary for survival. Since dialysis and transplant are both major medical interventions, it is undeniably best to try to keep your kidneys healthy from the start.

What can you do to maintain good kidney health? While you have no control over your genetics, there are things you can do to help your kidneys continue helping you. Below are my recommendation for taking good care of your kidneys.

1. Drink plenty of fluids. While there is some controversy over exactly how much fluid is necessary to stay healthy, it is clear that low fluid intake is an important risk factor for kidney stones. In addition to causing a lot of pain, a kidney stone can cause a urinary blockage that could permanently damage kidney function. A daily fluid intake of around 2 liters or 67 ounces is often enough to minimize kidney stone risk.

2. Maintain healthy bladder habits. Those that hold their urine for long periods throughout the day and empty the bladder infrequently are at an increased risk for urinary tract infections (UTIs). UTIs can cause permanent scars in the kidney and recurrent UTIs can lead to kidney failure. Emptying your bladder about every 3 hours during the day and making sure you empty completely each time can help cut your risk.

3. Avoid frequent use of medications that are known to be damaging to the kidney. The main over-the-counter medication in this category would be ibuprofen. This can cause a decrease in blood flow to the kidneys and can sometimes lead to kidney failure. There may certainly be times when ibuprofen is fine to use for pain or inflammation, but overuse puts your kidneys at risk. If necessary, use sparingly, follow the directions on the bottle, and take with lots of fluids. If your pain or inflammation is not improving, then get checked by your doctor.

4. Be sure your blood pressure is under good control. Chronic high blood pressure is a common cause for kidney failure and the need for dialysis. Get your blood pressure checked, and if it is high, be sure to follow your doctor’s diet, exercise, and medication recommendations.

5. Talk to your doctor right away if you have any symptoms that could suggest kidney problems or kidney failure. If you notice blood in the urine or swelling in the legs, you shouldn’t wait to seek medical care. Get regular check-ups and periodically have your urine checked for blood and protein. Have your blood pressure measured. If you have diabetes, take extra care to keep your blood sugar levels in check so you are less likely to suffer diabetic kidney disease.
Dr. Feldenberg is a pediatric nephrologist at St. Louis University School of Medicine. His science blog is http://darwinskidneys.wordpress.com