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Archive for the ‘History and physical exam’ Category


Occupational Therapy

Larry H. Bernstein, MD, FCAP, Curator

LPBI

 

Definition of Occupational Therapy

Occupational therapy is a client-centred health profession concerned with promoting health and well being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupational engagement.(WFOT 2012)

Read the Statement on Occupational Therapy

In occupational therapy, occupations refer to the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do.

Definition of Occupational Therapy Practice for the AOTA Model Practice Act

http://www.aota.org/-/media/Corporate/Files/Advocacy/State/Resources/PracticeAct/Model%20Definition%20of%20OT%20Practice%20%20Adopted%2041411.ashx

The practice of occupational therapy means the therapeutic use of occupations, including everyday life activities with individuals, groups, populations, or organizations to support participation, performance, and function in roles and situations in home, school, workplace, community, and other settings. Occupational therapy services are provided for habilitation, rehabilitation, and the promotion of health and wellness to those who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. Occupational therapy addresses the physical, cognitive, psychosocial, sensory-perceptual, and other aspects of performance in a variety of contexts and environments to support engagement in occupations that affect physical and mental health, well-being, and quality of life. The practice of occupational therapy includes:

A. Evaluation of factors affecting activities of daily living (ADL), instrumental activities of daily living (IADL), rest and sleep, education, work, play, leisure, and social participation, including:

1. Client factors, including body functions (such as neuromusculoskeletal, sensory-perceptual, visual, mental, cognitive, and pain factors) and body structures (such as cardiovascular, digestive, nervous, integumentary, genitourinary systems, and structures related to movement), values, beliefs, and spirituality.

2. Habits, routines, roles, rituals, and behavior patterns.

3. Physical and social environments, cultural, personal, temporal, and virtual contexts and activity demands that affect performance.

4. Performance skills, including motor and praxis, sensory-perceptual, emotional regulation, cognitive, communication and social skills.

B. Methods or approaches selected to direct the process of interventions such as:

1. Establishment, remediation, or restoration of a skill or ability that has not yet developed, is impaired, or is in decline.

2. Compensation, modification, or adaptation of activity or environment to enhance performance, or to prevent injuries, disorders, or other conditions.

3. Retention and enhancement of skills or abilities without which performance in everyday life activities would decline.

4. Promotion of health and wellness, including the use of self-management strategies, to enable or enhance performance in everyday life activities.

5. Prevention of barriers to performance and participation, including injury and disability prevention.

C. Interventions and procedures to promote or enhance safety and performance in activities of daily living (ADL), instrumental activities of daily living (IADL), rest and sleep, education, work, play, leisure, and social participation, including:

1. Therapeutic use of occupations, exercises, and activities.

2. Training in self-care, self-management, health management and maintenance, home management, community/work reintegration, and school activities and work performance.

3. Development, remediation, or compensation of neuromusculoskeletal, sensory-perceptual, visual, mental, and cognitive functions, pain tolerance and management, and behavioral skills.

4. Therapeutic use of self, including one’s personality, insights, perceptions, and judgments, as part of the therapeutic process.

5. Education and training of individuals, including family members, caregivers, groups, populations, and others.

6. Care coordination, case management, and transition services.

7. Consultative services to groups, programs, organizations, or communities.

8. Modification of environments (home, work, school, or community) and adaptation of processes, including the application of ergonomic principles.

9. Assessment, design, fabrication, application, fitting, and training in seating and positioning, assistive technology, adaptive devices, and orthotic devices, and training in the use of prosthetic devices.

10. Assessment, recommendation, and training in techniques to enhance functional mobility, including management of wheelchairs and other mobility devices.

11. Low vision rehabilitation.

12. Driver rehabilitation and community mobility.

13. Management of feeding, eating, and swallowing to enable eating and feeding performance.

14. Application of physical agent modalities, and use of a range of specific therapeutic procedures (such as wound care management; interventions to enhance sensory-perceptual, and cognitive processing; and manual therapy) to enhance performance skills.

15. Facilitating the occupational performance of groups, populations, or organizations through the modification of environments and the adaptation of processes.

Adopted by the Representative Assembly 4/14/11 (Agenda A13, Charge 18)

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Pain Management

Larry H Bernstein, MD, FCAP, Curator

LPBI

 

Pain Management Health Center

http://www.webmd.com/pain-management/

 

Pain Management Overview

Pain management is important for ongoing pain control, especially if you suffer with long-term or chronic pain. After getting a pain assessment, your doctor can prescribe pain medicine, other pain treatments, or psychotherapy to help with pain relief.

Nearly any part of your body is vulnerable to pain. Acute pain warns us that something may be wrong. Chronic pain can rob us of our daily life, making it difficult and even unbearable. Many people with chronic pain can be helped by understanding the causes, symptoms, and treatments for pain – and how to cope with the frustrations.

You know your pain better than anyone — and as hard as it’s been to handle it, your experience holds the key to making a plan to treat it.

Each person and their pain are unique. The best way to manage your case could be very different from what works for someone else. Your treatment will depend upon things such as:

  • The cause
  • How intense it is
  • How long it’s lasted
  • What makes it worse or better

It can be a process to find your best plan. You can try a combination of things and then report back to your doctor about how your pain is doing. Together, you can tweak your program based on what’s working and what needs more help.

All Pain Is Not the Same

In order to make your pain management plan, your doctor will first consider whether you have sudden (“acute”) or long-term (“chronic”) pain.

Acute pain starts suddenly and usually feels sharp. Broken bones, burns, or cuts are classic examples. So is pain after surgery or giving birth.

Acute pain may be mild and last just a moment. Or it may be severe and last for weeks or months. In most cases, acute pain does not last longer than 6 months, and it stops when its underlying cause has been treated or has healed.

If the problem that causes short-term pain isn’t treated, it may lead to long-term, or “chronic” pain.

Chronic pain lasts longer than 3 months, often despite the fact that an injury has healed. It could even last for years. Some examples include:

  • Headache
  • Low back pain
  • Cancer pain
  • Arthritis pain
  • Pain caused by nerve damage

It can cause tense muscles, problems with moving, a lack of energy, and changes in appetite. It can also affect your emotions. Some people feel depressed, angry, or anxious about the pain and injury coming back.

Chronic pain doesn’t always have an obvious physical cause.

What Can I Do to Feel Better?

1. Keep moving. You might think it’s best to rest on the sidelines. But being active is a good idea. You’ll get stronger and move better.

The key is knowing what’s OK for you to do to get stronger and challenge your body, without doing too much, too soon.

Your doctor can let you know what changes to make. For instance, if you used to run and your joints can’t take that now because you have a chronic condition like osteoarthritis, you might be able to switch to something like biking or swimming.

2. Physical and occupational therapy. Take your recovery to the next level with these treatments. In PT, you’ll focus on the exact muscles you need to strengthen, stretch, and recover from injury. Your doctor may also recommend “occupational therapy,” which focuses on how to do specific tasks, like walking up and down stairs, opening a jar, or getting in and out of a car, with less pain.

3. Counseling. If pain gets you down, reach out. A counselor can help you get back to feeling like yourself again. You can say anything, set goals, and get support. Even a few sessions are a good idea. Look for a counselor who does “cognitive behavioral therapy,” in which you learn ways that your thinking can support you as you work toward solutions.

4. Massage therapy. It’s not a cure, but it can help you feel better temporarily and ease tension in your muscles. Ask your doctor or physical therapist to recommend a massage therapist. At your first appointment, tell them about the pain you have. And be sure to let them know if the massage feels too intense.

5. Relaxation. Meditation and deep breathing are two techniques to try. You could also picture a peaceful scene, do some gentle stretching, or listen to music you love. Another technique is to scan your body slowly in your mind, and consciously try to relax each part of your body, one by one, from head to toe. Any healthy activity that helps you unwind is good for you and can help you feel better prepared to manage your pain.

6. Consider complementary treatments such as acupuncture, biofeedback, and spinal manipulation. In acupuncture, a trained practitioner briefly inserts very thin needles in certain places on your skin to tap into your “chi,” which is an inner energy noted in traditional Chinese medicine. It doesn’t hurt.

Biofeedback trains you to control how your body responds to pain. In a session of it, you’ll wear electrodes hooked up to a machine that tracks your heart rate, breathing, and skin temperature, so you can see the results.

When you get spinal manipulation, a medical professional uses their hands or a device to adjust your spine so that you can move better and have less pain. Some MDs do this. So do chiropractors, osteopathic doctors (they have “DO” after their name instead of “MD”), and some physical therapists.

Are There Devices That Help?

Although there are no products that take pain away completely, there are some that you and your doctor could consider.

TENS and ultrasound. Transcutaneous electrical nerve stimulation, or TENS, uses a device to send an electric current to the skin over the area where you have pain. Ultrasound sends sound waves to the places you have pain. Both may offer relief by blocking the pain messages sent to your brain.

Spinal cord stimulation. An implanted device delivers low-voltage electricity to the spine to block pain.  If your doctor thinks it’s an option, you would use it for a trial period before you get surgery to have it permanently implanted. In most cases, you can go home the same day as the procedure.

What About Medicine?

Your doctor will consider what’s causing your pain, how long you’ve had it, how intense it is, and what medications will help. They may recommend one or more of the following:

These may include over-the-counter pain relievers such as acetaminophen, aspirin, ibuprofen, or naproxen. Or you may need stronger medications that require a prescription, such as steroids, morphine, codeine, or anesthesia.

Some are pills or tablets. Others are shots. There are also sprays or lotions that go on your skin.

Other drugs, like muscle relaxers and some antidepressants, are also used for pain. Some people may need anesthetic drugs to block pain.

Will I Need Surgery?

It depends on why you’re in pain. If you’ve had a sudden injury or accident, you might need surgery right away.

But if you have chronic pain, you may or may not need an operation or another procedure, such as a nerve block (done with anesthetics or other types of prescription drugs to halt pain signals) or a spinal injection (such as a shot of cortisone or an anesthetic drug).

Talk with your doctor about what results you can expect and any side effects, so you can weigh the risks and the benefits. Also ask how many times the doctor has done the procedure they recommend and what their patients have said about how much relief they’ve gotten.

WebMD Medical Reference

Reviewed by Jennifer Robinson, MD on September 20, 2015

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Blood Pressure Lowering

Larry H. Bernstein, MD, FCAP, Curator

LPBI

 

Data analysis and publication of landmark NIH blood pressure study confirm that lower blood pressure target can reduce cardiovascular disease, deaths

http://www.nih.gov/news-events/news-releases/data-analysis-publication-landmark-nih-blood-pressure-study-confirm-lower-blood-pressure-target-can-reduce-cardiovascular-disease-deaths

 

NIH-supported researchers are reporting more details on a landmark study that announced preliminary findings in September showing a lower blood pressure target can save lives and reduce the risk of cardiovascular disease in a group of non-diabetic adults 50 years and older with high blood pressure. Results of the Systolic Blood Pressure Intervention Trial (SPRINT) appear in the current online issue of the New England Journal of Medicine and were discussed today at the American Heart Association 2015 Scientific Sessions in Orlando.

The study confirms that, in adults 50 years and older with high blood pressure, targeting a systolic blood pressure of less than 120 millimeters of mercury (mm Hg) reduced rates of cardiovascular events, such as heart attack and heart failure, as well as stroke, by 25 percent. Additionally, this target reduced the risk of death by 27 percent—as compared to a target systolic pressure of 140 mm Hg.

“SPRINT is part of a proud legacy of NIH-funded clinical trials that will change clinical practice and save lives for decades to come. These results reinforce the compelling public health importance of enhancing the awareness, treatment and control of hypertension in this country and around the world,” said Gary H. Gibbons, M.D., director of the National Heart, Lung, and Blood Institute (NHLBI), the primary sponsor of SPRINT.

The SPRINT study, which began in the fall of 2009, included more than 9,300 participants age 50 and older, recruited from about 100 medical centers and clinical practices throughout the United States and Puerto Rico. About 36 percent of participants were women, 58 percent were white, 30 percent were African-American, and 11 percent were Hispanic. The SPRINT study did not include patients with diabetes, prior stroke, or polycystic kidney disease, as other NIH trials were studying those particular populations. Approximately 28 percent were 75 or older and 28 percent had chronic kidney disease. The study tested a strategy of using blood pressure medications to achieve the targeted goals of less than 120 mm Hg (intensive treatment group) versus 140 mm Hg (standard treatment group). The NIH stopped the blood pressure intervention in August—a year earlier than planned—after it became apparent that this more intensive intervention was beneficial.

“When the benefits of the stronger intervention became apparent in SPRINT, we made a commitment to rapid public health communication and peer-reviewed publication of the study results,” Dr. Gibbons said. “We are pleased to present the details of the study’s potentially lifesaving findings at this time.”

In their report, investigators provided detailed data showing that both cardiovascular deaths and overall deaths were lower in the intensive treatment group.

Certain types of serious consequences were more common in the intensive group, including low blood pressure, fainting, electrolyte abnormalities, and acute kidney damage. However, other serious adverse events associated with lower blood pressure, such as slow heart rate and falls with injuries, did not increase in the intensive group. In patients with chronic kidney disease, there was no difference in the rate of serious decline in kidney function between the two blood pressure goal groups.

“The benefits of more intensive blood pressure lowering exceeded the potential for harm, regardless of gender or race/ethnicity,” said study co-author Paul Whelton, M.D., of Tulane University School of Public Health and Tropical Medicine in New Orleans, Louisiana. He is chair of the SPRINT Steering Committee.

In addition to its primary cardiovascular outcome, the study continues to examine kidney disease, cognitive function, and dementia among the SPRINT participants; however, these results are not yet available as additional information will be collected and analyzed over the next year.

“Although the study provides strong evidence that a lower blood pressure target saves lives, patients and their health care providers may want to wait to see how guideline groups incorporate this study and other scientific reports into any future hypertension guidelines. In the meantime, patients should talk to their health care providers to determine whether this lower goal is best for their individual care,” said study co-author Lawrence Fine, M.D., Chief, Clinical Applications and Prevention Branch at NHLBI.

“It’s also important to remember that healthy lifestyle changes can make a difference in controlling high blood pressure,” Dr. Fine added. He emphasized the importance of following a healthy diet, being physically active, maintaining a healthy weight, as well as learning to check your blood pressure.

In addition to primary sponsorship by the NHLBI, SPRINT is co-sponsored by the NIH’s National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.

Part of the National Institutes of Health, the National Heart, Lung, and Blood Institute (NHLBI) plans, conducts, and supports research related to the causes, prevention, diagnosis, and treatment of heart, blood vessel, lung, and blood diseases; and sleep disorders. The Institute also administers national health education campaigns on women and heart disease, healthy weight for children, and other topics. NHLBI press releases and other materials are available online at http://www.nhlbi.nih.gov.

About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

NIH…Turning Discovery Into Health®

Landmark NIH study shows intensive blood pressure management may save lives

Embargoed for Release:

September 11, 2015, 10:30 AM EDT

Lower blood pressure target greatly reduces cardiovascular complications and deaths in older adults

More intensive management of high blood pressure, below a commonly recommended blood pressure target, significantly reduces rates of cardiovascular disease, and lowers risk of death in a group of adults 50 years and older with high blood pressure. This is according to the initial results of a landmark clinical trial sponsored by the National Institutes of Health called the Systolic Blood Pressure Intervention Trial (SPRINT). The intervention in this trial, which carefully adjusts the amount or type of blood pressure medication to achieve a target systolicpressure of 120 millimeters of mercury (mm Hg), reduced rates of cardiovascular events, such as heart attack and heart failure, as well as stroke, by almost a third and the risk of death by almost a quarter, as compared to the target systolic pressure of 140 mm Hg.

“This study provides potentially lifesaving information that will be useful to health care providers as they consider the best treatment options for some of their patients, particularly those over the age of 50,” said Gary H. Gibbons, M.D., director of the National Heart, Lung, and Blood Institute (NHLBI), the primary sponsor of SPRINT. “We are delighted to have achieved this important milestone in the study in advance of the expected closure date for the SPRINT trial and look forward to quickly communicating the results to help inform patient care and the future development of evidence-based clinical guidelines.”

High blood pressure, or hypertension, is a leading risk factor for heart disease, stroke, kidney failure, and other health problems. An estimated 1 in 3 people in the United States has high blood pressure.

The SPRINT study evaluates the benefits of maintaining a new target for systolic blood pressure, the top number in a blood pressure reading, among a group of patients 50 years and older at increased risk for heart disease or who have kidney disease. A systolic pressure of 120 mm Hg, maintained by this more intensive blood pressure intervention, could ultimately help save lives among adults age 50 and older who have a combination of high blood pressure and at least one additional risk factor for heart disease, the investigators say.

The SPRINT study, which began in the fall of 2009, includes more than 9,300 participants age 50 and older, recruited from about 100 medical centers and clinical practices throughout the United States and Puerto Rico. It is the largest study of its kind to date to examine how maintaining systolic blood pressure at a lower than currently recommended level will impact cardiovascular and kidney diseases. NIH stopped the blood pressure intervention earlier than originally planned in order to quickly disseminate the significant preliminary results.

The study population was diverse and included women, racial/ethnic minorities, and the elderly.  The investigators point out that the SPRINT study did not include patients with diabetes, prior stroke, or polycystic kidney disease, as other research included those populations.

When SPRINT was designed, the well-established clinical guidelines recommended a systolic blood pressure of less than 140 mm Hg for healthy adults and 130 mm Hg for adults with kidney disease or diabetes. Investigators designed SPRINT to determine the potential benefits of achieving systolic blood pressure of less than 120 mm Hg for hypertensive adults 50 years and older who are at risk for developing heart disease or kidney disease.

Between 2010 and 2013, the SPRINT investigators randomly divided the study participants into two groups that differed according to targeted levels of blood pressure control. The standard group received blood pressure medications to achieve a target of less than 140 mm Hg. They received an average of two different blood pressure medications. The intensive treatment group received medications to achieve a target of less than 120 mm Hg and received an average of three medications.

“Our results provide important evidence that treating blood pressure to a lower goal in older or high-risk patients can be beneficial and yield better health results overall,” said Lawrence Fine, M.D., chief, Clinical Applications and Prevention Branch at NHLBI. “But patients should talk to their doctor to determine whether this lower goal is best for their individual care.”

The study is also examining kidney disease, cognitive function, and dementia among the patients; however, those results are still under analysis and are not yet available as additional information will be collected over the next year.  The primary results of the trial will be published within the next few months.

In addition to primary sponsorship by the NHLBI, SPRINT is co-sponsored by the NIH’s National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.

Supplemental Information

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Dense Breast Mammogram

Larry H. Bernstein, MD, FCAP, Curator

LPBI

 

 

The Problem With Mammograms

http://forward.com/culture/324003/the-problem-with-mammograms/#ixzz3queBnx00

 

Hallie Leighton had dense breasts — a fact she discovered only in her late 30s, via a mammogram. She grew up in an Ashkenazi family in New York, pursued a career in writing and worked with organizations promoting peace between Israelis and Arabs. By 2013 she was making a documentary on her father Jan Leighton, an actor who set the record as an actor for appearing in the most roles (2,407 according to the 1985 Guinness Book of World Records). She was never able to complete it. She died that year, at the age of 42.

Every woman in Leighton’s family had breast cancer, so she began getting annual mammograms at 35 — five years earlier than the recommended age. In 2009 the results of Leighton’s mammogram came in as “negative” or “normal”; by 2013 she was bedridden, undergoing her final days of chemotherapy.

When Leighton was first diagnosed in 2010, her doctor told her, “You have breast cancer, and it was there in 2009.” The tumor in Leighton’s breast went undiscovered until it was palpable — and at that point, the cancer was already in stage 4.

Happygram,” a documentary which exposes some of the shortcomings in mammography, chronicles Leighton’s struggle with cancer and the implications of having dense breasts.

“Most women simply aren’t informed that they have dense breast tissue,” said Leighton’s best friend Julie Marron. She wrote and directed the documentary, which is currently screening at film festivals around the country.

Breast density is defined by the relative amount of fat in relation to the amount of connective and epithelial tissue (tissue that lines blood vessels and cavities). When more than 50% of breast tissue is connective and epithelial tissue, instead of fatty tissue, the breasts are considered dense. Mammography is the only way to determine breast density.

“If you have dense breasts, what looks dense on a mammogram looks the same as a cancer would look. It tends to confuse or confound the physician, and reduces the sensitivity of the mammogram,” said Gerald Kolb, founder and president of The Breast Group, which counsels clients on different technologies in breast care. “Hallie Leighton’s breasts looked like snowballs; there was no chance they were going to find anything with the mammogram.”

Forty percent of women who are screened for breast cancer have dense breast tissue. These women also account for more than 70% of all invasive cancers. “Mammograms are not very effective screening tools for these women, as they miss between 50% and 75% of all invasive cancers in dense breast tissue,” Marron said. “This is obviously a very critical issue when you are dealing with a population that is more likely to develop cancer.”

Ashkenazi women are even more at risk. They are 1.6 times more likely than the general population to have dense breast tissue, according to Kolb. Moreover, one in 40 Ashkenazi women will test positive for one or both of BRCA gene mutations responsible for breast cancer. For the general population, that number is between one in 350 and one in 800.The BRCA 1 or 2 genes don’t cause cancer, they fight cancer, Kolb says. But if the gene is mutated, the body is not as well equipped to fight the cancer.

“A woman with a BRCA mutation has a lifetime risk of around 33% to 87%, depending on the gene and mutation,” Marron said. “Compare this to a lifetime risk of 12% for developing breast cancer for the overall population.” BRCA gene mutations can be inherited from either or both parents, and therefore they can be present in men as well as in women.

Breast density and BRCA gene mutations are not directly related, but both independently present an increased susceptibility to breast cancer.

“The biggest risk is that a doctor is not going to find the cancer when it’s really small,” Kolb said. When a tumor is detected at a centimeter or smaller, there’s a 95% cure rate. But if the cancer is the size of a golf ball by the time it’s detected, Kolb says, the woman has a 60% chance of living for five years, and then her mortality increases dramatically.

The good news is that mammography isn’t the only method of detecting breast cancer; the bad news is that very few people know this. “What we’re trying to do in the density movement is give women enough information so they can ask appropriate questions of a doctor,” Kolb said.

Kolb advises high-risk women to get a genetic risk analysis, which can be performed by a genetic counselor or a radiologist. He advises getting the risk analysis as early as age 25, but doing so is a personal decision. Not every woman is emotionally prepared to know the results.

“Mammography is a starting point,” said Dr. Dennis McDonald, a California-based women’s imager. Additionally, doctors recommend that women with dense breasts get an MRI, which McDonald says is reserved for high-risk women. It’s an expensive, invasive and time-consuming procedure that requires the injection of fluid in order to read the MRI. As of yet, doctors do not know the side effects of getting an annual MRI.

“A doctor should have started [Leighton] on an MRI right away. She was high risk and they chose to just monitor with a mammogram,” Kolb said. “That’s insufficient.”

Breast ultrasound is another alternative for women with dense breast tissue. “Most of the time, breast density doesn’t present a problem [with ultrasounds],” McDonald said. Though the ultrasound is effective in detecting cancer, he says the downside is that radiologists are often not that comfortable with the technology, simply because they have little experience with it. There are also a lot of false positives, he adds, which result in unnecessary exams or biopsies.

As “Happygram” documents, informing women of their breast density and of alternatives to mammography is a highly charged political issue.

“The whole breast cancer industry has grown up around mammograms,” Marron said. “Physicians weren’t educated on [breast density], deliberately so to a certain extent, and refused to inform patients on this issue, which is really outrageous if you think about it.” Marron says that doctors are required by law and ethical guidelines to inform patients of “material” medical information. “There is no legitimate reason that women have not been informed of this information,” she noted.

After Leighton’s diagnosis, she wanted to ensure that other women didn’t suffer the same misfortune of all-too-late tumor discovery on account of dense breast tissue. She gave media interviews, lobbied in Albany and starred in “Happygram,” all the while undergoing chemotherapy. She died four months after the Breast Density Information Bill passed in New York.

The law requires that every mammography report given to a patient with dense breasts inform the patient in plain language that she has dense breast tissue and that she should talk to her physician about the possible benefits of additional screenings. In New York, the first state in the nation to pass this kind of law, at least 2,500 women with dense breasts and invasive breast cancer received “normal” or “negative” results on their mammograms.

Similar legislation has been passed in more than 20 states throughout the country, but not without objection. Many well-intentioned radiologists, poorly informed about alternative screening options, feared that telling women the limitations of mammography would cause them to lose faith in it altogether and not get tested. Others argued that the information would make women anxious, and that it wouldn’t be fair for those who couldn’t afford additional testing. And still further arguments against informing women were possibly impacted by financial considerations, Marron added.

“Women aren’t getting the benefit of full notification across the board yet,” Marron said. “I think that has to change through education. That’s the primary reason we made this movie. There’s been so much resistance within the medical community to telling women. Change isn’t going to come from the medical community, it has to come from the patients.”

Ashkenazi women shouldn’t panic, Kolb says, but they need to carefully examine their breast density and alternative screening options: “Anytime you have a preventative tragedy like that, you have to do everything in your power to stop it from happening.”

Madison Margolin is a freelance writer based in New York. She writes frequently for the Village Voice.

Read more: http://forward.com/culture/324003/the-problem-with-mammograms/#ixzz3qufQOSmn

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Protein Energy Malnutrition and Early Child Development

Curator: Larry H. Bernstein, MD, FCAP

 

 

In the preceding articles we have seen that poverty and low social class combined with cultural strictures or dependence on a sulfur-poor diet results in childhood stunting and impaired brain development. This is a global health issue.

Protein-Energy Malnutrition

  • Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Romesh Khardori, MD, PhD, FACP

http://emedicine.medscape.com/article/1104623-overview

The World Health Organization (WHO)[1] defines malnutrition as “the cellular imbalance between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions.” The term protein-energy malnutrition (PEM) applies to a group of related disorders that includemarasmus, kwashiorkor (see the images below), and intermediate states of marasmus-kwashiorkor. The term marasmus is derived from the Greek wordmarasmos, which means withering or wasting. Marasmus involves inadequate intake of protein and calories and is characterized by emaciation. The term kwashiorkor is taken from the Ga language of Ghana and means “the sickness of the weaning.” Williams first used the term in 1933, and it refers to an inadequate protein intake with reasonable caloric (energy) intake. Edema is characteristic of kwashiorkor but is absent in marasmus.

Studies suggest that marasmus represents an adaptive response to starvation, whereas kwashiorkor represents a maladaptive response to starvation. Children may present with a mixed picture of marasmus and kwashiorkor, and children may present with milder forms of malnutrition. For this reason, Jelliffe suggested the term protein-calorie (energy) malnutrition to include both entities.
Although protein-energy malnutrition affects virtually every organ system, this article primarily focuses on its cutaneous manifestations. Patients with protein-energy malnutrition may also have deficiencies of vitamins, essential fatty acids, and trace elements, all of which may contribute to their dermatosis.

In general, marasmus is an insufficient energy intake to match the body’s requirements. As a result, the body draws on its own stores, resulting in emaciation. In kwashiorkor, adequate carbohydrate consumption and decreased protein intake lead to decreased synthesis of visceral proteins. The resulting hypoalbuminemia contributes to extravascular fluid accumulation. Impaired synthesis of B-lipoprotein produces a fatty liver.

Protein-energy malnutrition also involves an inadequate intake of many essential nutrients. Low serum levels of zinc have been implicated as the cause of skin ulceration in many patients. In a 1979 study of 42 children with marasmus, investigators found that only those children with low serum levels of zinc developed skin ulceration. Serum levels of zinc correlated closely with the presence of edema, stunting of growth, and severe wasting. The classic “mosaic skin” and “flaky paint” dermatosis of kwashiorkor bears considerable resemblance to the skin changes of acrodermatitis enteropathica, the dermatosis of zinc deficiency.

In 2007, Lin et al[2] stated that “a prospective assessment of food and nutrient intake in a population of Malawian children at risk for kwashiorkor” found “no association between the development of kwashiorkor and the consumption of any food or nutrient.”

Marasmus and kwashiorkor can both be associated with impaired glucose clearance that relates to dysfunction of pancreatic beta-cells.[3] In utero, plastic mechanisms appear to operate, adjusting metabolic physiology and adapting postnatal undernutrition and malnutrition to define whether marasmus and kwashiorkor will develop.[4]

In 2012, a report from Texas noted an 18-month-old infant with type 1 glutaric acidemia who had extensive desquamative plaques, generalized nonpitting edema, and red-tinged sparse hair, with low levels of zinc, alkaline phosphatase, albumin, and iron. This patient has a variation on kwashiorkor, and the authors suggest that it be termed acrodermatitis dysmetabolica.[5] On the same note, a boy aged 18 months with type 1 glutaric acidemia suffered from zinc deficiency and acquired protein energy malnutrition.[6]

For complex reasons, sickle cell anemia can predispose suffers to protein malnutrition.[7]

Protein energy malnutrition ramps up arginase activity in macrophages and monocytes.[8]

Protein energy malnutrition (PEM), brain and various facets of child development.

Protein energy malnutrition (PEM) is a global problem. Nearly 150 million children under 5 years in the world and 70-80 million in India suffer from PEM, nearly 20 million in the world and 4 million in India suffer from severe forms of PEM, viz., marasmus, kwashiorkor and marasmic kwashiorkor. The studies in experimental animals in the west and children in developing countries have revealed the adverse effects of PEM on the biochemistry of developing brain which leads to tissue damage and tissue contents, growth arrest, developmental differentiation, myelination, reduction of synapses, synaptic transmitters and overall development of dendritic activity. Many of these adverse effects have been described in children in clinical data, biochemical studies, reduction in brain size, histology of the spinal cord, quantitative studies and electron microscopy of sural nerve, neuro -CT scan, magnetic resonance imaging (MRI) and morphological changes in the cerebellar cells. Longer the PEM, younger the child, poorer the maternal health and literacy, more adverse are the effects of PEM on the nervous system. Just like the importance of nutrients on the developing brain, so are the adverse effects on the child development of lack of environmental stimulation, emotional support and love and affection to the child. When both the adverse factors are combined, the impact is severe. Hence prevention of PEM in pregnant and lactating mothers, breast feeding, adequate home based supplements, family support and love will improve the physical growth, mental development, social competence and academic performance of the child. Hence nutritional rehabilitation, psychosocial and psychomotor development of the child should begin in infancy and continue throughout. It should be at all levels, most important being in family, school, community and various intervention programmes, local, regional and national. Moreover medical students, health personnel, all medical disciplines concerned with total health care and school teachers should learn and concentrate on the developmental stimulation and enrichment of the child.

Cognitive development in children with chronic protein energy malnutrition

Behav Brain Funct. 2008; 4: 31.  http://dx.doi.org:/10.1186/1744-9081-4-31 
Background: Malnutrition is associated with both structural and functional pathology of the brain. A wide range of cognitive deficits has been reported in malnourished children. Effect of chronic protein energy malnutrition (PEM) causing stunting and wasting in children could also affect the ongoing development of higher cognitive processes during childhood (>5 years of age). The present study examined the effect of stunted growth on the rate of development of cognitive processes using neuropsychological measures.
Methods: Twenty children identified as malnourished and twenty as adequately nourished in the age groups of 5–7 years and 8–10 years were examined. NIMHANS neuropsychological battery for children sensitive to the effects of brain dysfunction and age related improvement was employed. The battery consisted of tests of motor speed, attention, visuospatial ability, executive functions, comprehension and learning and memory
Results: Development of cognitive processes appeared to be governed by both age and nutritional status. Malnourished children performed poor on tests of attention, working memory, learning and memory and visuospatial ability except on the test of motor speed and coordination. Age related improvement was not observed on tests of design fluency, working memory, visual construction, learning and memory in malnourished children. However, age related improvement was observed on tests of attention, visual perception, and verbal comprehension in malnourished children even though the performance was deficient as compared to the performance level of adequately nourished children.
Conclusion: Chronic protein energy malnutrition (stunting) affects the ongoing development of higher cognitive processes during childhood years rather than merely showing a generalized cognitive impairment. Stunting could result in slowing in the age related improvement in certain and not all higher order cognitive processes and may also result in long lasting cognitive impairments.
Malnutrition is the consequence of a combination of inadequate intake of protein, carbohydrates, micronutrients and frequent infections [1]. In India malnutrition is rampant. WHO report states that for the years 1990–1997 52% of Indian children less than 5 years of age suffer from severe to moderate under nutrition [2]. About 35% of preschool children in sub-Saharan Africa are reported to be stunted [3]. Malnutrition is associated with both structural and functional pathology of the brain. Structurally malnutrition results in tissue damage, growth retardation, disorderly differentiation, reduction in synapses and synaptic neurotransmitters, delayed myelination and reduced overall development of dendritic arborization of the developing brain. There are deviations in the temporal sequences of brain maturation, which in turn disturb the formation of neuronal circuits [1]. Long term alterations in brain function have been reported which could be related to long lasting cognitive impairments associated with malnutrition [4]. A wide range of cognitive deficits has been observed in malnourished children in India. In a study, malnourished children were assessed on the Gessell’s developmental schedule from 4 to 52 weeks of age. Children with grades II and III malnutrition had poor development in all areas of behaviour i.e., motor, adaptive, language and personal social [5]. Rural children studying in primary school between the ages of 6–8 years were assessed on measures of social maturity (Vineland social maturity scale), visuomotor co-ordination (Bender gestalt test), and memory (free recall of words, pictures and objects). Malnutrition was associated with deficits of social competence, visuomotor coordination and memory. Malnutrition had a greater effect on the immediate memory of boys as compared with those of girls. Malnourished boys had greater impairment of immediate memory for words, pictures and objects, while malnourished girls had greater impairment of immediate memory for only pictures. Delayed recall of words and pictures of malnourished boys was impaired. Malnourished girls had an impairment of delayed recall of only words. The same authors measured the intelligence of malnourished children using Malin’s Indian adaptation of the Wechsler’s intelligence scale for children. IQ scores decreased with the severity of malnutrition. Significant decreases were observed in performance IQ, as well as on the subtests of information and digit span among the verbal subtests [6]. The above study has shown that though there is decrease in full scale IQ, yet performance on all the subtests was not affected. This suggests that malnutrition may affect different neuropsychological functions to different degrees. Studies done in Africa and South America have focused on the effect of stunted growth on cognitive abilities using verbal intelligence tests based on assessment of reasoning [7]. Such an assessment does not provide a comprehensive and specific assessment of cognitive processes like attention, memory, executive functions, visuo-spatial functions, comprehension as conducted in the present study. Information about the functional status of specific cognitive processes has implications for developing a cognitive rehabilitation program for malnourished children. A neuropsychological assessment would throw light on functional status of brain behaviour relationships affected by malnutrition. Deficits of cognitive, emotional and behavioural functioning are linked to structural abnormalities of different regions of the brain. Brain structures and brain circuits compute different components of cognitive processes [8]. Malnutrition has long lasting effects in the realm of cognition and behaviour, although the cognitive processes like executive functions have not been fully assessed [9]. The differential nature of cognitive deficits associated with malnutrition suggests that different areas of the brain are compromised to different degrees. A neuropsychological assessment would be able to delineate the pattern of brain dysfunction. Malnutrition is a grave problem in our country as 52% of our children are malnourished. Effects of protein-calorie malnutrition are inextricably blended with the effects of social cultural disadvantage; even within the disadvantaged class, literacy environment at home and parental expectation regarding children’s education are powerful variables. Perhaps membership in a higher caste confers some advantage in regard to home literacy, and parental expectation. Short and tall children do differ in some cognitive tests, but not in all as demonstrated in a study done in Orissa, India [10]. But whether or not stunted growth alone is the causative variable for cognitive weakness is not determined as yet. Moreover, the functional integrity of specific cognitive processes is less clear. Chronic PEM resulting in stunting and wasting could result in delay in the development of cognitive processes or in permanent cognitive impairments. Neuropsychological measures can demonstrate delay in normally developing cognitive processes as well as permanent cognitive deficits.
Children in the age range of 5–10 years attending a corporation school in the city of Bangalore participated in the study. Corporation schools in India are government schools with minimal fee attended by children from lowmiddle class. There were 20 children in adequately nourished group and 20 in the malnourished group. The gender distribution was equal. Children in both the groups were from the same ethnic/language background. They were natives of Karnataka living in Bangalore.
After identifying the malnourished and adequately nourished children the coloured progressive matrices test [12] was administered to rule out mental retardation. Children falling at or below the fifth percentile were excluded from the sample, as the 5th percentile is suggestive of intellectually defective range. The percentile points were calculated from the raw scores using Indian norms [13]. Mental retardation was ruled out as otherwise scores on neuropsychological tests would be uniformly depressed and a differentiation of deficits might not occur. Intelligence was not treated as a covariate in the study. The groups did not differ significantly in their scores on CPM (a screening instrument to rule out intellectual impairment in both the groups).
Table 1: Demographic details of the participants
                            Adequately nourished N = 20                  Malnourished N = 20
Mean age              5–7 years        8–10 years                     5–7 years      8–10 years
                               5.8 years        8.8 years                          6.3 years      9.3 years
Gender                   Girls:10           Boys: 10                          Girls:10         Boys: 10
Stunted %
(height for age -2 SD from the median) —-                                  70%
Stunted and wasted %
(height for age and
weight for height: -2 SD from the median) —-                               30%
Exclusion of behaviour problems and history of neurological disorders The children’s behaviour questionnaire form B [14] was administered to the class teachers of the identified children. Children who scored above the cut off score of 9 were not included in the sample. The personal data sheet was filled in consultation with the parents and teachers to rule out any history of any neurological/psychiatric disorders including head injury and epilepsy and one child with epilepsy was excluded. This was one of the exclusion criteria.
Exclusion of behaviour problems and history of neurological disorders The children’s behaviour questionnaire form B [14] was administered to the class teachers of the identified children. Children who scored above the cut off score of 9 were not included in the sample. The personal data sheet was filled in consultation with the parents and teachers to rule out any history of any neurological/psychiatric disorders including head injury and epilepsy and one child with epilepsy was excluded. This was one of the exclusion criteria.
The tests have been grouped under specific cognitive domains on the basis of theoretical rationale and factor analysis. Factor analysis has been done for the battery and the grouping of tests under cognitive functions like executive functions, visuospatial functions, comprehension and learning and memory was done on the basis of the clustering observed in factor analysis as well as on theoretical grounds
The neuropsychological battery consisted of the following tests:
1. Motor speed  Finger tapping test [15]
2. Expressive speech  Expressive speech test was administered to rule out speech related deficits
3. Attention  Color trails test [18] is a measure of focused attention and conceptual tracking.
4. Color cancellation test [21] is a measure of visual scanning/selective attention
5. Executive functions FAS phonemic fluency test is a measure of verbal fluency.
6. Design fluency test [24] is a measure of design fluency, cognitive flexibility and imaginative capacity.
7. Visuo-spatial working memory span task [23]: This test is a measure of visuo-spatial working memory (VSWM) span.
8. Visuospatial functions Motor-free visual perception test [29] is a measure of visuoperceptual ability, having 36 items for visual discrimination, visual closure, figure-ground, perceptual matching and visual memory. Since this test has been originally developed for children between 5–8 years of age, it was modified and items in increasing difficulty level were added by the authors to make it applicable for the children above 8 years. Number of correct responses comprises the score.
9. Picture completion test [30] is a measure of visuoconceptual ability, visual organization and visuo-conceptual reasoning.
10. Block design test [30] is a measure of visuoconstructive ability.
11. Comprehension, learning and memory Token test [31] is a measure of verbal comprehension of commands of increasing complexity.
12. Rey’s auditory verbal learning test (RAVLT) [32] is a measure of verbal learning and memory.
13. Memory for designs test [34] is a measure of visual learning and memory.
Comparison between the performance of adequately nourished children and malnourished children Table 2.0 shows that malnourished group differed significantly from the adequately nourished group on tests of phonemic fluency, design fluency, selective attention, visuospatial working memory, visuospatial functions, verbal comprehension and verbal learning and memory showing poor performance. The two groups did not differ on the test of finger tapping. Since expressive speech was a question answer type assessment looking at repetitive speech, nominative speech and narrative speech, which is like an initial screening for aphasia, like symptoms. Since it did not give a quantitative score, hence was not taken for analysis. As a descriptive account of expressive speech it was observed that malnourished children did not have any difficulty with respect to expressive speech.
Comparison of age related differences in cognitive functions between adequately nourished and malnourished children Data was further subjected to post hoc analysis to compare the two groups across the two age groups to study the rate of improvement with age (Table 2). In both the age groups of 5–7 years and 8–10 years the adequately nourished children performed better than the malnourished children. Figures 1, 2, 3, 4, 5, 6 indicate age related improvement in performance across different cognitive functions in adequately nourished children as compared to malnourished children. Motor speed and coordination was not significantly affected in malnourished children as compared to the adequately nourished children (figure 1). The rate of age related improvement across the two age groups was found rapid on certain functions like selective attention (figure 2) and verbal fluency (figure 3) in malnourished children. However, working memory, design fluency, visuospatial functions, comprehension, learning, and memory showed slowing in terms of age related improvement in malnourished children. Most of the cognitive functions like design fluency (figure 3), working memory (figure 3), Visual perception (figure 4), visuoconceptual reasoning (figure 4), visual construction (figure 4), verbal comprehension (figure 5), verbal and visual memory (figures 6) have shown a very slow rate of improvement with respect to the difference in performance between the two age groups of 5–7 and 8–10 years. On the contrary functions like verbal fluency (figure 3), motor speed (figures 1), and selective attention (figure 2) showed similar rates of improvement in adequately nourished children and malnourished children while comparing the two age groups.
Table 2: Mean comparisons for the cognitive functions across the two age groups of adequately nourished and malnourished children (not shown)
Table 3: Post-hoc comparisons between adequately nourished and malnourished groups across the two age groups (not shown)
Figure 1 Age related comparisons between adequately nourished and malnourished children on motor speed (right and left hand) Age related comparisons between adequately nourished and malnourished children on motor speed (right and left hand). (not shown)
Figure 2 Age related comparisons between adequately nourished and malnourished children on selective attention (color cancellation test). (not shown)
Post-hoc comparisons were computed with Tukey’s posthoc tests to compare the means across age groups between malnourished and adequately nourished children for those test scores that showed significant effects. Hence, post hoc tests were not computed for the finger tapping test scores assessing motor speed. Table 3 presents the post-hoc results with the significance (probability level) levels of the differences across age groups and between adequately nourished and malnourished children. Post hoc results have been done to support our theoretical claims about the lack of age related improvement in certain cognitive functions on one hand and the nature of cognitive impairments on the other in malnourished children. Four comparisons were interpreted i.e., comparing performance between the two age groups of adequately nourished and malnourished children separately. The other comparison was between the adequately nourished and malnourished children for the age group of 5–7 years and similarly for the age group of 8–10 years. Results indicate age related differences within each group as well as between the two groups. Age related differences were found significant for some of the test scores between 5–7 and 8–10 year old children in the adequately nourished group but not for most of the test scores for malnourished group indicative of a delay in development of certain cognitive functions. Differences were found significant between the adequately nourished and malnourished children for the same age group for most of the test scores indicative of a deficit in a particular cognitive function. In few of the tests, performance was not found to be significantly different between the two age groups for both adequately nourished and malnourished children.
Discussion The findings of the present study could be discussed in terms of the effect of chronic malnutrition on neuropsychological performance and with respect to the rate of development of cognitive processes.
Effect of malnutrition on neuropsychological performance Our study indicates that malnourished children perform poor on most of the neuropsychological tests except that of motor speed as compared to adequately nourished children. Malnourished children showed poor performance on tests of higher cognitive functions like cognitive flexibility, attention, working memory, visual perception, verbal comprehension, and memory. These findings are supported by another study on Indian malnourished children, which reported memory impairments in undernourished children and spared fine motor coordination [36]. Malnourished children showed poor performance on novel tasks like tests of executive functions i.e., working memory spatial locations. Poor performance on the tests of fluency and working memory also coincides with very slow rate of improvement between the age groups of 5–7 years and 8–10 years. Poor performance on most of the neuropsychological tests indicated a diffuse impairment including attention, executive functions, visuospatial functions, comprehension and memory.
Effect of malnutrition on cognitive development Both the groups were tested on a neuropsychological battery, which has been found to be sensitive to age related differences in cognitive functions in children (5–15 years). The age trends reported in the present study are based on the assessment that employed the NIMHANS neuropsychological battery for children [13]. The test battery has been standardized based on the growth curve modeling approach for empirical validation of age-related differences in performance on neuropsychological tests. The tests in the battery were found sensitive to show age related differences.
Malnourished children showed poor performance with respect to age as compared to adequately nourished children. The performance of malnourished children in the 5–7 years age group was poor and much lower than the adequately nourished children and did not seem to show much improvement in the 8–10 years age group. The rate of cognitive development was found to be different for different cognitive functions. The rate of development was affected for some of the cognitive functions showing minimal age related improvement across the age range of 5–7 years and 8–10 years such as design fluency, working memory, visual construction, verbal comprehension, learning and memory for verbal and visual material. On the contrary, age related improvement was observed on certain other cognitive functions in malnourished children, where the level of performance was low for both the age groups but the rate of improvement between the two age groups was similar to adequately nourished children.
Not shown
Figure 3 Age related comparisons between adequately nourished and malnourished children on executive functions.
Note: VF: verbal fluency; DF: design fluency; WM: working memory; AN: adequately nourished; MN: malnourished.

MN 5–7 vs 8–10 p > .05 5–7 years AN vs MN p > .05 8–10 years AN vs MN p < .05 Visual memory (memory for designs test) AN 5–7 vs 8–10 p > .05 MN 5–7 vs 8–10 p > .05 5–7 years AN vs MN p < .05 8–10 years AN vs MN p < .05

Figure 4 Age related comparisons between adequately nourished and malnourished children on visuospatial functions.
Figure 5 Age related comparisons between adequately nourished and malnourished children on verbal comprehension and verbal learning.
Motor speed (right and left hand) was not found impaired in malnourished children and the rate of development was also found similar to adequately nourished children.
Executive functions such as design fluency, selective attention and working memory were found deficient in malnourished children also showing poor rate of improvement between the two age groups. All the three tests of executive functions like fluency, selective attention and working memory for spatial locations involved novel stimuli and performance required cognitive flexibility as well as faster information processing which was affected in malnourished children. Results also indicate that malnourished children showed a very slow rate of improvement on these functions.
Visuo-spatial functions like visual perception, visual construction and visuo-conceptual reasoning showed significantly poor performance when compared to the adequately nourished children but showed a steep age related improvement in performance. Performance on functions like visual perception (visual discrimination, perceptual matching, visual closure and visuospatial relationships) and visual construction was severely affected in malnourished children and also showed poor rate of improvement with age.
Verbal comprehension, learning and memory for verbal and visual material was found poor as compared to adequately nourished children but the rate of improvement between 5–7 years age group and 8–10 years age group was similar to that of adequately nourished children. These results suggest that development of comprehension with age might not be affected in malnourished children. However, other than the poor performance on the AVLT test of verbal learning, malnourished children also showed minimal improvement between the two age groups as compared to the greater magnitude of difference between the two age groups in adequately nourished children. Visual memory was most severely affected in malnourished children in terms of the poor performance on delayed recall on design learning test as well as in terms of the difference between the two age groups.
Malnutrition affects brain growth and development and hence future behavioral outcomes [37]. School-age children who suffered from early childhood malnutrition have generally been found to have poorer IQ levels, cognitive function, school achievement and greater behavioral problems than matched controls and, to a lesser extent, siblings. The disadvantages last at least until adolescence. There is no consistent evidence of a specific cognitive deficit [38]. The functional integrity of specific cognitive processes is less clear. Stunting in early childhood is common in developing countries and is associated with poorer cognition and school achievement in later childhood [39]. Deficits in children’s scores have been reported to be smaller at age 11 years than at age 8 years in a longitudinal study on malnourished children stunted children suggesting that adverse effects may decline over time [7]. In our study also all the children in malnourished group were stunted and the cross sectional assessment of age related improvement has shown similar rate of improvement across 5–7 years to 8–10 years age groups as observed in adequately nourished children though the baseline performance was low in malnourished children. These results indicate that the adverse effects of malnutrition (stunting in particular) may decline with age only for certain cognitive functions but the rate of cognitive development for most of the cognitive processes particularly higher cognitive processes including executive processes and visuospatial perception could be severely affected during the childhood years. Decline in the effects of malnutrition overtime has been reported to be independent of differences in educational, socioeconomic and psychosocial resources [7]. Hence, malnutrition (particularly stunting) may result in delayed development of cognitive processes during childhood years rather than a permanent generalized cognitive impairment.
The neuropsychological interpretation of the cognitive processes more severely affected in malnourished children suggests a diffuse cortical involvement. This is with reference to deficits pertaining to functions mediated by dorsolateral prefrontal cortex (poor performance on tests of attention, fluency and working memory), right parietal (poor performance on tests of visuospatial functions) and bilateral temporal cortex (poor performance on tests of comprehension, verbal learning, and memory for verbal and visual material). The prefrontal cortex may be particularly vulnerable to malnutrition [4]. The adverse effects of malnutrition (PEM-stunting) on cognitive development could be related to the delay in certain processes of structural and functional maturation like delayed myelination and reduced overall development of dendritic arborization of the developing brain [1].
The present study highlights two ways in which malnutrition particularly stunting could affect cognitive functions. On one hand age related improvement in cognitive performance is compromised and on the other hand there could be long lasting cognitive impairments as well. However, the effect is nor specific to a particular cognitive domain and is rather more diffuse. Results of the study also indicate that: certain cognitive functions could be vulnerable to the effect of malnutrition in terms of showing impairment but the rate of development of these functions may not be affected. On the other hand, rate of development of certain cognitive functions may be affected and may also show impairment when compared with adequately nourished children.
Conclusion Chronic protein energy malnutrition (stunting) results in cognitive impairments as well as slowing in the rate of the development of cognitive processes. Rate of development of cognitive functions may follow different patterns in children with malnutrition. Chronic protein energy malnutrition affects the development of cognitive processes differently during childhood years rather than merely showing an overall cognitive dysfunction as compared to adequately nourished children. Stunting could result in delay in the development of cognitive functions as well as in permanent cognitive impairments which show minimal improvement with increase in age. Rate of development of attention, executive functions like cognitive flexibility, working memory, visuospatial functions like visual construction is more severely affected by protein energy malnutrition in childhood years, a period that is marked by rapid ongoing development of cognitive functions.
The effects of protein energy malnutrition in early childhood on intellectual and motor abilities in later childhood and adolescence.
Dev Med Child Neurol. 1976 Jun;18(3):330-50.

Three groups of Ugandan children (20 in each group) and one comparison group of 20 children were examined between 11 and 17 years of age. The first three groups had been admitted to hospital for treatment of protein energy malnutrition between the ages of eight to 15, 16 to 21 and 22 to 27 months, respectively. The comparison group had not been clinically malnourished throughout the whole period up to 27 months of age. All the children came from one tribe and were individually matched for sex, age, education and home environment. It was found that the three malnourished groups fell significantly below the comparison group in anthropometric measurements and in tests of intellectual and motor abilities. No evidence was found for a relationship between the deficit and age at admission. Further analysis among the 60 malnourished children revealed that anthropometry and intellectual and motor abilities are the more affected the greater the degree of ‘chronic undernutrition’ at admission, but no correlation was found with the severity of the ‘acute malnutrition’. The results show a general impairment of intellectual abilities, with reasoning and spatial abilities most affected, memory and rote learning intermediately and language ability least, if at all, affected. These findings are discussed in the context of a comprehensive and critical appraisal of the existing literature.

Quake-Hit Nepal Gears up to Tackle Stunting in Children

By Gopal Sharma  July 08, 2015  http://www.medscape.com/viewarticle/847572

HECHO, Nepal (Thomson Reuters Foundation) – Shanti Maharjan, who gave birth to a baby girl 10 days ago, has spent the last two months living under corrugated iron sheets with her husband and five others after two major earthquakes reduced her mud-and-brick home to rubble.

Adequate food, drinking water and aid such as tents and blankets have been hard to come by, she says, though scores of aid agencies rushed to the Himalayan nation to help survivors.
What worries the 26-year-old mother most is her inability to produce breastmilk for her new-born daughter, who she fears is at serious risk of malnutrition in the aftermath of the 7.8 and 7.3 magnitude quakes in April and May.

“The earthquake destroyed everything, including our food reserves,” said Maharjan, sitting under the iron sheeting on farmland on the outskirts of the capital, Kathmandu.

“There is not enough food. Getting meat, oil and fruits to eat is difficult in this situation. I am worried about my daughter’s nourishment,” she said as the baby, wrapped in a green cloth, lay sleeping on a wooden bed.

The government, aware that disruption caused by the quakes could worsen the country’s already high rate of child malnutrition is sending out teams of community nurses to give advice and food supplements to women and children in the affected areas.

A 2011 government study showed that more than 40% of Napel’s under-five-year-olds were stunted, showing that the country’s child malnutrition rate was one of the world’s highest.
Experts say the two quakes, which killed 8,895 people and destroyed half a million houses, could make things worse as survivors have inadequate food, water, shelter, healthcare and sanitation.

United Nations officials warn that the rate of stunting among children in the South Asian nation could return to the 2001 level of 57%, if authorities and aid agencies do not respond effectively.

“The risk of malnutrition is high and requires the nutrition and other sectors like agriculture, health, water, sanitation, education and social protection to respond adequately,” said Stanley Chitekwe, UNICEF’s nutrition chief in Nepal.

DRIVE TO NOURISH

Child malnutrition is an underlying cause of death for 3 million children annually around the world – nearly half of all child deaths – most of whom die from preventable illnesses such as diarrhoea due to weak immune systems.

Those lucky enough to survive grow up without enough energy, protein, vitamins and minerals, causing their brains and bodies to be stunted, and they are often unable to fulfill their potential.

Government officials admit the challenges, citing data showing that almost 70% of Nepali children under the age of two suffer from anaemia caused by iron deficiency.

“This shows that (poor) nutrition is a very big problem. The earthquake will further worsen the situation because people simply don’t have enough to eat, let alone have a nutritious diet,” said Health Ministry official Krishna Prasad Paudel.

Supported by UNICEF, authorities have now launched a drive to reach out to more than 500,000 women and children who need supplementary food and medicines.

More than 10,000 female community volunteers will be fanning out across 14 districts affected by the earthquakes, visiting devastated towns and villages and speaking to new and expectant mothers about breast-feeding their infants.

The volunteers will also advise families on eating locally available nutritious foods such as green vegetables and meat and will distribute vitamin A, iron and folic acid, and other micronutrient supplements to pregnant and breastfeeding women.

In Imadole, a prosperous district on the outskirts of the ancient town of Patan, health volunteer Urmila Sharma Dahal found an extremely thin two-year-old boy weighing 7.5 kg (16.5 pounds) last week, suffering from severe acute malnutrition.

Dahal said she provided his family with sachets of ready-to-use therapeutic food – a paste of peanut, sugar, milk powder, vitamin and oil – and the child gained nearly a kilo (2.2 pounds) in weight in just seven days.

“It does not take much. It can be done with small but right interventions,” said Dahal as she sat next to the child in the family’s brick-and-cement home.

Protein-energy malnutrition occurs due to inadequate intake of food and is a major cause of morbidity and mortality in children in developing countries (Grover and Ee 2009).

http://www.wcs-heal.org/global-challenges/public-health-issues-and-costs/malnutrition/protein-energy-malnutrition

http://www.wcs-heal.org/uploads/images/Chris_Golden-malnourished_children_692x513_scaled_cropp.jpg

Protein energy malnutrition (PEM) has significant negative impacts on children’s growth and development (Grover and Ee 2009). Chronic PEM causes children to have stunted growth (low height for age) and to be underweight (low weight for age); it is estimated that among children under age five, one in every four is stunted and one in every six is underweight. PEM also causes two specific conditions in children: marasmus, which is characterized by an emaciated appearance, and kwashiorkor, in which children develop swollen bellies due to edema (abnormal accumulation of fluid) and discoloration of the hair because of pigment loss among other symptoms (UNWFP 2013b, Ahmed et al. 2012). Countries in sub-Saharan Africa and south Asia have the highest proportions of children suffering from PEM (UNWFP 2013a).

PEM causes direct mortality in children and also increases vulnerability to other serious diseases including diarrhea, pneumonia, and malaria. Children suffering from PEM have compromised immune systems, making them particularly susceptible to infectious diseases.  Furthermore, PEM has negative impacts on children’s brain development, resulting in issues with memory and delayed motor function; these children have decreased ability to learn and have lower productivity as adults. PEM also has serious and potentially long-term impacts on other organ systems including the cardiovascular, respiratory, and gastrointestinal systems (Grover and Ee 2009).

Many adults in developing countries also suffer from PEM, with women disproportionately impacted compared with men, particularly in south Asian countries (UNWFP 2013a). Pregnant women who are undernourished can fall even further behind in their nutritional status due to the increased demand for nutrients by the developing fetus. Women who don’t gain sufficient weight during pregnancy are at increased risk for complications including maternal morbidity and mortality, low birth weight, and neonatal mortality. These women can also have difficulty providing sufficient quantities of breast milk, leading to malnutrition among neonates (Ahmed et al. 2012).

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Abraham Verghese, MD, Physician and Notable Author

Curators: Larry H. Bernstein, MD and Aviva Lev-Ari, PhD, RN

LPBI

Series E. 2; 12.3

There are few who combine a career as physician, teacher and author as well as Abraham Verghese, whose name is a frequent byline in newspapers and magazines across the world, and more recently, in demand as aTED speaker. He himself is also a regular focus of attention in media – both medical and general – that range from National Public Radio, the New England Journal of Medicine, and the New York Times to The Guardian, and The Times of India.

His work as a physician informs his writing and the reflection that comes through his writing helps him empathize with his patients, and to see them individually, as human beings who are suffering, fearful and in need not just of treatment, but of comfort and reassurance. Imagining his patients’ experience has driven his work throughout his medical career. His emphasis on empathy and healing is the focus of his talks, nationally and internationally, as he stresses the importance of the patient-physician relationship in an era of advances in medical technology that often tend to de-personalize medical care.

“I still find,” he says, “the best way to understand a hospitalized patient is not by staring at a computer screen, but going to see that patient. For it is at the bedside that I can figure out what’s important to the patient and how the data you have accumulated makes sense.”

Abraham Verghese talks about medicine and fiction to Kim O’Dell of the Heinz Foundation after receiving the 2014 Heinz Award for Arts and Humanities.

Abraham Verghese, MD, MACP, is Professor and Linda R. Meier and Joan F. Lane Provostial Professor, and Vice Chair for the Theory and Practice of Medicine at the School of Medicine at Stanford University. He is also a critically acclaimed, best-selling author and a physician with an international reputation for his focus on healing in an era where technology often overwhelms the human side of medicine. In February 2014, he received a Heinz Award from Teresa Heinz and the Heinz Family Foundation. The awards given annually in the areas of Arts and Humanities; Environment; Human Condition; Public Policy; and Technology, the Economy and Employment, celebrate the enduring spirit of hope and the power of innovation.

Early Years

Born in Addis Ababa in 1955,  the second of three sons of Indian parents recruited by Emperor Haile Selassie to teach in Ethiopia, he grew up near the capital and began his medical training there. When the emperor was deposed, Verghese briefly joined his parents who had moved to the United States because of the war, working as an orderly in a hospital before completing his medical education in India at Madras Medical College. Both the civil unrest and this time as a hospital orderly were to leave a significant mark on his life and work.

After graduation, he left India for a medical residency in the United States and, like many other foreign medical graduates, he found only the less popular hospitals and communities open to him, an experience he described in one of his early New Yorker articles, The Cowpath to America.

From Johnson City, Tennessee, where    he was an internal medicine resident from 1980 to 1983, he moved to the Northeast for a fellowship at Boston University School of Medicine, working at Boston City Hospital for two years. It was here that he first saw the early signs of the HIV epidemic and later, when he returned to Johnson City as an assistant professor of medicine, he saw the second epidemic, rural AIDS, and his life took the turn for which he is now so well known – caring for a seemingly unending line of young AIDS patients in an era when little could be done other than help them through their premature and painful deaths. Long before retrovirals, this was often the most a physician could do and it taught Abraham Verghese the subtle difference between healing and curing.

First Books

Abraham Verghese’s early years as an orderly, his caring for terminal AIDS patients, the insights he gained from the deep relationships he formed and the suffering he witnessed were intensely transformative. These were the cumulative experiences around which his first book, My Own Country: A Doctor’s Story, is centered.

Such was his growing interest in writing in the late 1980s that he decided to take some time away from medicine to study at the Iowa Writers Workshop at the University of Iowa, where he earned a Master of Fine Arts degree in 1991. Since then, his writing has appeared in The New Yorker, Texas Monthly, Atlantic, The New York Times, The New York Times Magazine, Granta, Forbes.com, and The Wall Street Journal, among others.

After leaving Iowa, he became professor of medicine and chief of the Division of Infectious Diseases at Texas Tech Health Sciences Center in El Paso, Texas, where he lived for the next 11 years. In addition to writing his first book, which was one of five chosen as Best Book of the Year by TIME magazine and later made into a Showtime movie directed by Mira Nair, he also wrote a second best-selling book, The Tennis Partner: A Story of Friendship and Loss, about his friend and frequent tennis partner’s losing struggle with addiction. This was named a New York Times’ Notable Book.

Emphasis on the Physician-Patient Relationship

He left El Paso in 2002 and, as founding director of the Center for Medical Humanities & Ethics at the University of Texas Health Science Center San Antonio, he brought the deep-seated empathy for patient suffering that had been honed by his previous experiences to his new role in the medical humanities.

He gave the new Center a guiding mission, “Imagining the Patient’s Experience,” to emphasize the importance of interactive patient care. He saw empathy as a way to preserve the innate caring and sensitivity that brings students to medical school, but which the rigors of their training frequently suppress. In San Antonio, also, he became more focused on bedside medicine, inviting small groups of medical students to accompany him on bedside rounds. Rounds gave him a way to share one-on-one the value he placed on the physical examination in diagnosing patients and demonstrating attentiveness to patients and their families, a vital key in the healing process.

Dr. Verghese’s deep interest in bedside medicine and his reputation as a clinician, teacher and writer led to his recruitment to Stanford University School of Medicine in 2007 as a tenured professor and senior associate chair for the Theory and Practice of Medicine. He has since been named the Linda R. Meier and Joan F. Lane Provostial Professor Vice Chair for the Theory and Practice of Medicine at the Stanford School of Medicine.

In his writing and his work, he continues to emphasize the importance of bedside medicine and physical examination in an era of advanced medical technology. He contends the patient in the bed often has less attention than the patient data in the computer. His December 2008 article in the New England Journal of Medicine, Culture Shock: Patient as Icon, Icon as Patient, clearly lays out his viewpoint.

In his novel, Cutting for Stone, he also addresses the issue.

“I wanted the reader to see how entering medicine was a passionate quest, a romantic pursuit, a spiritual calling, a privileged yet hazardous undertaking,” he said. “It’s a view of medicine I don’t think too many young people see in the West because, frankly, in the sterile hallways of modern medical-industrial complexes, where physicians and nurses are hunkered down behind computer monitors, and patients are whisked off here and there for all manner of tests, that side of medicine gets lost.”

Today, as a popular invited speaker, he has more forums than his writing to expound on his views on patient care. He talks nationally and internationally on the subject, in addition to talks and readings from his books. He has also led the effort at the Stanford School of Medicine to establish the Stanford 25, where residents and students are taught techniques and skills to recognize the basic phenotypic expressions of disease that manifest as abnormal physical signs.

More About Abraham Verghese

Physician Returns: Stanford Medical Center Report

Bedside Manners: Q/A with Abraham Verghese in Texas Monthly

Treat the Patient, Not the CT Scan: Op Ed in the New York Times

Click on a topic or read the entire series.

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Cutting for Stone, Origin of the Title
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Bedside Medicine

You talk a lot about the lost art of bedside diagnosis. Can you describe what that is and why losing it is a bad thing?

As we’ve gotten very fancy in technology and the incredible detail with which we can see the body, we sometimes lose sight of how much we can see about the body just from examining the patient. The physical exam really allows you to order tests more judiciously and to ask better questions of the test.

Tell us about your vision for teaching medical students and physicians.

Yes. I’ve learned by coming full circle that the most important way we have to influence medical students and residents is really at the bedside, one by one. There really is no shortcut; there is no classroom lecture that can substitute. Stanford has such a wonderful reputation for research, and we wanted to try and make sure that it also had an equivalent reputation for the clinical training of our students and our residents.

So the clinical encounter at the bedside is terribly important. In other words, you can have all the theoretical knowledge in the world, and if your interaction with the patient is somehow clumsy and not done well, the relationship won’t even begin.

The computerized medical record, along with burgeoning technology, has seriously threatened the patient/physician interaction in the hospital.

I would contend, and I will keep saying this till the day it stops being true, that the patient in the bed has now become an icon for the real patient, who is in the computer, the patient I call the iPatient. The patient in the bed simply exists to signify that there is a file in the computer.

Now, of course, I’m being facetious. We clearly pay attention to the person in the bed, but what I mean to say is that looking at the body, orienting oneself from the body has become almost passé. The body is viewed as incidental, in many cases for good reason, because a mammogram or CT scan can perhaps see much more clearly than the human hand. Nevertheless, there are things that only the human hand can find, like whether it’s painful in a particular spot. That’s not something that any machine can tell you. There isn’t any machine in the world that can do a knee reflex and convey the information of a tendon reflex. There are elements of this exam that are so important, and in this era of biomarkers and other sexy tests, we have forgotten the value of the good physical.

What is it about the practice of medicine today that prompts doctors to rush into ordering tests vs. taking their time to do the bedside diagnosis?

For one thing, the tests are very, very good. The kind of detail you can get from a CAT scan is far superior to what your hand can tell you. On the other hand, only your hand can tell you where it hurts by pushing on a certain place. … We’re all intrinsically prone to allowing technology to take the place of common sense and I think that’s a danger. … The tests have become an easy shortcut. They’re an efficient, quick way to get information. But the great danger I see is this: I think that people fail to really connect with patients when they don’t examine them. I think the carefully done physical is a wonderful way to convey your attentiveness to the patient.

How can professors and medical schools help address the primary care shortfall?

It’s a struggle … but if you’re going to do it, you’re going to do it only by showing them the charm and the magic of being at the bedside. There is no passion and romance that you can illustrate to them in front of a computer, which is where a lot of care takes place these days. The only way to excite students about medicine is to do it one by one, by them seeing you being the kind of physician that they’d like to be.

Your two non-fiction books are very autobiographical. What’s the difference between penning fiction and non-fiction? How was the process of writing Cutting for Stone different for you than penning the other books?

I must say that fiction was always my first love; indeed, one of my first published stories as a very dark AIDS story titled ‘Lilacs’ which appeared in the New Yorker. That led to my getting a contract to write My Own Country, a non-fiction book about my AIDS practice and experience in small town Tennessee, followed by another memoir, The Tennis Partner (the story of the loss of a physician friend to drug addiction and suicide). These were things I had witnessed that I had to tell, but when I was done with the second book, I was keen to get back to fiction.

What was so different about writing a novel for me was that sense of discovering the story (unlike non-fiction, where you sort of know what happened and what you will write about–the story has presented itself so to speak, and now it is about selection). My ambition for the novel was tell a great story, an old-fashioned, truth-telling story.

All I had at the outset was an image of a beautiful Indian nun giving birth in a mission hospital in Africa, a place redolent with Dettol and carbolic acid scents, a place so basic, so unadorned, that nothing separates doctor and patient, no layers of paperwork, cubicles and forms. That is all I had. I did not know the whole plot or how it ended. (and see answer to next question as to how I eventually did plot, and even then there were surprises).

did know that I wanted the whole novel to be of medicine, by which I mean I wanted every person, scene and place to be informed by medicine, kind of the way that Zola’s novels are of Paris. I wanted very much to celebrate an aspect of medicine that gets buried in the way television depicts the practice: I wanted the reader to see how entering medicine was a quest, a romantic pursuit, a spiritual calling, an undertaking that could put you at some personal risk (of losing your selfhood, your obligation to family) but which could also save you. It’s a view of medicine I don’t think too many of my students see – we live in a world of haste where physicians and nurses are hunkered down behind computer monitors, and patients are whisked off here and there for this and that test, that side of medicine gets lost.

What inspired you to write each of your books? Was there a moment of epiphany for each one, when you decided that you simply had to put that story down on paper?

Many moments of epiphany in all of my books. There was no real moment in time when any of them started, but very often for me, writing about something is a way to understand it better, or just understand it in the first place. I became a character in the stories with a sense of discovering the import as I wrote rather than writing because I understood it.

Living through the time of AIDS in Tennessee, and helplessly with David as he was spiraling down in El Paso – writing these first two books helped me more deeply understand those experiences. With Cutting for Stone, I arbitrarily chose twins, then twins became the motive for the story, and ultimately they were the focus for the characters’ redemption. I could not have anticipated any of that when I began writing, but it became clear as I progressed. A series of epiphanies, you could say.

Was there a single idea behind or genesis for Cutting for Stone?

My ambition as a writer was to tell a great story, an old-fashioned, truth-telling story. But beyond that, my single goal was to portray an aspect of medicine that gets buried in the way television depicts the practice: I wanted the reader to see how entering medicine was a passionate quest, a romantic pursuit, a spiritual calling, a privileged yet hazardous undertaking.

It’s a view of medicine I don’t think too many young people see in the West because, frankly, in the sterile hallways of modern medical-industrial complexes where physicians and nurses are hunkered down behind computer monitors, and patients are whisked off here and there for this and that test, that side of medicine gets lost.

So I began with the image of a mission hospital in Africa, redolent with Dettol, the antiseptic of choice of the tropics; I wanted to portray a place so basic, so unadorned, that nothing separates doctor and patient, no layers of paperwork, technology or specialists, no disguising of the nature of the patient’s experience or the raw physician experience. It’s a setting where the nature of the suffering, the fiduciary responsibility and moral obligation to the patient and society are no longer abstract terms. In that setting I wanted to put very human, fallible characters-people like Sister Mary Joseph Praise and Thomas Stone. I wanted the whole novel to be of medicine, populated by people in medicine, the way Zola’s novels are of Paris.

Where did the idea for the story of these twins germinate and how did it grow?

When I actually sat down to begin to write this book, what kept recurring was an image of a beautiful, south-Indian nun who suddenly and precipitously goes into labor in a mission hospital in Africa. That act of her going into labor throws everyone for a loop and causes utter confusion at the hospital. That’s all I had to begin with.

I saw her succumbing in that labor, and I saw one of the twins becoming the narrator of the story and looking back in somewhat of an antique voice. So I kept writing, developing the ideas, themes, and characters.

I found some reassurance in a quote by E.L. Doctorow who says about writing that, ‘It’s like driving a car at night. You never see further than your headlights, but you can make the whole trip that way.’ It was often nerve wracking not to know what lay ahead. I’d heard master storytellers like John Irving say that if you’re just making it up as you go along, if you have no plot, then you weren’t a writer, but an ordinary liar!

Halfway through the book, I felt my characters were so alive that their choices were infinite. I had to know what was going to happen, so I met with my editor and we hammered out a plot. My relief at that point was huge; I could concentrate on language and the telling. What surprised me is that even then there were so many discoveries, so many truths that emerged unexpectedly. It affirms for me what I most love about writing, and that is that it is not a rational, logical process

One of the most striking elements of Cutting for Stone is the intimacy with not just one character, but an entire cast. Though Marion tells the story, we become deeply involved in each person’s struggles, not just his own. Which characters did you feel closest to while writing the book? And why did others feel more distant?

Characters, by the way, do not start out rounded. They emerge. I think Ghosh is the character whose emergence and whose full blossoming I loved most. He is essentially fair, kind and eminently faithful, a family man, and above all patient – all the qualities I would like to have myself, but don’t always. He is the consummate internist too, which I also aspire to be. He gives me something to strive for.

Hema, too, is someone I deeply understood – or understand as well as a male writing a novel can understand a woman. Thomas Stone is both more alien and familiar – a doctor caught up in the illusion that work can redeem his character failings. Shiva – I let him be distant, impenetrable, because that is the nature of his character. My editor would sometimes be frustrated with me because she could not ‘see’ Shiva, and I would say to her, ‘Yes! That is the point. There is a quality to him, an Asperger’s-like patina, that makes him hard to know.’

In your earlier books, you touch on the breakup of your personal life due to the strain of practicing medicine. Do these experiences echo through Dr. Stone’s choosing work over life – and to what degree?

Yes, I felt a great empathy for Stone and his feeling that medical work is the most wonderful work you can ever do and yet how he hurt the people around him by losing himself in a love for his work that was so extreme.

An aim of the novel was to show just how medicine and the magic word, ‘work’ can both heal and cripple, how it is a trap and yet it is a balm and as Yeats would say, the challenge is to find that balance between the ‘perfection of the life or of the work’ and in the book there are characters who exemplify both ends of that spectrum. Dr. Stone was very skilled, he focused on the moment and had great knowledge and wisdom, but it was not enough to save him. Perhaps there is some of my own life in that thought, who knows?

At the heart of this novel there is a love story – that of Sister Mary Joseph Praise and Dr. Thomas Stone – which informs almost everything that happens to each character in the book, and yet one of these characters is dead and one has not been seen by anyone for decades. How did you conceive of their relationship, and how do they exert such force on the novel even though neither is present for the majority of it?

Love to me has a quality to it like a trip wire – hence we ‘fall’ in love, instead of simply ‘arriving’ to love. Love comes down to a set of wills trying to match and sometimes mismatching in spectacular fashion; I think all love is unrequited unless we have a clone of ourselves and even then the love is unrequited. In my day job I see all too often that people’s appreciation of the existence of love, of the meaning of love, or of the idea that the meaning of life turns out to be love – all these are arrived at too late, when the love is long lost, or arrived at just before the moment of death.

The medical passages were fascinating. Do you keep a medical journal?

I don’t keep a journal as much as I write notes when I observe something I want to remember later, so I can recall the situation – the feelings, the interaction – at a later time. I have always scribbled. For some of the intense medical situations in the book, some very fine, accomplished surgeons allowed me over the years to be present as they worked, understanding that I wanted to be able to convey the wonder of surgery, of curing, of healing. It was an honor and I am deeply grateful to have been able to do this.

Where does the title ‘Cutting for Stone’ come from?

There is a line in the Hippocratic Oath that says: … I will not cut for stone, even for patients in whom the disease is manifest … It stems from the days when bladder stones were epidemic, a cause of great suffering, probably from bad water and who knows what else. Adults and children suffered so much with these – and died prematurely of infection and kidney failure.

There were itinerant stone cutters – lithologists – who could cut either into the bladder or the perineum and get the stone out, but because they cleaned the knife by wiping it on their blood-stiffened surgical aprons, patients usually died of infection the next day.

Hence the proscription, ‘hou shall not cut for stone.’ It has always seemed to me a curious thing to say when we recite the oath in this day and age. But I love the Hippocratic Oath (or oaths, because its origins and authorship are far from clear), and always try to attend medical school commencement. When the new graduates stand and take the oath, all the physicians in the room are invited to rise and retake the oath.

You bring Ethiopia to life so vividly – its contradictions of beauty and poverty. Addis Ababa (and Missing Hospital) is so much a part of each character though some come to it from other places or leave it for other places. Why did you decide to set much of this novel there? And how do you think the atmosphere of the place affected your life?

Even in this era of the visual, I think a novel can bring out the feel of a place better than almost any vehicle. It’s another thing that Somerset Maugham did so well. The few images one sees of Ethiopia are uniformly negative, about war and poverty. I wanted to depict my love for that land and its people, for their incredible beauty and grace and their wonderful character.

I wanted also to convey the loss many felt when the old order gave way to the new. Ethiopia had the blight of being ruled by a man named Mengistu for too many years, a man propped up by Russia and Cuba. My medical school education was actually interrupted when Mengistu came to power and the emperor went to jail. As an expatriate, I had to leave. It was my moment of loss. Many of my medical schoolmates became guerilla fighters, trying to unseat the government. Some died in the struggle. One of them fought for over twenty years, and his forces finally toppled the dictator.

What books have made the most difference in your life?

Several books were seminal in my coming to medicine, allowing me to see medicine as a calling, a romantic and noble pursuit. Of Human Bondage by Somerset Maugham was one such book. Also A.J. Cronin’s The Citadel and Keys of the Kingdom. That used to be how people came to be drawn to medical school. Now, perhaps television and movies fulfill that role.

My favorite novel has little to do with medicine despite its name, and happens to be a great love story – it’s Love in the Time of Cholera by Gabriel Garcia Marquez. Some writers read George Eliot’s Middlemarch every year. I read Love in the Time of Cholera.

What’s the best way to get a child interested in reading?

I don’t know the best way, and I wish someone would show me! But I do know it’s important. What we often forget is that when we read and enjoy a good novel, we are engaging in a collaborative act with the writer. The writer gives us the words, we provide the imagination, and somewhere in middle space, we jointly create this fictional dream, this mental movie. It requires effort on our part – it is not a passive act, but a creative one to read a book. The writer has to give you just enough words, not too many; just enough so that you can imagine the rest. If you have ever been horribly disappointed when your favorite book was made into a movie, because the actor looked nothing like the person you had conjured up in my mind, then you know what I mean.

I believe that, as the writer John Fowles has said, that if you don’t practice this skill of taking words on a page and turning them into pictures, then a part of the brain atrophies. I try to make this point with our medical students: that reading stories, novels, keeps a part of the brain alive, and it relates to the clinical imagination. I don’t know a single clinician I have greatly admired over the years who has not also enjoyed good literature or some aspect of the arts. I think it is no coincidence. That is where the right brain comes in. Medicine is, and will always be – no matter how much technology we introduce – an art and a science. You need both.

Your first two books are non-fiction, but you’ve said that you have always thought of yourself as a fiction writer first. How so?

Fiction is truly my first love. To paraphrase Dorothy Allison, fiction is the great lie that tells the truth about how the world really lives. It is why in teaching medical students I use Tolstoy’s The Death of Ivan Ilych to teach about end-of-life, and Bastard out of Carolina to help students really understand child abuse. A textbook rarely gives them the kind of truth or understanding achieved in the best fiction.

One of my first published short stories was ‘Lilacs,’ in which the protagonist has HIV. Its appearance in The New Yorker in 1991 was a part of what led to my contract to write My Own Country, a memoir of my years of caring for persons with HIV in rural Tennessee. While writing that book I found myself living through an intense personal story of friendship and loss that led to a second non-fiction book, The Tennis Partner. But after that, I passed up on an offer to write a third non-fiction book. I was keen to get back to fiction, to explore that kind of truth.

My true call to medicine came in the form of a book. By the time I picked up Of Human Bondage by Somerset Maugham I had already read Lolita and Lady Chatterley’s Lover. I was twelve, I think. Maugham’s protagonist, Philip, sets out for Paris to become an artist. Money is tight, and he lives on the brink of starvation, and finally finds he does not have the talent. He is crushed and disappointed but also relieved to have discovered what is not to be his calling. He returns to London and enters medical school. When after years of slogging away he enters the outpatient clinic for the first time, he realizes he has made the right choice. The particular lines that stayed with me, that have haunted me, were: ‘there was humanity there in the rough, the materials the artist worked on; and Philip felt a curious thrill when it occurred to him that he was in the position of the artist…’

The phrase ‘humanity there in the rough’ spoke directly to my twelve-year-old mind. I took it to mean that if one had no God-given talent to be an artist (or mathematician), one could aspire to be a doctor, perhaps even a good one. The beauty of medicine is that it is proletarian, and its prime prerequisite is that you have an interest in humanity in the rough. Many of us also come to medicine because we are wounded in some way. Thomas Stone is a great example, but so is Marion Stone.

Medicine plays a big part in your novel, and it is also something that unites people of different races and religions in Cutting for Stone: Hindus, Christians, Indians, Africans and Westerners all work for a common goal: curing the patient. Is this the message of your book?

Indeed, I wanted the whole novel to be of medicine, populated by people in medicine, the way Zola’s novels are of Paris. If I begin with a mission hospital in Africa, a place redolent with Dettol and carbolic acid scents, it is because I think that in a place so basic, the nature of the suffering, the fiduciary responsibility and moral obligation to the patient and society are no longer abstract terms. Indeed, nothing separates doctor and patient, no layers of paperwork, technology or specialists and you can’t disguise the nature of the patient’s experience or the raw physician experience.

Then I put in very human, fallible characters — people like Sister Mary Joseph Praise, Thomas Stone. To take the story to America was to contrast this world with Western medicine, its power and beauty, but also its failings. Contrasting an inner city underfunded non-academic center with a ‘Mecca’ of a tertiary referral center was also I think a good way to point out the strengths and weaknesses of both and also to highlight the very different people who inhabit such places.

But ultimately, I think the intent was to point out that even though medicine changes, the fundamental role of the physician, the need for their presence, does not change, and the importance of that presence is greater than ever. Cure is laudable but not always something we achieve, but comforting and healing is something we can do. It is the healing or Samaritan or priestly function of being a physician that we seem loath to claim.

A few months ago, a 40 year-old woman came to an emergency room in a hospital close to where I live,and she was brought in confused. Her blood pressure was an alarming 230 over 170. Within a few minutes, she went into cardiac collapse. She was resuscitated, stabilized, whisked over to a CAT scan suite right next to the emergency room, because they were concerned about blood clots in the lung. And the CAT scan revealed no blood clots in the lung, but it showed bilateral, visible, palpable breast masses,breast tumors, that had metastasized widely all over the body. And the real tragedy was, if you look through her records, she had been seen in four or five other health care institutions in the preceding two years. Four or five opportunities to see the breast masses, touch the breast mass, intervene at a much earlier stage than when we saw her.

http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch?language=en#

https://www.youtube.com/user/TEDtalksDirector

TEDED – A doctor’s touch

Welcome to the Stanford Medicine 25 website. Remember, this site is NOT the Stanford Medicine 25; it is only a map to a territory, one that must be explored in person! The Stanford Medicine 25 consists of hands-on sessions in small groups. You can’t substitute for that, and we don’t try to. However, this site provides a place to go to remind ourselves of what we have learned, or are about to learn in a hands-on session.

http://stanfordmedicine25.stanford.edu/the25/

American College of Cardiology 2015 Annual Meeting: Simon Dack Lecture: “I Carry Your Heart” by Abraham Verghese, MD

Reporter: Aviva Lev-Ari, PhD, RN

https://pharmaceuticalintelligence.com/2015/04/08/american-college-of-cardiology-2015-annual-meeting-simon-dack-lecture-i-carry-your-heart-by-abraham-verghese-md/

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