2 Gazette Health | Summer 2012
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Summer 2012 | Gazette Health 3
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Summer 2012 | Gazette Health 5
Because they have the wrong ratio of protein, fat and carbohydrates, cow’s milk, soy milk, rice milk and homemade formulas should not be given to babies younger than 1.
WAYS TO TEMPT YOUR PICKY EATER Picky eating is generally temporary in young children. If you don’t make a big deal out of it, it will usually end before school age.
1 2 3
want broccoli for dinner?” ask, “Which would you like for dinner: broccoli or cauliflower?”
SERVE THE SAME FOODS TO THE ENTIRE FAMILY.
Don’t be a short-order cook, making a different meal for your preschooler. Your child will be OK even if she doesn’t eat a meal now and then. NAME A FOOD THAT YOUR CHILD HELPS CREATE.
Make a big deal of serving “Dawn’s Salad” or “Peter’s Sweet Potatoes” for dinner. CUT FOOD into fun shapes with cookie cutters.
ENCOURAGE YOUR CHILD TO INVENT and to help you prepare new snacks or sandwiches. Have him help you make your own trail mixes from dry cereal and dried fruit.
HAVE YOUR CHILD MAKE TOWERS out of
JAZZ UP THE TASTE of vegetables with low-fat dressings or dips. Try hummus or bean spread as a dip for veggies.
whole-grain crackers, spell words with pretzel sticks or make funny faces on a plate using different types of fruit.
CHOOSE FUN SNACKS AND MEALS:
Split mini bagels in two. Cut each piece into half circles. Spread the halves with toppings like tuna salad, egg salad or peanut butter. Decorate with sliced cherry tomatoes or banana slices. Arrange the half circles to form the body of a snake. Use olives or raisins for the eyes.
•ENGLISH MUFFIN PIZZA: Top half
of an English muffin with tomato sauce, chopped veggies and low-fat mozzarella cheese. Heat it until the cheese is melted.
6 Gazette Health | Summer 2012
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Top a slice of bread with peanut butter and use an apple slice for a smile and raisins for eyes.
Percent of adults who have trouble sleeping who report difficulty remembering things
•FROZEN BANANAS: Insert
a wooden stick into a peeled banana. Cut large bananas in half first. Wrap in plastic wrap and freeze. Once frozen, peel off the plastic and enjoy.
•POTATO PAL: Top half of a small baked potato with
eyes, ears and a smile. Try peas for eyes, a halved cherry tomato for a nose and a low-fat cheese wedge as a smile.
Percent who say they have trouble getting work done due to lack of sleep
GRAHAM CRACKER SANDWICHES: Mix mashed bananas and peanut butter, spread between graham crackers and freeze.
•FROZEN JUICE CUPS: Pour 100
percent fruit juice into small paper cups. Freeze. To serve, peel off the paper and eat.
Percent of U.S. youth who are obese, triple the rate of the last generation
Spread peanut butter thinly onto celery sticks. Top it with a row of raisins or with other diced and dried fruit. - USDA
Percent of U.S. adults who are obese
90 to 98
Percent of sinus infections believed to be caused by viruses; antibiotics are ineffective in treating these
most common reason antibiotics are prescribed: sinus infection
-SOURCES: CDC and University of British Columbia and Vancouver General Hospital
ISTOCKPHOTO: SINUS INFECTION, LUGO; OBESITY, JANGELTUN; YAWN, BY_NICHOLAS; PICKY EATER, NCOGNET0
OFFER CHOICES. Rather than asking, “Do you
Summer 2012 | Gazette Health 7
AS MANY AS 1 IN 5 TEENS WILL SUFFER FROM MAJOR DEPRESSIVE DISORDER.
MORE THAN A MOOD
BAT T L I N G D E P R E S S I O N I N T E E N S BY KAREN FINUCAN CLARKSON
There is a laundry list of warning signs, but, according to Shull, the three more common ones are depressed mood, loss of interest in activities and general irritability. Irritability, which does not always present in adults, includes “frequent outbursts and increased frustration over minor issues that doesn’t subside and go away,” said the registered nurse. “Red flags are noticeable changes in thinking and behavior,” said Pedro Sarmiento Jr., M.D., a Waldorf pediatrician with privileges at Southern Maryland Hospital Center in Clinton. Teens “may lack motivation; become withdrawn, staying behind closed doors; sleep excessively; or experience a change in their eating habits. Softer, more subtle signs include apathy, body aches or pains, difficulty concentrating or making decisions, excessive guilt, forgetfulness or memory loss, and anxiety.” It is a willingness to engage in risky behaviors—such as drug and alcohol use, promiscuity, shoplifting and fistfights—that differentiates teen depression from adult depression, according to NAMI. It is a preoccupation with death and dying or suicidal or homicidal thoughts that necessitates immediate intervention.
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eens are known during the pubescent period to be anxious, a little rebellious and moody,” said Jackee Shull, staff clinical educator at Adventist Behavioral Health Rockville. Rapid developmental changes in the adolescent mind and body can result in moods that swing like a pendulum. But when melancholy becomes “pervasive and doesn’t go away and affects all aspects of life—biologically, academically, emotionally, socially and spiritually—that’s something else.” Depression is a serious medical condition that, untreated, can lead to substance abuse, criminal activity and suicide. Teens living with depression “talk about an overriding sense of inadequacy, hopelessness and helplessness in every part of their lives,” said Shull. In any given year, about 8 percent of adolescents will have a major depressive episode, according to the National Alliance on Mental Illness (NAMI). And multiple authorities, including NAMI, say that at some point, up to 20 percent of teens will suffer from one. While depression does occasionally resolve spontaneously in youths, it tends to be recurrent, with one episode increasing the risk for another. Some 40 percent of teens will have a second bout of depression within two years.
SEVERAL BIOLOGICAL FACTORS ARE
known to contribute to depression in adolescents. The brain of a depressed teen may appear physically different than [continued on 26]
Summer 2012 | Gazette Health 9
DIZZINESS AND HEADACHE ARE THE MOST COMMONLY REPORTED SYMPTOMS RIGHT AFTER A CONCUSSION.
Concussion takes a toll on young athletes
BY KAREN FINUCAN CLARKSON
10 Gazette Health | Summer 2012
A CONCUSSION RESULTS FROM SOME SORT OF
trauma, direct or indirect, that causes the brain to move within the skull. Gerard A. Gioia, director of Children’s National Medical Center’s Safe Concussion Outcome Recovery & Education (SCORE) Concussion Program in Rockville, likens it to a yolk swaying inside a shaken egg. “The head takes a blow and the brain moves back and forth. As it stretches and strains, chemicals are released and a metabolic cascade unfolds,” he said. The result is a disruption in brain function.
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RECOGNIZING A CONCUSSION ISN’T ALWAYS EASY.
“Sometimes the symptoms are subtle or we link them to an existing problem,” said Gioia. Occasionally “we attribute behaviors to their being goofy teenagers.” While the signs of a concussion are usually evident within minutes, they can take hours to fully manifest and that, noted Gioia, may lead parents to think something else is the culprit. Concussions bring about a change in behavior, thinking or physical functioning. “It’s as though your software is messed up without any change in the structure of the hardware,” Andrew Tucker, M.D., head team physician for the Baltimore Ravens, said at the Whitman forum. Some symptoms—such as loss of consciousness, seizures, headache, disorientation, or slurred speech—mandate an immediate visit to the emergency room. A child who appears dazed, confused or forgetful, or who reports feeling nauseous, dizzy, sluggish or sensitive to light or noise following a hit, also may have suffered a concussion. “If after 72 hours a child is still symptomatic, [continued on 21]
PHOTO BY RAPHAEL NEGRON, COURTESY OF KAREN FINUCAN CLARKSON
Bradford Clarkson, son of the author, plays basketball in April after having recovered from a concussion sustained in December.
he blow to the head that temporarily transformed my reserved, contemplative 12year-old into a goofy, giddy chatterbox went virtually unnoticed. There was no bump or bruise where the other child’s knee had met his head. And, by all accounts, the blow barely broke his stride. No one picked up on his condition for nearly two hours. “If I didn’t know he’d been playing basketball, I would swear he’d been drinking,” my husband said with concern just minutes after Bradford had gotten home. Guiding our son through the evening’s events—a tough task given his inability to stay focused—it became clear that he had a concussion. With that, Bradford joined an estimated 3.8 million Americans who suffer from recreation-related concussions each year, according to the Centers for Disease Control and Prevention (CDC). Annually, more than 170,000 people under 20 are treated in emergency rooms for traumatic brain injuries— including concussions—that happened during a sport or recreational activity.
Concerned by the number of students missing school or struggling with studies as a result of concussions, Alan Goodwin, principal at Walt Whitman High School in Bethesda, convened a panel of experts in April to address the topic. What’s unclear is whether students are suffering from more concussions or being diagnosed with greater frequency. Gioia contends it’s the latter. “There’s been an explosion in the diagnosis of concussions,” he said, due to increasing awareness among parents, coaches, school officials and student athletes. In the last 10 years, the number of children treated in emergency rooms for sports/recreation-related traumatic brain injuries, including concussion, has jumped 60 percent, the CDC reported.
Summer 2012 | Gazette Health 11
COLORECTAL CANCER IS THE THIRD MOST COMMONLY DIAGNOSED CANCER IN THE UNITED STATES.
BY BILL HOLLERAN
12 Gazette Health | Summer 2012
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reduce your risk compared to doing nothing.” -Sean Hunt, M.D.
“There is no single cause of colon cancer,” according to PubMed Health, a service of the U.S. National Library of Medicine. “Nearly all colon cancers begin as noncancerous polyps, which slowly develop into cancer.” “We’ve made amazing progress in early detection and prevention since 1999,” said Richard Chasen, M.D., a gastroenterologist who is a partner with the Capital Digestive Care in Laurel and Takoma Park. “That’s when the American Cancer Society and American College of
Gastroenterology began recommending colonoscopy screenings starting at age 50 for Caucasians and age 45 for African-Americans.” African-Americans have the highest incidence and death rate from colon cancer in the United States, hence the recommendation for earlier screening, according to the American Cancer Society. These target ages are for average-risk individuals with no family history of colorectal cancer or personal history of polyps, Chasen pointed out. Since 1999, approximately 65 percent of Americans who should have been screened have been screened, according to Chasen, who has privileges at Washington Adventist Hospital in Takoma Park and at Laurel Regional Hospital. “In that period of time, according to a recent article in The New England Journal of Medicine, we have lowered the colon cancer death rate by 53 percent,” Chasen said. “Now the challenge is to screen the other 35 to 40 percent of people who are at risk.” According to PubMed Health, people have a higher risk for colon cancer if they:
olon or rectal cancer—also known as colorectal cancer—is one of the leading causes of cancer-related deaths in the United States. In 2012, the National Cancer Institute (NCI) estimates that there will be more than 143,460 new cases of colorectal cancer and 51,690 deaths from the disease. This makes colorectal cancer the third most common cancer diagnosed in both men and women in the United States (excluding skin cancers), according to the American Cancer Society. The good news, said Anu Gupta, M.D., a radiation oncologist who is medical director of the Cancer Center at Gaithersburg, is that the society’s statistics show that the death rate from colorectal cancer has been dropping for more than 20 years. When it comes to preventing colorectal cancer, screening makes all the difference. Colorectal cancer begins in the tissues lining the large intestine (colon) or the rectum (end of the colon).
“If you do anything, you are going to
THERE ARE SEVERAL SCREENING
methods for the prevention of colorectal cancer. “Evidence from the National Polyp Study showed clear evidence that removing (polyps) during a colonoscopy reduces risk for colorectal cancer significantly,” according to the Washington, D.C.area based advocacy group Fight Colorectal Cancer. A colonoscopy is a procedure that allows the doctor to see the entire colon by using a thin, long, flexible instrument with a lighted lens or video camera at its end, according to a description of the procedure by Fight Colorectal Cancer. Polyps can be removed and tissue samples taken for biopsies
using instruments that are introduced through the scope. In some cases, said Chasen, during a colonoscopy, the cancer can be caught before it has grown from the polyp into the wall of the colon. “The polyp is just turning into cancer and that’s all that needs to be removed.” Routine colonoscopy screenings should continue every 10 years up to age 75, according to the U.S. Preventive Services Task Force. Between 75 and 85, screenings are recommended only when risk factors are present. After 85, the screenings are not recommended by the task force. MEANWHILE, THE EFFECTIVENESS OF
flexible sigmoidoscopy as a screening test for colorectal cancer has been supported by the results of a study NCI announced in May. That study concluded that sigmoidoscopy “is less invasive and has fewer side effects than colonoscopy (and) is effective in reducing the rates of new cases and deaths due to colorectal cancer.” During a flexible sigmoidoscopy exam, a thin tube known as a sigmoidoscope is inserted into the rectum. A tiny video camera at its end provides a view of the rectum and the end of the large intestine. If necessary, biopsies can be taken through the scope, according to the Mayo Clinic. In that study announced by NCI, “researchers found that overall colorectal cancer mortality was reduced by 26 percent and incidence [new cases] was reduced by 21 percent as a result of screening with sigmoidoscopy.” The study spanned almost 20 years. According to Hunt, the recommendation for sigmoidoscopy screening is once every three to five years, more frequent than the colonoscopy because the procedure does not provide a view of the entire colon. Additional screening methods include: [continued on 20]
• Are older than 60 • Are African-American or of eastern European descent • Eat a diet that is high in red or processed meats • Have colorectal polyps • Have inflammatory bowel disease (such as Crohn’s disease or ulcerative colitis) • Have a family history of colon cancer • Have a personal history of breast cancer Both polyps and early-stage colorectal cancer are usually asymptomatic, according to Chasen. “Symptoms of more advanced colorectal cancer are abdominal pain, bleeding, anemia or change in bowel habits,” said Sean Hunt, M.D., a gastroenterologist with Frederick Gastroenterology Associates, who has privileges at Frederick Memorial Hospital. “But here’s the sad part. If you have a symptom that is related to the cancer, you’re probably not curable. That’s why it is so important to follow the screening recommendations.” “The most important thing, by far, is prevention,” Hunt said. “By finding polyps and removing them, we can prevent colon cancer 70 to 90 percent of the time.”
Summer 2012 | Gazette Health 13
4 OUT OF 5 WHO EXPERIENCE INCONTINENCE ARE WOMEN.
No more suffering in silence the latest treatments for urinary incontinence BY ARCHANA PYATI
the elderly, doctors say they are seeing greater numbers of younger women—in their 30s and 40s— coming to their offices complaining of involuntary loss of urine. “They want to come in, they’re doing their research, they’re leaking, and they’re asking their gynecologists about it,” said Anita Pillai-Allen, M.D., the pelvic surgeon and urogynecologist who performed Merryman’s surgery at Holy Cross Hospital in Silver Spring.
14 Gazette Health | Summer 2012
STRESS AND URGE INCONTINENCE
“The more they void without their bladder being full, the more the bladder feels like it has to void without being full.” -Lynne Schill, physical therapist
While both sexes suffer from incontinence, it is more common in women. The National Association For Continence estimates that of the 25 million adult Americans who experience incontinence, as many as 80 percent are women. And while incontinence has long been associated with
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are two distinct conditions, although occasionally, a woman will have both. Stress incontinence happens when the urethra, the tube that carries urine from the bladder out of the body, loses support from the pelvic floor muscles and becomes hypermobile. A woman with stress incontinence will leak urine when she exerts herself through coughing, laughing, sneezing, vigorous exercise or heavy lifting. Pelvic floor muscles deteriorate for a variety of reasons, said Pillai-Allen. Vaginal births and surgical procedures that assist vaginal births, such as an episiotomy, traumatize the muscles and nerves of the pelvic floor. Genetic factors also come into play, with some women inheriting weaker connective tissue around the pelvis. Hormonal changes may also prevent women from tightly contracting pelvic floor muscles, said Cynthia Moorman, M.D., a staff urologist with Frederick Memorial Hospital. “As we get older, estrogen levels decrease, which decreases strength and tightness in those muscles,” she said. That may be why some women, like Merryman, don’t
n a gorgeous day in May, Terri Merryman and her husband celebrated their 25th wedding anniversary by heading to Chesapeake Beach. The couple hopped in the car for a relaxing hour-long drive, lingered over a seafood lunch at the Rod ‘N’ Reel Restaurant and took a leisurely stroll along the water before returning home. For Merryman, a 51-year-old nurse who lives in Silver Spring, the occasion wasn’t just a watershed moment in her marriage, but also a personal milestone: “I did the whole drive without having to go to the bathroom,” she said. Before her pelvic reconstructive surgery in 2011, the trip would’ve been impossible. For years, she suffered from urinary incontinence, a problem she had postponed treating out of fear and uncertainty. Outings with her family had become a thing of the past as her need to be near a bathroom took priority. “My husband and I never went very far,” she recalled. “It was upsetting to him, and upsetting to me because I was holding everyone back.” Urinary incontinence itself is not a disease, but rather a serious symptom of underlying damage to the muscles, nerves and tissues surrounding the bladder. In Merryman’s case, her pelvic organs— her bladder, uterus and rectum—had fallen out of place, a problem known as prolapse. The cause is a common one among women who have experienced vaginal childbirth. Both of Merryman’s children had been 10 pounds at birth, causing her pelvic floor muscles to stretch and lose their supportive function.
experience loss of urethral support until years after giving birth. “Our bodies are better at recovering when we’re younger.” The most common treatment of stress incontinence is the surgical placement of a sling around the urethra. The sling, crafted from a narrow strip of a synthetic material called polypropylene, is inserted through the vagina and held in place by tissue surrounding the urethra and bladder, according to interviews with doctors and marketing materials from American Medical Systems Inc., a manufacturer of a brand of the sling. While the sling procedure is widely practiced and considered safe, after receiving complaints of pain and injury among women who had undergone the surgery, the U.S. Food and Drug Administration released a statement last year urging doctors and patients to proceed with caution. Slings have a less than 1 percent chance of eroding and breaking through the vaginal wall, a result more commonly seen with larger meshes used to treat prolapse, where all the pelvic organs need to be lifted back into place, said Moorman. “People
are hesitant to use meshes. The bigger the mesh, the more problems you could have with them.” URGE INCONTINENCE IS CAUSED BY A MIS-
communication among bladder nerves, the central nervous system and the brain, resulting in an overwhelming urge to urinate, said Moorman. Much less is understood about its origins and the best way to treat it. Women with neurological damage caused by strokes, Parkinson’s disease, multiple sclerosis, spinal cord injuries—even diabetes, as high blood sugar levels can impair nerves—may struggle with urge incontinence. “The bladder is saying to the brain, ‘you’ve got to go,’” even if the bladder isn’t full, said PillaiAllen. Two-thirds of women who incessantly feel the need to urinate, also known as overactive bladder or urgency frequency syndrome, don’t actually wet themselves, she said. Yet they may be running to the bathroom dozens of times a day. “We have to teach them to overcome the urge and to enable their bladder to fully expand,” said Lynne Schill, a physical therapist at FMH
Crestwood in Frederick who treats women with incontinence. “The more they void without their bladder being full, the more the bladder feels like it has to void without being full.” Medications can temporarily calm the bladder’s hyperactivity but have significant side effects, such as dry mouth and constipation, said Moorman. In those cases, doctors may recommend InterStim Therapy. InterStim Therapy stimulates nerves that control the bladder by sending electrical pulses through a thin wire inserted near the tailbone. During a trial period, the pulses are generated through a device a woman wears externally, according to Medtronic, which manufactures the device. If the therapy proves successful, as a long-term solution, a neurostimulator can be surgically implanted under the skin of the upper buttock. While InterStim has proven life changing for many patients, doctors say it won’t guarantee dryness 100 percent of the time. “They will still have good days and bad days,” said Moorman. “If you were [continued on 28]
Summer 2012 | Gazette Health 15
BEGINNING IN THEIR 30s, MEN START TO EXPERIENCE ABOUT A 1% PER YEAR DROP IN TESTOSTERONE LEVELS.
BY KAREN FINUCAN CLARKSON
16 Gazette Health | Summer 2012
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exam can uncover causes other than aging, for which treatments may return testosterone levels to normal. There is a range of normal. A lab test measures the amount of testosterone in the blood. Results typically would fall between 300 and 1,200 ng/dL (nanograms per deciliter). If a man is experiencing symptoms associated with low testosterone—such as low libido, erectile dysfunction, reduced muscle mass or irritability— “but is told he has ‘normal testosterone,’ he should press the doctor and find out if he is in the lower third, middle third or upper third. If he has a level of 350 and we can get it to 600 or so, he may see significant improvement,” said Litvak. Low testosterone affects men differently, said Eric Emanuel, M.D., a urologist at MidAtlantic Urology Associates with privileges at Doctors Community Hospital in Lanham. “There are men with low testosterone who are completely unaware of it; they have no outward indications,” he said. Treating low testosterone has become easier and more convenient over the past decade. Because oral testosterone is toxic to the liver,
hile it’s not realistic to look at testosterone replacement as a fountain of youth, the increasingly popular therapy holds great promise for men whose quality of life has deteriorated over the decades due to a drop in hormone levels. “The benefits of therapy include increased sexual desire and function, improved muscle mass, enhanced mood and even perhaps improved cognitive function,” said Jared Berkowitz, M.D., a urologist with Frederick Urology Specialists and privileges at Frederick Memorial Hospital. More than 13 million men in the U.S. suffer from low testosterone, according to the American Diabetes Association, but less than 10 percent of them receive treatment. Still, that’s significantly higher than treatment rates around the globe. The average across European countries is under 1 percent and in Australia it’s just over 1.6 percent, according to a March 2009 report on the National Center for Biotechnology Information’s website.
Produced primarily in the testes, testosterone is a hormone “that during fetal development and puberty leads to the growth of the male sexual system,” said Berkowitz. During puberty, it puts hair on the chest and deepens the voice. “It also has an important role in the general physiology of the male, our overall homeostasis,” said Juan Litvak, M.D., a urologist with Urological Consultants, who has privileges at Suburban Hospital in Bethesda. “It influences energy, bone and muscle health, and metabolism—the way we process and store fat.” A dip in testosterone levels is normal as men age. “Men in their 30s start to see a slow decrease, about 1 percent a year,” said Berkowitz. “But it’s generally not until their 50s that they start to notice changes.” There are other reasons, apart from aging, why testosterone levels may be low. Kidney or liver disease, diabetes, obesity, injury to the gonads or testes, or a disorder of the pituitary gland in the brain that controls the release of many hormones may be the culprit, according to Berkowitz. “Rarely, some medications may lead to low testosterone,” he said. A medical
“Anyone who is potentially interested in fathering a child should understand the risk.” The therapy does not cause prostate cancer, “but it can accelerate pre-existing prostate cancer,” said Kurnot, who uses a prostatespecific antigen (PSA) test to help detect cancer. “Hormone-dependent cancers, such as prostate cancer, are easy to detect.” While men with prostate cancer are not candidates for testosterone replacement, it’s less clear as to whether former cancer patients should undergo the therapy. “Some newer studies say those who were adequately treated and whose cancer has not recurred may be eligible,” said Berkowitz. “It’s an area of ongoing investigation.”
The newest treatment option is pellets, known as Testopel, implanted in the buttock. Testopel is the most effective treatment currently available. “A topical [gel] might bring levels up 20 to 30 percent. With continuous dosing, a patient might go from 300 to 400,” said Emanuel. “With Testopel, a patient could go from the mid 300s to 700 or 800, even to the higher end of normal.” Testopel requires that patients see their doctor every three to six months, according to Richard A. Kurnot, M.D., a urologist with Chesapeake Urology Associates who has privileges at MedStar Montgomery Medical Center in Olney. “I bring them back in the first couple of months to check their blood cell count and liver enzymes,” he said. Testosterone replacement can cause polycythaemia, “a condition where the blood gets too thick. It can also be toxic to the liver.” Replacing testosterone can have “a detrimental effect on sperm production,” said Emanuel.
The effects of testosterone replacement therapy are felt in short order, according to Kurnot. “Patients can feel good within weeks—a whole lot better. It differs from patient to patient, but the sky’s the limit.” Men who begin testosterone replacement therapy may need to continue with it over the long term as it “actually shuts off the body’s own production of testosterone,” said Kurnot. “The higher levels of testosterone in the blood signal the brain that the body doesn’t need to create any more, and so it shuts down.” While testosterone replacement therapy may come across as the ultimate anti-aging formula, physicians claim that’s not so. “We are not using super-therapeutic amounts but, rather, bringing testosterone levels back to where they should be,” said Litvak. It is about “restoring health and a general sense of well-being.”
the delivery mechanism of choice was, for many years, injection. “That would require office visits every three weeks,” said Emanuel. Patches came next, but caused skin irritation in some men. “Then there was a whole run of topical gels and, more recently, Axiron, which you rub into your armpit much like you do with an antiperspirant. The newest option is implantable pellets.” Known as Testopel, these cylindrical pellets are about an eighth of an inch wide and three-eighths of an inch long. “I numb a 2-by-2centimeter area on one buttock and make a 3-millimeter incision,” said Emanuel. “Then I use an insertion device to implant the pellet in the subcutaneous tissue.”
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Summer 2012 | Gazette Health 17
How minimally invasive surgery fixed this Silver Spring man’s massively herniated discs BY KAREN FINUCAN CLARKSON
18 Gazette Health | Summer 2012
Spring. The diagnosis was a massive disk herniation. Three disks in Herzstein’s lower back were implicated. A spinal disk is similar to a jelly doughnut. Its soft center rests within a firm, durable case. Each of the 23 disks cushions the spine and separates vertebrae. A rupture or herniation occurs when some of the “jelly” pushes out through a crack in the casing, irritating surrounding nerves. Pain, tingling, numbness or weakness in the back or legs can result from herniated disks in the lumbar, or lower, region. Age-related wear and tear is the main cause of a herniated disk. As the spinal disk dries up over the years, flexibility is reduced. That makes it more prone to tearing or rupturing
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with even a minor strain or twist. Painful lumbar disk herniation affects 1 to 2 percent of Americans at some point in their lives, most often in their 30s and 40s, according to the American Academy of Orthopaedic Surgeons. Schneider recommended Herzstein undergo a minimally invasive surgical technique called microdiscectomy. The procedure alleviates pain in 90 to 95 percent of patients, according to the spine surgeon. Herzstein, miserable with pain, was ready “to fix it up and move on. We agreed upon it and Dr. Schneider did the surgery two days later. I was not inclined to waste any time.” The microdiscectomy was done as an outpatient procedure at Holy Cross [continued on 24]
PHOTO BY MATT MENDELSOHN PHOTOGRAPHY/COURTESY OF HOLY CROSS HOSPITAL
cuba diving in the Cayman Islands, Basil Herzstein never imagined that within a few days he’d be in such excruciating pain that he wouldn’t be able to leave his bed. “I was fit—played squash five days a week—and had no problem carrying the tank, belts and equipment down to the water,” said the 61-year-old Silver Spring resident. “I swam and carried on just fine.” The plane ride home in August 2010 changed that. Coming to the aid of a fellow passenger, Herzstein hoisted her bag into an overhead compartment. “The suitcase must’ve weighed 100 pounds,” he said, “and I remember thinking, ‘There goes my back.’” Although Herzstein knew he had done some damage, he didn’t realize the extent of his injury. “It was sore, but I’d pulled muscles here and there before,” he said. “This time, however, the pain got progressively worse and worse.” Shortly thereafter, he was bedridden. “I could barely walk from the bedroom to the bathroom. No drug could relieve the pain.” Herzstein tried injections and therapy, but neither was effective. Anxious to return to both his job as a certified financial planner and his squash game, he saw Philip Schneider, M.D., an orthopedic surgeon and medical director of the Holy Cross Hospital Spine Center in Silver
1 IN 50 AMERICANS SUFFERS FROM OCD, WHICH IS CLASSIFIED AS AN ANXIETY DISORDER.
BY KAREN FINUCAN CLARKSON
And they cannot stop even if the practice becomes physically painful or damaging, he said. “Patients generally know there’s a problem, that their thoughts are irrational,” said Eduardo Espiridion, M.D., chief of psychiatry for Frederick Memorial Hospital. That does not mean they readily get help. “By the time most seek treatment, they’ve been suffering for years.” The average age of onset is 19, according to the National Institute of Mental Health. “We usually see it in early adulthood,” Espiridion said. “There’s no predilection for gender; men are equally as affected as women.” Gender may not matter, but intelligence does. “There’s a positive correlation between higher intellect and this disorder,” said Eyre. He points to the 18th-century author Samuel Johnson. “If you read his works, you’ll see that he had a real issue with his compulsions and was very ashamed.”
or some, relief comes only after washing their hands, perhaps a dozen times or more, until the parched skin cracks and bleeds. Others must check, sometimes several times an hour, that the door is locked, the stove is off, the hair dryer is unplugged. Still others become extreme pack rats, cluttering their homes with useless items. These rituals are a few of the more common ways in which people with obsessive-compulsive disorder (OCD) seek to alleviate the stress associated with their illness. Classified as an anxiety disorder, OCD afflicts roughly one in 50 Americans, according to Stan Eyre, administrative director/educator of psychiatry at Southern Maryland Hospital Center in Clinton.
THE DISORDER IS CHARACTERIZED BY
unwanted, irrational thoughts and compulsive behaviors, which a person adopts to hold the thoughts at bay. “These are intrusive thoughts or images that an individual can’t shut off,” said Lynnae A. Hamilton, who is program director for adult services at Adventist Behavioral Health Rockville. “The thoughts are not usually associated with real-life concerns, such as being late to the babysitter or forgetting to pay a bill. They can be violent or sexual in nature and repulsive to the person—not at all consistent with the person’s selfconcept,” she said. The inability to control the thoughts and their objectionable content drives OCD sufferers to embrace ritualistic behaviors to try to ward off the thoughts. “There’s nothing exact or prescriptive about the rituals,” said Hamilton, noting that the obsession and compulsion “are not always tied together.” While rituals—such as hand washing, showering, cleaning and repeatedly checking things—are routinely associated with OCD,
OCD SHOULD NOT BE CONFUSED
Recognizing and living with obsessive-compulsive disorder compulsions can take other forms, such as avoidance or hoarding. Hamilton noted that someone with obsessive thoughts about injuring a child might avoid holding a baby or visiting playgrounds or schools. Compulsive hoarding is experienced by 25 to 40 percent of those with OCD, according to the Obsessive-Compulsive Disorders Clinic at the University of California, San Diego. Not all hoarding is compulsive, however, and may be caused by other psychiatric disorders, or no psychiatric disorders at all. Studies
to identify root causes are ongoing, according to the clinic. THERE IS NO ENJOYMENT, ONLY A
temporary sense of relief, associated with the rituals and behaviors of OCD sufferers. In many cases, the compulsion, like the obsession, does not mesh with an individual’s selfimage, Eyre said. And as the need to perform the ritual or behavior eventually grows, so too does the shame associated with it. “It’s amazing how secretive this class of patient can be,” said Eyre. “They will turn themselves into pretzels to do it.”
with a condition known as obsessive-compulsive personality disorder (OCPD), said Hamilton. Those with OCPD tend to be preoccupied with orderliness, perfectionism and control in every part of their lives. “Imagine a type ‘A’ personality on steroids—meticulous, rigid. That person does not, however, have obsessions and compulsions,” she said. “Another key difference between the two disorders is that those with OCPD find their personality consistent with their self-concept and those with OCD do not.” Obsessive-compulsive disorder tends to run in families. Recent research found that low levels of a neurotransmitter known as serotonin could be responsible for the disease. This serotonin imbalance also may be genetic, Eyre said. The prevailing theory is that stress does not cause OCD, but that it serves as a trigger. “Many researchers believe it [OCD] has been at the sublevel all along and a trauma brings [continued on 23]
Summer 2012 | Gazette Health 19
COLORECTAL CANCER, continued from 13
STANDARD TREATMENT OPTIONS FOR COLORECTAL
cancer are surgery, chemotherapy and radiation treatments, according to Gupta. Colorectal cancer is “potentially curable” with surgery, said Hunt. “It depends on the stage. Stage 4 is not curable, but stage 1 has a 90 percent cure
African-Americans have the highest incidence of and death rate from colon cancer in the U.S., so screenings for that population should begin at 45.
• Virtual colonoscopy, a computerized tomography (CT) scan or MRI with special software to focus on the colon. No scope is used. According to Hunt, a virtual colonoscopy can detect “good sized”—one centimeter in length—polyps just as effectively as a traditional colonoscopy, but may miss smaller polyps. “If you find a polyp with a virtual colonoscopy, then you need a regular colonoscopy to remove it,” he said. The recommended screening frequency for virtual colonoscopy, according to Hunt, is once every five years. • Barium enema, which Hunt said can reduce risk by 30 to 50 percent if conducted once every five years • Stool testing for occult (hidden) blood. According to Hunt, “If you do stool testing once a year and act on a positive result, risk is reduced by 30 percent.” When it comes to screening for colorectal cancer, “If you do anything, you are going to reduce your risk compared to doing nothing,” Hunt said.
rate with surgery.” Surgery, he said, involves cutting out the cancerous part of the colon and “hooking it back together.” According to Gupta, chemotherapy is usually indicated for large tumors or when lymph nodes have become involved. Radiation, she said, is used “routinely” in the treatment of rectal cancer because surgery is more difficult due to the location of the rectum near the pelvis.
Research is being conducted “into more targeted therapies that work on the cellular level, looking at what transforms normal cells into cancerous cells,” Gupta said. There are certain pathways that a cell goes through to become cancerous, she explained, and this research “is gathering information about what happens along these pathways so that new drugs can be developed to stop that progression from happening.”
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CONCUSSION, continued from 10
RECOVERY CAN TAKE WEEKS OR
months. “Everyone recovers in their own time and there’s no way to predict at the outset how long that will be,” said Gioia. Certain factors can prolong recovery. A second concussion before the first has healed or repeat concussions within several months may take longer to resolve. Children or adolescents with ADHD, learning disabilities, headaches, or sleep or emotional problems may require additional time to recover. “Certain neurochemical conditions [such as ADHD and anxietyrelated conditions] don’t mix well with concussions,” he said. Given the brain’s complexity and role, it needs a break—from both physical and intellectual activity— to heal. “We want to avoid activities that exacerbate symptoms or overexert the body or brain,” said Gioia. Too much activity too soon may delay recovery. A child should not return to sports until he is symptom free, and that decision is best made by a health care professional, experts agree. MSDE regulations dictate that a student-athlete “shall not return until cleared by a licensed health care provider authorized to
provide sports physical examinations and trained in the evaluation and management of concussions.” Determining when a child may return to sports has become somewhat easier with the advent of baseline testing. Both SCORE and MedStar use a program known as ImPACT that assesses a child’s brain function, including memory, processing speed and reaction time. Baseline results can be compared to post-injury test results to help clinicians gauge when it is safe for the child to resume normal activities. “It’s not a vaccine. It’s a tool, not a panacea,” said Milzman, noting that some parents mistakenly think ImPACT affords athletes some level of protection against concussions. Baseline testing usually is not covered by insurance, according to Gioia. Parents and high school sports-booster associations generally cover the cost of the 30-minute assessment, which runs about $30$35 per student. Once a child’s brain function has returned to normal, best practices in concussion management call for a gradual return to play.
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WHILE THE OVERALL RISK OF
concussion in sports ranges from 5 to 10 percent, according to the Sports Concussion Institute, the threat is significantly higher in contact sports. Males playing football have a 75 percent chance of getting a concussion and females playing soccer have a 50 percent chance. The risk for boys as opposed to girls is not as high in basketball, my son’s sport of choice. But, now that Bradford has had one concussion, he is more susceptible to another. And a second could be more damaging than the first, as the effects of multiple concussions can be cumulative. “It’s important for kids to engage in athletic activities,” said Gioia, “but they need to be smart about it. I tell them, ‘Your brain is your future and you don’t want to screw around with that future.’…There’s too much at stake.”
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he needs to see someone,” David Milzman, M.D., a Whitman parent and director of medical research for the MedStar Sports Medicine Concussion Program, said at the forum. A child with a concussion should be benched, experts agree. The Maryland State Department of Education (MSDE) requires that any public school student-athlete suspected of sustaining a concussion immediately be removed from practice or play. Continuing to practice or play leaves the athlete vulnerable to a more severe brain injury or, rarely, death. A second blow, mild or severe, to the head before a young athlete has recuperated can cause fatal brain swelling. The risk of second impact syndrome is one reason “why we don’t let athletes participate until they are fully recovered,” said Tucker.
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OCD, continued from 19
it to the surface,” said Eyre. “I’m convinced that something happens chemically due to a life-changing event,” thereby causing OCD. Despite the possible biological component, there is no lab test to diagnose OCD. A mental health practitioner bases a diagnosis on an assessment of the patient’s symptoms—including how much time a person spends on rituals or compulsive behaviors—based on interviews with the individual and, when possible, family members or a significant other. Many clinicians rely on the YaleBrown Obsessive Compulsive Scale, which is designed to rate the severity and nature of OCD symptoms. “The scale is an important tool, but the patient history is how you really hone the diagnosis,” said Eyre. “There is no cure for obsessivecompulsive disorder, but there are treatments,” said Espiridion. “The most effective combines medication with cognitive behavioral therapy.” The idea behind that therapy “is to cut the relationship between the obsession and compulsion and to give the patient back control,” said Espiridion. “We try to disconnect the two so that even if you have the thought, you don’t have the action.” The therapy includes something known as exposure and response prevention. “Slowly, over time, we
expose them to what they fear….It can take years to achieve. We can’t just flood them with stimuli or they won’t stay in therapy. It must be done gradually.” The first medication considered when treating OCD is a type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI), such as Paxil, Zoloft or Prozac, according to the National Institutes of Health. If the SSRI is ineffective, older antidepressants may be prescribed. The advantage to SSRIs is that there generally are fewer side effects. Anti-anxiety medications may also be combined with these treatments. While the majority of patients benefit from treatment, some 30 percent retain some level of impairment, according to Espiridion. But, he said, treatment is imperative. “People who have OCD are predisposed to develop depression, and when they are depressed, they are at risk for suicide.” While OCD symptoms may ebb and flow, there is virtually no such thing as a symptom-free period, according to Eyre. Throughout the sufferer’s life, obsessions and compulsions will diminish and escalate. But those who “remain in behavioral therapy will get the redirection and support needed to maintain control in their lives.”
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Can you please explain the significance of the color-coded air quality warnings? Which colors could be harmful to my children when they play outdoors?
The Air Quality Index is a system to measure and warn the public when air pollution levels are dangerous. Green means air quality conditions are good. Yellow means levels are in a moderate range and those with sensitive lungs should limit prolonged outdoor exposure. Orange, Red and Purple are unhealthy days and can be dangerous for those with trouble breathing because pollution irritates the lungs and respiratory system. This is especially concerning for children with asthma and other respiratory conditions. Before you let your children play outside, check the air quality forecast. Elderly adults and other sensitive populations, such as those with chronic lung or heart conditions, should also watch this index before heading outdoors. -Scott Freedman, M.D., Medical Director, Pediatric Emergency Medicine at Shady Grove Adventist Hospital GAZETTE.NET
Summer 2012 | Gazette Health 23
HIS STORY, continued from 18
Hospital. After making a small incision—which in this particular procedure is usually no larger than 1 ½ inches—Schneider removed bone fragments and disk material from around the nerve roots to relieve pressure and create space for Herzstein’s nerves to heal. Staples sealed the incision. Because the surgery left the joints, ligaments and muscles virtually intact, healing was rapid and there was no change to the mechanical structure of the spine. In preparing for the procedure, Herzstein thought about his mother’s hip replacement surgery in South Africa in the 1970s. “She was flat on her back for seven weeks….I thought I’d be in the hospital four or five days,” he said. But less than eight hours after his microdiscectomy, Herzstein was home. “I was sitting at the kitchen table joking with my kids,” said the father of two adult daughters.
“I was a little dopey from the anesthetic and a touch nauseous, but otherwise feeling fine.” Relief came quickly. Herzstein used pain killers “for only a day or two” and began physical therapy within a few days of the surgery. “I did therapy three times a week, followed all of the rules and did everything by the book,” he said. After a month, he was hitting a squash ball, and by the six-week mark, he was playing again. “I think I’m at least back to where I started and maybe better off,” he said. While he’s careful to watch what he lifts, he doesn’t let the thought of injury interfere with his enjoyment of life. “I still play squash four or five times a week for an hour-and-change each time.” He takes a break from squash only when he travels. As he prepared to visit a daughter in Israel in mid-May, Herzstein did so without any hesitation or concern that back pain might frustrate his plans.
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24 Gazette Health | Summer 2012
I’ve recently been diagnosed with atrial fibrillation, and a friend of mine told me she had an ablation procedure to fix her abnormal heart rhythm. What is that, and how do I know if I’m a candidate? Atrial fibrillation (AF) is a common, abnormal heart rhythm problem where, ‘unorganized’ electrical activity causes the upper part of the heart to beat faster than the rest of the heart. An ablation is an option for people who cannot tolerate medications or when medications are not effective in maintaining a normal heart rhythm. During the procedure, a catheter is positioned inside your heart near the pulmonary veins and radiofrequency energy is used to eliminate the heart tissue around the pulmonary veins. As a result, the abnormal electrical signals can no longer reach the rest of the heart. Most patients who undergo an ablation will have complete elimination or significantly reduced AF episodes. Some people live for years with AF without any problems, but it can lead to some serious long-term issues, such as an increased risk of stroke and heart failure. You should talk to your doctor to discuss treatment options and together decide what’s best for you. -Sung Lee, M.D., medical director of electrophysiology at Washington Adventist Hospital
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TEEN DEPRESSION, continued from 8
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that of his peers and may not contain the proper balance of neurotransmitters, chemicals that help communicate information, according to the Mayo Clinic. Changes in hormonal levels may have some bearing on depression as well. Environmental factors include high levels of stress, major losses— such as the death of a loved one— and early childhood trauma. Being subjected to bullying or struggling with one’s sexual identity can increase the risk of depression, according to NAMI. Socioeconomic factors also have been implicated. A brief from the National Institute for Health Care Management (NIHCM) Foundation points to studies showing that depression is nearly twice as high among adolescents whose mothers didn’t graduate from high school and 1.5 times as high for teens living with a single parent. Gender plays a role. Girls are twice as likely as boys to suffer from depression. “It’s not that girls are more emotional or dramatic,” said Shull. “It’s that boys tend to choose physical ways of acting out or avoiding problems, whereas girls tend to ruminate, thinking things over and over in their minds.” Girls also are more prone to experience eating disorders, such as anorexia nervosa or bulimia, in conjunction with their depression, according to NAMI. Other coexisting conditions include ADHD, learning disabilities, and in 40 percent of cases, anxiety, according to the NIHCM report. Somewhere between 20 and 40 percent of teens with depression will, within five years of onset, show signs of bipolar disorder, an illness characterized by both manic and depressive episodes, according to the National Institute of Mental Health. A comprehensive medical exam and psychological evaluation can determine if the bipolar disorder is a coexisting condition or the cause of the depression. MOST TEENS RECOGNIZE THAT
something is wrong, though they may not be able to label it or accurately articulate what they are
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A GAZETTE PUBLICATION
“If they are diagnosed and there’s intervention in their teen years, they’ll
go on to lead productive lives.” -Jackee Shull, staff clinical educator
feeling, said Sarmiento. “Half the battle is getting the teenager to open up and become aware. That requires trust.” “Hopefully you already have established effective ways of communicating,” said Shull, who suggested that parents address the issue openly and matter-of-factly. “Explain why you are concerned. Be specific. Describe the changes you’ve seen. Let them know that there is hope and help.” Listen intently. If a child’s problem is “specific to a situation—my boyfriend broke up with me or I wasn’t picked for a team—it may be something to work through and keep an eye on,” said Shull. If the mood seems more pervasive, with or without cause, help is in order. No matter what the parent-child dynamic, some teens are hesitant to share their depression with a parent. “Find somebody else who your son or daughter can relate to,” said Sarmiento—another relative, clergy member or pediatrician. The pediatrician is often the first stop on the road to treatment. “Be prepared to describe the changes you’re seeing or comments the child is making in order to help the pediatrician understand that this is not just the usual teenage stuff. Some pediatricians are comfortable treating depression. For most, it’s not their area of expertise and they will refer your child for a mental health assessment,” said Shull. A DIAGNOSIS OF MAJOR DEPRESSION
is based on professional observation and evaluation, information provided by family members, as well as the criteria in the American Psychia-
SEVERAL ANTIDEPRESSANTS ARE
available to treat depression but, noted Shull, not all are approved for
“Half the battle is getting the teenager
to open up and become aware.” -Pedro Sarmiento Jr., M.D.
teens, whose brains are still developing. “Because everyone’s chemistry is different, it may take time to find the best medication that will stabilize a teenager’s mood.” Although antidepressants generally are considered safe when taken as directed, they can in some instances increase the risk of suicide. In 2004, the U.S. Food and Drug Administration required that warnings to that effect be included with antidepressants. The greatest risks associated with the use of antidepressant medications exist in the first few months of treatment, so teens should be closely monitored. Because some can cause withdrawal symptoms, teens should not abruptly stop taking their medication. While depressive episodes may recur throughout the teenage years, they generally stop by early adulthood. “Statistics show that about 20 percent who have risk factors may go on to have depression in their adulthood,” said Shull. “But if they are diagnosed and there’s intervention in their teen years, they’ll go on to lead productive lives. They’re not fated to deal with it forever.”
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tric Association’s Diagnostic and Statistical Manual of Mental Disorders—commonly referred to as the DSM. Those criteria mandate, for example, that a depressed mood must last more than two weeks and that symptoms interfere with day-to-day activities. The assessor is likely to ask parents to provide detail about any trauma a teen has previously experienced and any challenges he is facing, according to NAMI. Of the 1.9 million teens who suffered a major depressive episode in 2010, the most recent year for which statistics are available, about 38 percent received treatment, according to the Substance Abuse and Mental Health Services Administration. Medications and psychological counseling, individually or in concert, can help most with depression. Psychotherapy and cognitive behavioral therapy are the two most common nonmedicinal forms of treatment for teen depression. Psychotherapy is intended to help teens find relief from emotional pain and gain insights into their struggles. When done on a regular basis, it allows the teen “to build a trusting relationship—one where they feel understood by a person whose empathy is authentic—with a supportive adult,” said Shull. “Cognitive behavioral therapy helps teens…change the way they are thinking and perceiving things. It is very empowering,” said Shull. “Instead of someone else figuring them out, they begin to figure themselves out and master skills— ways to relax and cope—that can be used for the rest of their lives.” In some cases, family or group therapy may prove beneficial. Improving interpersonal relationships and communication and decreasing conflict is at the heart of family therapy, said Shull. Group therapy, as a supplement to individual therapy, can “help a teenager realize there are others with similar feelings and who also have experienced rejection.”
Summer 2012 | Gazette Health 27
INCONTINENCE, continued from 15
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doctors use a variety of diagnostic tools to understand a woman’s specific case of incontinence. Urodynamic testing determines how well the bladder and urethra are functioning. One test involves patients voiding into special equipment that measures the amount of urine and the rate at which it flows out of the body, while another requires insertion of a catheter into the urethra to examine the bladder. Burkhardt Zorn, M.D., a urologist with Chiaramonte Huisman and Zorn Urology in Clinton, suggests sticking to a schedule for going to the bathroom, a technique he calls “timed voiding,” and retraining the bladder to hold urine for longer than what might initially feel comfortable. Physical therapy for the pelvic floor is another popular nonsurgical treatment for incontinence. A woman consciously contracts and releases pelvic floor muscles, exercises named after California gynecologist Arnold Kegel. Physical therapist Schill asks patients to practice Kegels while connected via vaginal and abdominal sensors to a biofeedback machine. The machine measures how strong their muscle contractions are, and then the results are displayed as peaks and valleys on a monitor for the doctor. “When it comes to the pelvic floor, we can’t see what’s happening on the inside, so this is a great way for us to see what’s happening without having to do an internal exam every time they come in,” she said. In addition to Kegels, patients practice lunges and squats to strengthen hip, back and abdominal muscles. Schill also recommends deep breathing from the diaphragm to help relax patients, many of whom are in an emotionally fragile and physically tense state. “I encourage positive self-talk,” she
PHOTO BY ARCHANA PYATI
This urodynamics machine in Anita Pillai-Allen, M.D.’s office is among the diagnostic tools used to assess patients with incontinence.
said. “They have such a negative self-perception, so I get them to tell themselves: ‘I deserve to be dry. I deserve to not have to wear mini pads during the day. I deserve to sleep through the night.’” TERRI MERRYMAN SAID SHE STARTED
to feel depressed the longer she held herself back from participating in activities with her family. Women may isolate themselves and feel embarrassed by having to be near a bathroom at all times or by odor caused by leaks. Incontinence can also be detrimental to a woman’s sex life with her partner. Beyond sex, Moorman said, what’s most devastating to her patients—especially baby boomers and younger generations—is stopping their exercise routine or curbing their social activity. “There are [also] old ladies who stop going to church. They’re afraid they’re going to wet themselves and won’t make it to the bathroom.” More and more, these women are exploring their options instead of suffering in silence—like Merryman, whose surgery last year changed her life forever. “I was so happy I did it,” she said. “It’s such a relief to know I can go places with my husband and my kids and not have to worry about stopping every 10 minutes.”
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experts’ advice National Institutes of Health
Breaking Bad Habits
“Humans are much better than any other animal at changing and oriyou know something’s bad for you, why can’t you just stop? About 70 percent of smokers say they’d like to quit. Drug and enting our behavior toward long-term goals, or long-term benefits,” said alcohol abusers struggle to give up addictions that damage their bodies Dr. Roy Baumeister, a psychologist at Florida State University. His studand tear apart families and friendships. And many of us have unhealthy ies on decision-making and willpower have led him to conclude that excess weight that we could lose if only we would eat right and exercise “self-control is like a muscle. Once you’ve exerted some self-control, like a muscle, it gets tired.” more. So why don’t we do it? After successfully resisting a temptation, Baumeister’s research “Habits play an important role in our health,” said Dr. Nora Volkow, director of the National Institutes of Health’s (NIH) National Institute on shows, willpower can be temporarily drained, which can make it hardDrug Abuse. “Understanding the biology of how we develop routines er to stand firm the next time around. In recent years, though, he’s that may be harmful to us—and how to break those routines and found evidence that regularly practicing types of self-control—such as embrace new ones—could help us change our lifestyles and adopt health- sitting up straight or keeping a food diary—can strengthen resolve. “Any regular act of self-control will gradually exercise your ‘muscle’ ier behaviors.” Habits can arise through repetition. They’re a normal—often helpful— and make you stronger,” he said. One approach: focus on becoming more aware of unhealthy habits. part of life. We can drive along familiar routes on mental auto-pilot withThen, develop strategies to counteract out really thinking about the directions. them. For example, you could develop a “When behaviors become automatic, it plan to avoid walking down the hall gives us an advantage,” Volkow said, where there’s a candy machine. Resolve “because the brain does not have to use to avoid going places where you’ve usuconscious thought to perform the activially smoked. Stay away from friends and ty,” freeing it up to focus on other things. situations linked to problem drinking or Habits can also develop when good or drug use. enjoyable events trigger the brain’s Try to kick bad habits by replacing reward centers. This can set up potentialunhealthy routines with new, healthy ly harmful routines, such as overeating, ones. Some people find they can replace smoking, drug or alcohol abuse, gama bad habit, even drug addiction, with bling and even compulsive use of comanother behavior, like exercising. “It puters and social media. doesn’t work for everyone,” Volkow Both good and bad habits are based The brain’s reward centers keep us craving the said. “But certain groups of patients who on the same types of brain mechanisms. things we’re trying so hard to resist. have a history of serious addictions can “But there’s one important difference,” engage in certain behaviors that are ritusaid Dr. Russell Poldrack, a neurobiologist at the University of Texas at Austin. And this difference makes the alistic and in a way compulsive—such as marathon running—and it helps pleasure-based habits so much harder to break. Enjoyable behaviors can them stay away from drugs. These alternative behaviors can counteract the urges...to take a drug.” prompt your brain to release a chemical called dopamine. Another thing that makes habits especially hard to break is that replac“If you do something over and over, and dopamine is there when you’re doing it, that strengthens the habit even more. When you’re not ing a first-learned habit with a new one doesn’t erase the original behavdoing those things, dopamine creates the craving to do it again,” ior. Both remain in your brain. In ongoing research, Poldrack and his colPoldrack said. “This explains why some people crave drugs even if the leagues are using brain imaging to study the differences between firstlearned and later-learned behaviors. drug no longer makes them feel particularly good once they take it.” Some NIH-funded research is exploring whether certain medications In a sense, then, parts of our brains are working against us when we try to overcome bad habits. “These routines can become hard-wired in can help to disrupt hard-wired automatic behaviors in the brain and our brains,” Volkow said. And the brain’s reward centers keep us craving make it easier to form new memories and behaviors. Other scientific teams are searching for genes that might allow some people to easily form the things we’re trying so hard to resist. The good news is humans are not simply creatures of habit. We have and others to readily suppress habits. many more brain regions to help us do what’s best for our health. -NIH News in Health
why it’s so hard to change:
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