The Fractal Whisperer: Musings on health

What is “healthy” and would you know it if you saw it?

From nature, we gather our understanding of life and how our environment affects us.  We develop insights or “laws” – of gravity, entropy and heavenly bodies, through the observations we make in the world around us. 

At its essence, a law is a concept that is simplified, universal and expected.  If I dropped my cellphone as I was trying to put it into my pocket, I would expect that it would fall down not up.  The same goes with any sized object and from any height.  In health, for a law to exist, we would expect that it would be, at its core, an explanation that could be applied to any living organism with consistent results.  Even as we gain a greater understanding of molecular structure and other chemical signals that interface with health and disease, a law would be further enhanced through these discoveries, not broken.      

We are at a crossroads in our understanding of health, which I believe will take us to a time where more people will be able to realize better health and enjoy a long and productive life.  Can our understanding of “healthy” form a basis of how to construct health promotion and disease prevention efforts?  For example, wouldn’t it be better to determine a patient at risk for a stroke, than for s/he to have one and offer therapy afterwards.  Although many doctors already see patient with behavior challenges in their clinics – those who continue to smoke or do harm to themselves that do not want to change.  We already know that our current health system is “problem-focused” and limited in scope, since addressing disease is a palliative effort compared to preventing it and assisting in behavior change.  Still pharmaceutical companies spend millions of dollars on research and earn millions more on medications for depression, diabetes, heart failure and erectile dysfunction.

What is “healthy” and would you know it if you saw it?

The motif of nature and the four seasons and how it resonates in understanding our lives has been the subject of much writing and poetry.  We are born, as a seed germinates, then develop and ripen to our sweetest and most active forms before we begin to diminish, wither and die.  Nature is also a biologic mirror as well to the story and structures of our bodies…which takes me to a contemplative walk in the park to think of these questions.

Does nature provide lessons to us about our health?

When I am out in the park, I take a look at the oak trees and think about their components from most peripheral to most internal:  the leaves, the branches the trunk, the bark, and the roots.

The branch formations of the oak tree are vaguely familiar to our bronchiole system

In the spring, I look around and see the trees and their outstretched branches with blossoms in full bloom and small leaf buds starting to develop and grow into what will become full leaves in summer.  Each leaf shows veins that make patterns not unlike the branches of a tree itself.  The leaf identifies the tree and vice versa.  Using a magnifying glass, I see how complex the patterns areI realize that each leaf is fulfilling a role for the entire tree.    Is optimal growth and functioning a clue to what it is to be healthy as humans?

Our respiratory system reminds me of the trees and branches that I see outside on my hikes.  I read that if you were to take the segments of our lung airways and place them end-to-end, it would measure 1500 miles!  That is a lot of detail inside our chestThe characteristic of branching patterns that display self-similarity is the definition of a fractal.  This complexity seems inherent in what it means to be healthy.

It also interesting and not coincidental that our lungs represent the pathway of oxygen into the bloodstream, while the leaves are the surface, in which carbon enters the tree and oxygen exits.

How does outside interact with inside?  With a tree, there are two routes:  from the immediate outside – that which the leaves and branches comes directly across and from within the network of roots that connect the outside soil to the trunk, branches and leaves.

It is fascinating to see how a seed that may have been carried by the wind or a bird was able to germinate – in otherwise desert of volcanic rock where only lichens are seen.

The trunks of some trees that I see have either small knobby areas or oval-like structures which are known as a callus.  It occurs when something happened to the tree that disrupted the bark.  The tree heals like what would happen if we had an injury to our skin – our skin heals with a scar.  Does that tell me about what happens to our health?

My mother was diagnosed with diabetes when I was in medical school.  I learned that blood in her circulatory system became thicker and overburdened by too much sugar, as insulin secretion was diminished or was made less effective by adipose tissue.  Even the process of the decay in insulin production is tied to a similar disease process.  In this setting, the sugar could get through the entire system and cause changes from within the circulatory beds that can affect one’s vision, kidney function and sensation – their ability to feel what they are touching and more.  This could lead to skin ulcers on their feet and legs.  What initially starts in the circulatory system leads to damage to the other systems and affects the body as a whole.

So, health seems to relate to the natural design of our body and how it adjusts to the outside environment.  Like the root system in a tree, maybe our gastrointestinal system serves that purpose in our bodies, by breaking down the food we eat and absorbing the nutrients, proteins, sugars and fats in food.  Our liver is a filter system with a series of tubes that allow detoxification of the blood to be secreted as bile in the intestines.

How can we see the health of the trees and our body from the outside in?

When I look at nature and analyze the trees, I notice that some of the trees don’t look completely upright or as healthy as others.  What happened in the lives of those trees?  When I see how leaves change color in the fall, the color changes occur along the areas of the venations or are initially small areas where chlorophyll pigmentation has altered  

I notice people who are overweight and wonder what is happening in their bodies to cause them to gain weight. Is it just a question about what types of food one is eating that leads to this weight gain. Maybe it is like a plant that deals with a specific type of soil nutrient – it continues to work, even if the soil may not be right, until it can later improve. Only we are putting in the wrong food source.

Does the body work better when it is a specific weight?

A tree is capable of making its own food source through photosynthesis using the light of the sun, chlorophyll and water. As the food is created by the tree, it is directly used in growth. Any unused sugar is transported from the leaf through the phloem to be stored in the trunk or roots as a starch. It can then be converted back to sugar for growth during the next spring.

This process is not unlike what is planned in our bodies with the excess sugar. We take in food – sometimes in disequilibrium, which is utilized for maintenance and functioning of the body. Any excess sugar will be stored in the adipose tissue as triacylglycerols to be used for growth or in a state of starvation (such as in between meals).

The process of storage in adipose tissue continues providing there is a trigger – and it comes in the form of excess carbohydrates in the diet. In one way glucose is a energy source for the body; in another way, it is toxic to the blood in high levels. Insulin’s role then is to transport sugars out of the bloodstream to be used as energy – including energy storage. This leads to deposits in adipose tissues and weight gain. It is only with a shift in diet toward lower carbohydrates, that these stores can be utilized and weight loss can occur.

Excess adipose tissue hinders movement and body mechanics, alters pressures and challenges metabolism, thereby affecting normal processes. The adipose tissue makes it harder for the heart to beat and the lungs to aerate properly.

To some extent, the body adapts – but only up to a point. Complex organisms are able to adapt, the term homeostasis. When my father was diagnosed with high blood pressure, he was told that it might get better with weight loss. He fueled himself with a mostly plant-based diet and at one point lost weight. Even with as little as five to ten pounds, blood pressures improve. These changes seen in weight normalization are far greater than the activity of any pill.

How does our food intake affect our health?

I observe how leaves and other vegetables are so complex and whether that is the way our food should be – more complex in structure.

Romanescu Broccoli, a natural fractal

In Sicilian, things that are good are measured up to bread. “As good as bread!”

Look at the foods above: the top is Romanescu broccoli and the bottom is sliced bread. Compare the inherent complexity of spinach leaves, cauliflower and cabbage with that of processed foods, originally harvested from nature. The very act of processing food releases some of the most important constituents of food – the fiber – to create a food more akin to Euclidean geometry – the square piece of bread, the round cookie or biscuit. These foods are composed of simple and complex sugars.

It seems that these simple foods that we eat may be the wrong types of food for our complex bodies. The foods are held by loose bonds that break upon entering our mouth. There is no further digestive component needed, and the sugar is absorbed into the portal bloodstream through the jejunum. The liver meets it head on and attempts to detoxify the glucose. Insulin shifts the sugars to be stored as glycogen and fat in the liver, and once a critical threshold is met, complexed sugar spills out into the bloodstream as triglycerides. They trigger inflammation in the blood vessels contributing to atherosclerosis or otherwise get stored in adipose tissue. What was taken from the outside is processed in the body and enters into the bloodstream to affect our our entire body. The spikes in insulin and products of bacterial fermentation of sugar in the gut lead to important biological changes including creating pleasure and craving with foods higher in sugars, to the further detriment of the organism. It is only further compounded by liquid sugar found in sodas and juices.

How about getting older?

As we grow older, our structure changes – we shorten in stature because our bones demineralize and desiccate (dry up); our skin wrinkles and fingers and toes get colder; we can’t see or hear as well as our eyes and ears change.  My patients remind me that even our ability to taste decreases – and might lead some to choose sweeter foods.  Do these changes represent the tip of an iceberg about what is happening in our entire bodies?

When we look at the season of autumn – when the leaves start to dry up and change color.  A close look at a leaf with a magnifying glass reveals that these changes in color and appearance of the leave occur in small fragments congregating around the venations of the leaf prior to the confluent color change.  Similarly, the changes of the skin – a decrease in collagen production – that produces wrinkles occurs over time, as we move toward a phase of wilting.

Depending on how warm the climate is, the leaves on some trees stay viable toward the month of December, while the trees in colder climates are bare of leaves by then.  Are there ways to reduce the process of aging in our bodies?

It also reminded me of our experiment with Protozoa, single-celled organisms.  As a child, I remember a class experiment with Paramecia, where we put a dropper full of concentrated saline (salt) solution into the fluid where the Paramecia were swimming around.  Immediately, they swam away in the opposite direction from where the solution was coming.  Does our body have a way to protect itself from these changes?

The acid-base buffering system of our body is an example of how dynamic our bodies are.  If there were an ingestion of acid (like a poisoning of aspirin, causing metabolic acidosis), our body would be able to balance that effect without killing us – up until a point.  It wouldn’t be the same with the Paramecia – they would die with a little perturbationOur bodies are able to adapt to the environment and that dynamic ability is a picture of health.

Think about how our heart beats – is it like clockwork?  It actually isn’t.  The system adapts to changes in position, respiration and other stimuli to allow for the dynamic sinus arrhythmia.  Studies have found that when pulsations are less dynamic, there is an increased risk for mortality. 

Is the “climate” in our bodies something we can control – and can this extend the time of our healthy years?  It reminded me of my grandfather who a lot of people thought was younger than his age.  You and I have seen people in the gym, thriving, working out and keeping up with others decades younger – and the looks of disbelief when they reveal their age.  

Think about the natural cycle of nature – starting with the blossoms and leaf buds of the spring, proceeding to the fully developed leaves of the summer, then with the changes and eventual death of the leaves during the autumn and the slow state of the tree during the winter time.

Do we also become less complex as we go through this process of dying?

What is health and how can I tell it when I see it?

That brings us back to the first question.  I am observing what is happening in front of me, though it proceeds as it has for decades and centuries.  Trees stay alive even during the winter – the main structures that die are the leaves, only to grow back next spring. Even this process is happening in our bodies, as we shed hair, skin and cells in our gut – up until a point – some of which is programmed and some of which is modifiable.  We are interested in the modifiable. 

As I see it, health is a state that is far from staticit is the ability of an organism to withstand the environment, to harness it and to grow and maintain itself – to thrive.  We have organs in us similar to filter system or a root system which allow us to take in nutrients needed for growth and metabolic operations and use what is in the environment.  Just like the when you cut a tree you don’t see the soil inside it, so too does our blood work with what is absorbed after the liver detoxifies it – up until a point. 

Our bodies are a reflection of what is inside and how it relates to what is outside.  A diabetic may have numbness in their legs; a person with high blood pressure may have swelling in their legs; a person with a bad liver will develop jaundice.  As our bodies change, our structure changes and inherently our function changes.  We do have some control over this.  I am reminded of some of my patients, after they were diagnosed with diabetes, who started an exercise program and began to eat healthy food:  they were able to lose a significant amount of weight and reduce or stop insulin and other diabetic medications.

Ultimately what is in play is a shift from our more complex, functioning, dynamic lives to one where complexity diminishes, either slowly, from the blunting and structural changes in aging, or more rapidly, with the damage that occurs with disease.  The change in complexity to simplicity reaches a threshhold when we die – and even then our bodies further disintegrate into the various chemicals that were holding our lives in place.

Summary

1. Health requires the interplay of multiple complex structures that provide protection, buffering and dynamic adaptation to the host.

2. Disease can occur by way of external (injury or trauma) or internalized toxins (via the gastrointestinal system). Chronic metabolic disease occurs in the bloodstream and works its way through the entire body via the bloodstream.

3. Food should be complex, largely plant-based to balance short and longer term energy needs, while avoiding excess of simplified, processed foods that are easily broken down and enter the bloodstream.

4. Aging and disease represent forms where the complex structure begins to be blunted or simplified largely as a result of inflammation and scarring, such that a change in structure leads to a diminishment of function. These changes are in part modifiable.

5. The body external is a window to the body internal and We achieve dynamic stability as we approach being “healthy”.

Thanks for reading. If you enjoyed what you read, please share.

A brief discussion of our daily (genetic) expression of self

I hope everyone takes some time out each and every day to appreciate and marvel at the wonderful miracle that is your life. Isn’t it fascinating that all of our cells have the DNA which define how the entire system works? It is only through various cell signals that these cells express DNA differently to become specialized into the tissues that make up our bodies.

I think as we gain a greater understanding of epigenetics, and even with what has already been understood, we begin to see genetics as “fluid” not static, i.e. capable of being optimized by the way that we live as humans in the environment, the way in which we manage our physical and psychological stressors, the food and drink that we consume, and how we treat our body (sleep, habits, social) from day to day. Already studies are finding trauma, poor sleep and diet have been tied to increased inflammation and changes in genetic expression. The central dogma is explained by DNA being transcribed to RNA and then translated to protein.  So when we speak of expression, it entails that both of these steps are optimized at the time of these actions.    

The empowering message of all of this is that we are not only a sum-total of the genetic legacy that we inherit but also how we live our lives. We are not fated by our parent’s “bad genes” but how we actively choose to live our lives and the behaviors we foster. As trauma is interwoven with our genetic expression, our lives are not as much about applying blame to the negative experiences that we have had but how we interact with them to create resilience and growth.

As we live this human experience, we blaze a path into the uncertainty that is our future.  Each decision that we make and do not make contribute to the quality of our live at this moment and ultimately factors into our healthspan – the period at which we can stay healthy and are capable of performing all of the activities that give meaning to our lives.  Ideally, if healthspan perfectly coincides with lifespan, we die in our sleep sometime in our nineties – the day before having enjoyed <insert meaningful daily activity>.

So the ball is really in our court, when we think about all our thoughts, behaviors and actions, are we making overall the healthiest choices?

For diet:

Are we consuming the food and drink that is easiest to digest for our body, that contains a surplus of nutrients and that is free of toxins?  Using a car analogy, what would happen if you gave your car the wrong fuel?

For stress and lifestyle:

Do we really need to take issue, have a breakdown, yell and name-call so that our needs can be met or that we can get our points across?  Obviously, this is a complex interaction and cannot be resolved simply by thinking yourself out of it. Or can it?  Are your needs being met?   Would adding just a little time in between received message and expressed response allow our mind to construct the message that has reduced internal bias, preparing our bodies to not be thrown into a flight-or-fight response?  For instance, the cortisol, epinephrine and norepinephrine released from stress or trauma, real or perceived, have been associated with pro-inflammatory states that may affect genetic expression.

For sleep:

We enjoy the time we have and living in the moment.  Sometimes this may lead us to continue to revel in it.  Do we need to rob ourselves of consistent sleeping habits to watch one more movie or to work the night shift?  This is similarly another challenging question in those whose livelihood depends on the extra money received by working nights.  But, is the financial compensation really worth affecting your health?

Final points to ponder:

1. How can we show gratitude to our bodies in the activities that we choose, the food we eat and through self-care?

2. How do we really spend our time each day? Do we just “wing it” and do the activities that we wish or do we plan a general path of our leisure time?  When we see a musician and think about how someone can be so skilled at an instrument, we often forget that their skill developed through time – short periods spanning years, rather than long periods spanning days.  Patience and discipline can be used toward “I always wanted to do that” goals.

3.  Think about your day being a mosaic of how you would like to direct your life.  In a way, it can then become a step on the path to the future you.

4.  Oh and as for cell phones – I have used the iPhone and have been surprised at how much active time I am spending on it daily.  Can you and I turn our phones off or put them in airplane mode for a larger part of the day?  Can we speak to the loved ones in our lives that our near to us, rather than the near-strangers in our lives that are far from us?

The last words come from from Satire X of the Roman poet Juvenal, credited for the contribution of the Latin phrase, “mens sana in corpore sano“, or “a healthy mind in a healthy body,” which is at the center of Your Health Forum:

You should pray for a healthy mind in a healthy body.
Ask for a stout heart that has no fear of death,
and deems length of days the least of Nature’s gifts
that can endure any kind of toil,
that knows neither wrath nor desire and thinks
the woes and hard labors of Hercules better than
the loves and banquets and downy cushions of Sardanapalus.
What I commend to you, you can give to yourself;
For assuredly, the only road to a life of peace is virtue. (t,r),

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Case Presentation: 66 year old with persistent cough after 3 weeks ago

In keeping with the recent post on pneumonia, here is a case challenge of a patient with a pulmonary process:

66 year old with a history of Parkinsonism, ongoing tobacco dependence developed head congestion, fevers and cough reports to the Emergency Department:

History:

-3 weeks ago, symptoms began with cough and fevers

-2 weeks ago, urgent care visit – felt to have a viral syndrome – did not improve

-1 week ago, urgent care visit – prescribed azithromycin for possible pneumonia

-ongoing productive cough, worse at night with on/off subjective fevers and sweats

ROS:  Some nausea and vomiting night before going to the hospital, some diarrhea after azithromycin.  Mild dyspnea.  No hemoptysis (blood in sputum)   No recent travel. 

PMHx:

  1. Parkinsonism – on carbidopa/levodopa
  2. Hypertension – stopped taking about 3 weeks ago
  3. Tobacco dependence

All:  Penicillin – as a child – may have had a rash.

Social:  Smokes 1 1/2 packs per day.  No illicit drug; occasional marijuana

Physical exam:  T 98.6, HR 102, BP 156/85, RR 18, Pulse ox 95% Room air

  • Gen: A/o x 3, cachectic-appearing, no acute distress
  • HEENT:  Moist membranes.  Mask facies
  • Neck:  Shotty posterior cervical lymph nodes
  • Chest:  Diminished breath sounds throughout, coarse crackles in the left base.  No wheeze.
  • Heart:  Regular rate and rhythm, no murmurs, rubs or gallops.
  • Abdomen;  Soft, thin, mild periumbilical tenderness, no rebound or rigidity
  • Ext: Warm, well perfused.  No evidence of cutaneous septic emboli.
  • Neuro:  Resting tremor of hands, cogwheel rigidity noted or arms

Bloodwork:

Wbc: 26,000,  Neutrophils 90%

H/H:  11/32

Platelet:  817

Chemistries:  Sodium: 130,  Potassium 3.3, BUN/Cre 20/1.1, Chloride 91

Alb 2.8, Protein 6.1, LFT: normal 

CXR upon presentation:

CT scan findings:

Sagittal Section
Coronal view

Questions:

  1. Review the bloodwork findings and how they are significant.
  2. After Reviewing the CT scan, which lobe is this pulmonary process involved?
  3. The CT findings is most consistent with what process?
  4. What are the possible organisms involved in causing this condition
  5. What would be a good empirical therapy to begin on this patient?

The Answers to these questions as well as an update on the case will be presented in a later post this week.

Protecting Yourself From Pneumonia

By Christopher M. CIRINO, DO MPH

Your Health Forum

Sir William Osler, one of the founders of modern medicine, used to refer to pneumonia as “the Captain of the men of death” and “friend to the aged”, relating to the often acute precipitation of death, “protecting them from the colds of degradation”.

Pneumonia is not an uncommon illness that often may require hospitalization. Now that we are in the flu season, I wanted to include a post on how to protect yourself from pneumonia. In the patients that I have evaluated, the pain that they experienced from pneumonia has left an indelible impression on me. Each year, I am saddened to see that several patients are unable to recover despite antibiotics and supportive care and ultimately succumb.

Pneumonia increases with age, and It is no coincidence that rates increase from 1 in 1,000 in the general population to 18 in 1,000 in those older than 65 years of age and up to 52 cases per 1,000 in those at least 85 years of age (Jackson et al, 2004). The rates of hospitalization and mortality are also much higher in the elderly, with a four-fold increase in hospitalization; the majority of deaths from influenza and pneumonia occur in age 65 and older ( compared to those in the 45-64 age range (Marston et al, 1997). Although we cannot change the chronology of aging – yes it is better than the alternative – we may be able to modify some of the risk factors of pneumonia and other infectious diseases and protect ourselves as we age.

Topics to be discussed: The influence of lung structure and function on pneumonia, the risk factors of age and pneumonia, and 6 ways you can prevent yourself from getting pneumonia.

Pneumonia and structure and function

The lungs are branching structures with multiple iterations until the microsopic alveoli sacs are reached, where gas exchange occurs. This is characteristic of a natural fractal. An incredible fact about our lungs is that they contain 1,500 miles of airways and up to 300 to 500 million alveoli! This expansive lung surface area with its angulations work to displace a direct insult to one area by an inhalant or particulate matter, mitigate the risk of aspiration, adapt to airway recruitment with increased demand, and function in concert for removal of particulate matter or microbes.

The alveoli can become inflamed from a viral infection, aspiration (for example, getting a small amount of gastric acid in the lungs) or from airways hypersensitivity, such as with an asthma exacerbation. Bacteria can enter the airways either in small respiratory droplets that are inhaled or aspirated. Inflammation ensues and leads to trapping of propagating bacteria in the lower airways. This leads to greater inflammation – ultimately reaching a tipping point and causing acute pneumonia.

At the time a person develops pneumonia, they may have a high fever, productive cough, chest pain, usually localized to the base(s) in bacterial lobar pneumonia. Findings can be abrupt with bacterial pneumonia, such as Streptococcus pneumoniae or Staphylococcus aureus. They are usually less severe with a more prolonged course in pneumonia caused by Mycoplasma or Chlamydophyla pneumoniae. A radiograph will demonstrate infiltrates usually in the lower lobes in the former; in the later, a radiograph will show patchy, tissue (“interstitial”) reticular (or “lacey”) changes.

Radiograph of a severe multilobar pnuemonia caused by Streptococcus pneumoniae
Same patient as above with CT scan showing “air bronchograms” – outlining of bronchioles by surrounding diseased tissue

Changes that Increase Risk of Pneumonia with Aging:

  1. Lung Structural and Mechanical changes: There are structural changes that occur with aging that may lead to an increased risk of pneumonia. The lungs have a mucus layer and cilia, which assist in protecting the lung space from invasion and mobilizing the secretions in a cough. There are also changes in the mechanics of the rib cage in aerating the lung and providing the negative pressure needed to more easily deflate and clear the lungs.
  2. Aspiration: There is also an increased risk of aspiration when we age – both large (macro-aspiration) and small particle (micro-aspiration). Swallowing may be altered by changes in the oropharynx (mouth/throat) or in the esophagus, leading to an increased risk of aspiration. The mouth becomes drier and risk for cavities increase. Changes in consistency of food may be necessary, otherwise a person is at increased risk for choking. To make matters worse, the cough reflex is blunted in advanced age.
  3. Immunosenescence: As with all other aspects of our bodies, the immune system also changes as we age, including all lines – the innate immunity, humoral immunity and cell-mediated immunity. Lymphatic structures, the spleen and bone marrow become less potent. This results in a relative decrease in activity and production of defenses, such as natural killer cell activity, antibodies (e.g. respiratory IgA antibodies), antigen processing and clearance of bacteria by macrophages, and increased risk for bacteria with capsules, such as Streptococcus pneumoniae and Haemophilus influenzae.

How to Prevent Pneumonia

Below is a list of recommendations by an infectious disease specialist in how to stay safe from getting pneumonia, or protect yourself from another bout.

1.Get Vaccinated

A yearly influenza vaccinations may not afford complete protection from acquiring influenza, but it has a likely rate of protection of 30-50%, from influenza depending on the vaccination selection for the influenza strains for that year. The newer influenza vaccination may afford better protection, as indicated by a better measured immune response after vaccination, when compared to the usual options. Remember by reducing the risk of influenza (which can cause a “pneumonitis” or inflammation of the airways), it will reduce the risk of lung tissue inflammation that can predispose to bacterial pneumonia, such as Streptococcus pneumoniae, Staphylococcus aureus and Haemophilus influenzae.

Other vaccinations that would be useful are the PREVNAR (PCV 13) and the PNEUMOVAX (PPSV23), which are conjugate and polysaccharide vaccinations, respectively, that afford some protection against Streptococcus pneumoniae.

How effective are they together? In a large-cohort study of Swedish patients >65 years of age, the “additive effectiveness” of influenza and pneumonia vaccination was approximately a 29% reduction in all-cause pneumonia and a 35% reduction in the death rate from all-cause pneumonia compared to the non-vaccinated groups.

It might also be a good time to get the vaccination for Haemophilus influenzae b, although there are no specific recommendations for vaccination in this age group.

2. Get Enough Sleep

Sleep efficiency drops as we age. This can lead to changes in our body’s mechanism of immunity as well. Studies have shown disturbances in the function of the innate (Natural killer cells) and adaptive immunity (T-cells and B-cells) with lack of sleep. Getting the right amount of sleep (approx 8 hours nightly) will protect you. If you are having difficulty with sleep, please review a prior post on sleep hygiene and recommendations for evaluation.

3. Keep acid reflux under control and protect yourself from aspiration

Studies suggest that up to 15% of cases of pneumonia are related to aspiration, an ingestion of oral secretions or gastric acid and contents into the airways. The incidence of aspiration pneumonia is higher in older age (Teramoto et al, 2008). Cough reflex and oropharyngeal and esophageal motility are also altered as we age. Eating slowly, ensuring that food is well-chewed and avoiding behaviors that can trigger acid reflux will protect you from aspiration, which will protect you from pneumonia.

4. Limit alcohol, smoking and vaping

Alcohol creates a host of problems with our mechanical clearance and our immune system and represents a significant risk factor to pneumonia and oropharyngeal colonization with Klebsiella pneumoniae. Alcohol impairs our gag and cough reflexes and can exacerbate acid reflux-associated microaspiration.

Our innate immunity, associated with alveolar macrophages and anti-bacterial proteins produced (e.g. chemokines), are suppressed from alcohol. Even lymphoid tissue, which plays a role in activation of our acquired immunity (T-cells) is altered. These impaired mechanisms can strain the body’s ability to respond to an infection, and lead to more overwhelming, life-threatening manifestations of pneumonia.

Smoking is clearly linked to airways sensitivity and impairment of the ciliary clearance mechanisms of our bronchi. Smoking not only increases the risk of getting pneumonia (Odds Ratio =2 – this means a two-fold higher risk) but also the risk of death from pneumococcal pneumonia. When smokers quit, the risk of pneumonia decreases by 50% after 5 years.

As of way of curbing vaping in adolescents in Oregon, the Governor approved of a ban to be effective Oct.15 on all flavored vaping products – (though it has been halted as of Oct. 17). This is because of a spate of cases, now more than 1,500 people in the United States, that were diagnosed with Vaping-Associated Lung Injury (VALI). If you are interested in reading more about this, See the Harms of Vaping post.

5. Keep exercising

A rolling stone gathers no moss. The same can be said about the importance of activity. Exercise leads to increase respiratory mechanics and lung expansion, which reduces the risk of collapse of alveolar sacs, or atelectasis. There may also be a more robust immune system in those who exercise. In one study of women who exercise and walk more frequently, they were less likely to develop pneumonia (18% lower risk). Another study showed an increase in natural killer and T cells in men who were involved in a moderate exercise program. Here it is – another good reason to exercise!

6. Optimize weight to protect or mitigate risks of pneumonia caused by Chronic Diseases such as Diabetes mellitus

Maintaining a healthy weight and avoiding obesity will protect you from the metabolic syndrome diagnoses, including diabetes, high blood pressure (hypertension), sleep apnea, as well as reduce the risk of reflux (heartburn)-associated aspiration. Obesity was found to be a unique risk factor for influenza disease severity during the 2009 H1N1 flu pandemic. A person who is obese (with a BMI between 30 and 34.9) has approximately 40% increased risk of pneumonia compared to someone with a healthy weight; someone with severe obesity (BMI >35) had a two-fold risk. A diabetic has a three-fold (i.e. 300%) higher risk of developing pneumonia and more likely to have a more severe presentation.

Other: Refer to the post on Wellness and Infection Prevention tips. This includes social distancing from other that are ill, hand-washing, dental hygiene and avoiding or limiting medications that can be harmful to the immune system.

Summary

Maintaining optimal health has benefits in protection from infection. There are several ways that one can follow the goal of a long and healthy life (lifespan and healthspan). As we gain a greater understand of the immune system, we learn that our risks are more mutable than we once had thought – that health and illness are not merely left to the fates.

Thanks for reading this. For more important content sign up for Your Health Forum email updates at yourhealthforumbydrcirino.org. If you found this helpful, please share it to your contacts.

Atrial Fibrillation: When can it be the Tip of an Iceberg?

The heart is the center of our circulatory system and its function affects the state of health of the rest of the body. When the movements in the atria (top chambers) becomes erratic, as in atrial fibrillation, the blood is not propelled efficiently, resulting in decreased output and a 5-fold risk of stroke. Atrial fibrillation is a common disease of aging. If you are under the age of 65, there is a 2% risk of developing this conditions. This increases to 1 in 10 persons in those older than eighty. The heart develops changes that increase the risk of being “once and a-fiber, always an a-fiber”. This post will detail the condition and how to prevent or mitigate the ongoing process.

Key points: Atrial fibrillation increases with ages and certain conditions. Early identification of risk factors or patients at risk can help to mitigate the long-term problems associated with this condition.



Mariana Ruiz Villarreal / ​Wikimedia Commons / Public Domain

An estimated 2.7 million to 6.1 million Americans are living with atrial fibrillation ( “AFib”). The condition causes a rapid or irregular heartbeat that increases the risk of heart failure, stroke, and other heart-related issues. Initially for most people, atrial fibrillation comes and goes. But later, the condition becomes long-lasting and gets to a point where it becomes necessary for medical treatment.

The key to understanding atrial fibrillation is that early identification and reduction of risk factors will reduce long-term problems. If someone has atrial fibrillation or has had a type of stroke associated with a blood clot, they should be evaluted for possible reasons of this condition early. In many ways, atrial fibrillation can be the tip of an iceberg of an underlying process that is putting the heart at risk. The most common identified risk I have found in patients is SLEEP APNEA.

What is Atrial Fibrillation?
The four-chambered human heart normally beats in unison. The atria fill with blood that is received from the periphery (right) or the lungs (left). The blood is then directed to the ventricles in a coordinated fashion prior to being pumped to the lungs (right) and body (left). With each heart beat, the heart’s intrinsic pacer system (shown below), coordinated by specialized muscle cells known as pacer cells, sends a wave from various concentrated areas, or nodes. The contractile signal begins in the sino-atrial (SA) node at the top of the right side; then atrio-ventricular (AV) node at the lowest aspect of the right atrium; then the His Bundle through to the chambers of the ventricle with the Purkinge fibers.

Within the atria, for different reasons, the pathway may become damaged or a new pacer signal is set to lead to dis-synchrony. In atrial fibrillation, one or both of the upper chambers get out-of-sync with the lower chambers. The result is usually weakness, easy fatigue, heart palpitations, and difficulty breathing. Though, sometimes in no symptoms are present.

Source: Alila Medical Media

Atrial fibrillation increases the risk of blood clots developing in the upper chambers of the heart. If blood clots form in these chambers, the clots can be propeled by the ventricles and travel to other parts of the body and the brain and hinder blood flow.

Rhythm strip showing Atrial Fibrillation with the irregular nature (look at small spikes (p waves) in between the peaks (QRS)
Source: ECG Academy

A blood clot propelled into the arteries system can lodge in an arterial supply within the brain and cause a stroke. It is estimated that 15 to 20 percent of stroke patients have atrial fibrillation; this increases to 40 percent of causes of stroke, in those older than 85. To reduce the risk of stroke, people with atrial fibrillation are usually placed on blood thinners.

What Contributes to Atrial Fibrillation?
Atrial fibrillation is most often caused by heart abnormalities or damage to the structure of the heart. Some other conditions that may possibly contribute to atrial fibrillation include:

1. High blood pressure. This condition, specifically with high systolic (heart contraction) and diastolic (heart relaxation) levels can lead to a dysfunction that weakesn the heart and increases the risk of atrial fibrillation.

2. A heart attack can cause structural damage to the heart. A heart muscle with scar tissue doesn’t pump as well as a healthy muscle; this can potentially lead to increased work of the heart, atrial dilation (expanding) and atrial fibrillation.

3. Coronary artery disease. It causes coronary arteries to become narrow or blocked. The cause is usually a buildup of plaque, which restricts blood flow to the heart muscle.

4. Intoxicants and other substances. Examples of these include tobacco, alcohol, caffeine, illicit drugs, specifically cocaine and methamphetamines, can potentially dangerously affect the heart and lead to atrial fibrillation. It is not uncommon for a long-term smoker to develop atrial fibrillation as the lung becomes scarred and leads to increased lung pressures. These pressure lead to a stretching of the atria and atrial fibrillation.

5. Obstructive sleep apnea. Sleep apnea is a breathing disorder, but it affects the cardiovascular system. The condition causes blood oxygen levels to drop. If this happens often enough, the low oxygen level can lead to remodeling of the right atria of the heart which leads to atrial fibrillation. These conditions are closely tied together: as many as 50% of those with atrial fibrillation have sleep apnea, and those with sleep apnea have a fourfold risk of developing a-fib.

6. Other. Any state which expands the atria of the heart (e.g. fluid overload) or taxes the heart in someone at risk (fevers, overactive thyroid) or lead to dysfunction of the heart, including various conditions where the heart contractility is reduced (Takotsubo’s cardiomyopathy – “broken heart syndrome”)

Options for Treatment
The best treatment for atrial fibrillation depends on three things: how long you’ve had the condition, the severity of the symptoms, and the underlying cause of the condition.

The treatment is two-pronged. One treatment is to either reset the rhythm of the heart (cardioversion) or interrupt the pacer signal (radioablation). Sometimes only the goal of RATE control is possible in long-standing atrial fibrillation, as people with afib generally feel better with a heart rate under 100 beats per minute.

Another treatment is to preventing the development of blood clots. If the cause of the condition is known, then treatment will be directed at the cause. For example, if atrial fibrillation is caused by sleep apnea, then treatment will focus on treating the sleep apnea.

Cardioversion is a procedure that allows doctors to reset the heart’s rhythm to normal. Electrical cardioversion uses patches or paddles placed on the chest to deliver a low-level shock to the heart.

The shock interrupts the heart’s rhythm. If the shock is successful, the heart’s rhythm resets and returns to normal. The procedure is quick and a sedative is used to reduce the discomfort.

Cardioversion with drugs is an option as well. This form of cardioversion uses medications to restore normal heart rhythm. The drugs are given by mouth or intravenously and require a short hospital stay. Cardiologists can monitor the effects of the medication to see if it is successful.

If the medications are effective, the doctor might prescribe the same medication to prevent recurrence of atrial fibrillation.

Blood thinners (anticoagulant) are often prescribed several days in advance of the cardioversion procedure. The blood thinners reduce the risk of complications, such as strokes and blood clots. Blood thinners are continued for several weeks after the procedure to prevent blood clots. The most common anticoagulant is warfarin. It requires calibration of doses by checking levels (INR), with goal INR for stroke prevention in between 2 and 3. Newer medications do not require levels and are well tolerated, either daily or twice daily.

If cardioversion isn’t an option, then a doctor might decide that heart rate control is the best choice. This involves prescribing a medication that controls the rate of the heartbeat and returns it to normal.

Beta-blockers are often used for heart rate control. These medicines slow the heart rate during activity and during times of rest, and can reduce exercise tolerance. Calcium channel blockers also control heart rate but aren’t recommended for people with low blood pressure or heart failure. Digoxin is an old treatment for atrial fibrillation, but doesn’t work as well as beta-blockers or calcium channel blockers.

Reduce Your Risk of Experiencing Atrial Fibrillation


The best way to lower the risk of atrial fibrillation is to avoid contributing factors and screen for underlying conditions. For example, following a diet that’s good for the heart can possibly prevent a heart attack. Consider getting screened for sleep apnea if you are finding yourself waking up frequently and urinating or noticing heart palpations. Regular exercise can be protective for the rhythm of the heart. If the heart is otherwise healthy, then the chance of developing atrial fibrillation drops considerably.

Managing high blood pressure can also protect the heart. Daily exercise can help keep blood pressure under control. But if exercise isn’t enough, then it’s possible to control it with blood pressure medications.

If you drink coffee, soda or alcohol, do so in moderation. No illicit drug use can be safely taken in moderation. Usually the risk of atrial fibrillation increases excessive amounts of caffeine or alcohol.

Maintaining a healthy weight also lowers the risk of atrial fibrillation. People who are overweight experience atrial fibrillation at varying degrees of risk than those who are within a healthy weight range.

A person who is obese has a higher chance of developing the condition than a person who is slightly overweight. The heart’s left atrium is more likely to become enlarged if a person has excessive body weight. And an enlarged left atrium has been linked to the development of atrial fibrillation.

Summary

There are ways that an individual can reduce the risk of potentially chronic heart conditions. Knowledge is power on the journey to health. An early intervention – either by reducing smoking, alcohol or caffeine, quitting drug use, getting your sleep checked and keeping a healthy weight – can prevent the heart from decompensating.

Thanks for reading this and please pass it along if you have found it useful.

Neuroscience recent discoveries: tetraplegic man learns to walk with robotic exoskeleton

The brain and body are completely tied into each other by our nervous system.

https://www.reuters.com/article/us-health-exoskeleton/paralyzed-man-walks-again-with-brain-controlled-exoskeleton-idUSKBN1WI2HQ?utm_source=applenews

The exoskeleton is controlled by brain signals generated by implanted epidural sensor. The brain can still be employed to direct an external system, even though the links may have been severed by an injury, infection or metabolic disease condition. Future application abound with all senses, including vision and hearing, as well as movement.

The brain’s pathways for movement is now being activated. I would suspect that this would lead to a compensatory increase in the density of the motor cortex of the brain.

Welcome to a new generation of neuroscience discovery and biomedical engineering advancements!

Our peripheral nervous system directly affects the brain, and our brain actively accommodates to learning and development as well as changes as a result of injury, illness and infection in the periphery – a process known as neuroplasticity.

Hebb’s theory of “if it fires together it wires together,” applies to the concept of adjustments that the brain makes in neurogenesis to accommodate for learning or change in the signaling. In the absence of firing, there is atrophy (shrinkage). One example, peripheral neuropathy results in a reduction of grey matter volume, and in painful peripheral neuropathy, this is associated with the somatomotor cortex.

This has similarly been shown in limb amputees who do not use their prostheses compared to those that use them.

https://diabetes.diabetesjournals.org/content/67/Supplement_1/550-P

Now, if we are trying to look at this preventatively, I would suggest the simple concept of “use it or lose it”, with “it” being the body and “it” #2 being the brain. Diseases or conditions which affect one aspect of our nervous system exert their effect along the whole pathway.

Biomedical engineering enhancements may reduce brain atrophy after a significant neurologic event and may provide a chance by which a person may have an improved quality of life.

Patient Information: Protecting Your Brain!

Let’s say you want to keep vibrant and stay vigorous. You really can prevent or slow the changes of aging on your brain. Think about where there is room to improve regarding your health and behaviors. Don’t set it off until later – that time will never come. Start now and use this checklist to give you ideas.

1.Keep the body moving

A. Start a walking program – aim for consistency. Try to keep a moderate pace (one that requires you to take breaths and not talk as easily!). Attempt to do this daily. Time yourself or keep track of your steps for additional motivation and goal-setting.

B. Find comfortable shoes that will protect you from ankle sprains and provide some protection from any back strain.

C. Consider lower body strengthening of the buttocks, hips and leg muscles. This will protect you from fall, protect your back, and keep the brain active.

D. Consider hiring a personal trainer to help you with your form, in order to protect you from injury.

2. Ensure that all senses are functioning at their best (use devices if needed)

A. Get your hearing tested and consider a hearing aide if recommended to maximize your brains ability to process what is said. We depend on visual and verbal cues to process what is said. We cannot store in our memory what we don’t hear correctly.

B. Get your vision tested, address the cataracts and use glasses to protect you from falls, to allow you vision to cue the other senses (lip-reading while listening, positioning legs while walking), and to help you enjoy the beauty around you.

C. Consider a physical therapy and occupational therapy referral, if you are developing challenges with your independent activities of daily living (e.g from osteoporosis, arthritis, memory impairment). These therapists can provide “hacks” to accommodate for some of those challenge.

3. Keep calm and carry on. 

A. Join a meditation group or spend some time – approximately 10-20 minutes – meditating in the comforts of your own. If you prefer, there are apps that can be purchased on smartphones that coach you through the process of meditation.

B. Set up a morning routine of walking or exercise. This will protect you during the day from heightening stress from external demands.

C. Communication between one another relies on interpretation. Attempt to put a gap between hearing a statement and immediately jumping to conclusions. A statement is just that and does not require emotion to tangle up the message. Often it just requires asking an open question to seek to understand.

D. Consider seeking a therapist or life coach. You deserve the pleasure of having someone listen to you.

4. Eat like it matters

A. If you enjoy sweets, set one or two days weekly where you can enjoy a small plate of your favorite desert. If you are inclined to ice cream, if you get a smaller container, you won’t feel forced not to waste it.

B. Try to eat mostly whole foods (from plants) to reduce the amount of carbohydrates that are consumed in each meal (this is bread, rice, pasta, pizza, pretzels, chips and noodles).

C. Avoid drinking sugary drinks – this includes juice, milk and soda. Try the flavored carbonated waters and add a little bit of juice squeezed from fruit to “doctor” it up.

5. Maintain social connections and healthy relationships

A. Join one or more meetup clubs. This is a wonderful way of getting to meet people of all ages that share a common interest – whether it is pugs, a foreign language, horror films (but see #3), meditation, or friendship and coupling.

B. Get in touch with old friends – they, like you, have just been so tied up in the ups and downs of life to stop and maintain their friendships. Call them and put it on the calendar.

C. If you enjoy work as a form of socializing, you don’t have to retire — consider working only 2 days a week or even volunteer to do something you were always curious about. Getting out of your comfort zone leads to new learning and new learning is only possible because of new neural connections!

6. Get some sleep!

A. Exercise in the morning to improve your chances of getting a good night’s rest.

B. Avoid caffeine in all of it’s forms after noon.

C. Avoid any contact with smartphones for at least an hour before sleeping

D. Set up a ritual of 1 hour of preparation before going to sleep, e.g. washing face, brushing teeth, putting on pajamas, dimming the lights – these are all signals that prepare your brain for sleep.

E. If you are waking up more than once nightly, have tense swelling in your legs, have dry mouth at night or have vivid dream while being older than 50, overweight and with higher blood pressure, you may have an undiagnosed condition, such as sleep apnea. Consider talking to your doctor to get tested.

7. Spend time outdoors in nature

A. Check out a meetup group for “Forest bathing”, nature walks or hikes. There are groups that look for birds, others for plants and still others for mushrooms. It is not only a relaxing and wonderful local experience, but also a great way to meet like-minded naturalists.

B. Try to get outdoors in the park at least 4 days a week, if not every day.

8. Stay at a healthy weight

A. Try to be consistent with your diet. Avoid alcohol and sugary drinks. If your pants are starting to get tight, consider tightening up your regular intake of sugar or complex carbohydrates.

B. Sometimes, a brief fast is a “reminder” to the mind is enough to get back into the usual healthy habits.

9. Pick up an instrument or just sing along.

A. Consider picking up an instrument of your choice and learning online for tips.

B. Add a group exposure – such as a song circle or ukulele or guitar group or open mic. This can accelerate learning far more than playing to yourself as the audience.

10. Refrain from recreational drug use

A. If you haven’t smoked or consumed alcohol regularly, you aren’t missing much – don’t start. If you do smoke or consume try to reduce the amount to as low as possible or quit.

B. Remember: the dose is the poison.

It is never too late to start on a pathway to protecting your brain from any further changes. Even with early cognitive deficits, someone can optimize their health to reduce the progression and compensate for the losses.

Answer to Case Report: 55 year old with fever and pelvic pain

Answer: Prostatic abscess (left lobe) secondary to Staphylococcus aureus

Question 1: The CT scan demonstrates evidence of swelling of the left lobe of the prostate with what appears to be an early ring-enhancing focus, probable abscess.

Question 2: 6/6 blood cultures positive. The Gram stain is consistent with Gram positive cocci in clusters. This is the classic Gram stain for Staphylococcus species. The growth from the culture was identified as methicillin sensitive Staphylococcus aureus (MSSA).

Question 3: The most appropriate antibiotic options include a broad spectrum cephalosporin, such as ceftriaxone or beta-lactam/beta-lactamase inhibitor combination such as piperacillin/tazobactam; a fluoroquinolone 1st or 2nd generation (ciprofloxacin or levofloxacin) may be considered in someone who is significantly allergic to ceftriaxone.

An important step in antibiotic decision-making is examining a patient’s specific history. This includes determining which antibiotics a patient may have been on before this occurrence (often a bacteria that is intrinsically resistant to the antibiotic is selected for) and the prior urine culture results – which bacteria and which antibiotic sensitivity. The clinician is advised to avoid using the same antibiotic that was used before.

In this specific case, the patient had chronic diabetic foot ulcers and had been complaining of a skin eruption in his eyelids. Diabetics are at particularly high risk for Staphylococcus aureus colonization. These complaints and the specific finding of the prostate abscess may have alerted you to an increased likelihood of infection with this bacteria.

Prostatic Abscess

A prostatic abscess is a rare disease process. It is generally a result of a more severe acute prostatitis but can similarly arise from a low-grade chronic infection. The bacteria that cause these conditions are also the same ones that are found in urinary tract infections. Bacteria may enter the prostate from reflux back from the urinary tract or epididymal infection; a less common route is through the bloodstream to the prostatic tissues. A chronic foley can be a source of inflammation and risk of bladder colonization and reflux to the prostate.

The most common cause of abscess is E. coli (70% of cases) or other members of the Enterobacteriaceae family. Staphylococcus aureus infection can be seen in patients that have had urinary tract manipulation, such as post-procedurally, or in those with chronic catheters. Enterococcus species is a less common cause; I often see this as a result of post-procedural bleeding, such as prostatectomy or cystoscopy, in a patient that was given cephalosporin antibiotics.

The treatment of a prostatic abscess ranges from conservative antibiotic only measures – in the case of diffuse prostatic disease (more prostatitis) or small abscess – to more drastic measures like a drainage procedure – transurethrally or transrectally.

Returning to Case

This patient had multiple positive blood cultures on multiple days for Staphylococcus aureus. He had a trans-esophageal echocardiograph (TEE) to ensure that there was no heart valve infection (e.g. endocarditis) since Staph is a less common cause of prostate abscess and because he had possibly a renal infarct as well. The constellation of findings suggested that he had hematogenous spread. After he became stable and endocarditis was mostly ruled out and a follow-up CT scan abdomen and pelvis showed improvement, he finished a course of approximately 10 days of IV antibiotics and then was transitioned to doxycycline 100mg twice daily to complete an additional 3 weeks.

Thank you for reviewing this case. I hope you enjoyed the information.

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