You and the Feedback Loop

The Georgetown Advocate
Webster Russell

It's been a while since I introduced you to one of those nerdy terms or phrases that are seldom used in normal conversation, so I thought, “lets do it again”. The phrase is “Feedback Loop”.

Innocuous as this phrase appears, it is the essential tool to the delivery and reception of quality patient healthcare. Now that's a pretty bold statement, so let me make my case.

Technology now plays a very important role in the feedback loop's success. I am going to use diabetes as an example. Part one of the feedback loop is personalized data. It is here you gather blood sugar, medication and dietary adherence data between physician visits. To accomplish this there are at least 90 or so iOS and Android apps that deal with diabetes documentation. The more committed you are to this documentation the better the outcomes can be.

The second section is relevance. Many of these apps have “normals” built in or the ability to add your doctors therapy expectations. These apps then look at your results and show the results in graphs or other formats of your efforts compared to your doctors expectations or app normals.

The third segment is choices. Based on the data you collected and its relation to your physician's expectations or normals, choices are created and agreed upon so you can go to the next step.

The next segment is action. You have collected data, compared it to expectations, reached some conclusions, determined your choices, selected a plan of action, and now you implement the new plan.

Once that plan is implemented, you start all over again with collecting personalized data to ascertain if the new plan you and your physician choose is going to meet your goals. Being a circle, these processes continue until no longer necessary.

Now I have used diabetes for this discussion, but this feedback loop can be used for any chronic disease treatment such as pain management, asthma, COPD, or cancer. To reiterate a past admonition, committing to the data collection process is the key to successfully using this evolution and today's smart phones and tablets make using the feedback loop not only easy, but educational as well.

On a personal note, we have been using the feedback loop process with the oncologist for almost a year and it has not only served us well but has helped him in his treatment approach as well.



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New Therapies to Help Stroke Survivors Recover Language Years After Injury

THE INFORMED PATIENT Updated July 9, 2013, 10:58 a.m. ETNew Therapies to Help Stroke Survivors Recover Language Years After Injury Nearly 20% of stroke victims are under 55, compared with fewer than 13% in the early 1990s, according to a 2012 study By LAURA LANDRO

An estimated two million Americans who have suffered a stroke or other brain injury have the condition known as aphasia. Evidence continues to emerge showing that the brain is able to recover even many years following injury. Laura Landro joins Lunch Break to discuss. Photo: Rehabilitation Institute of Chicago.

Eunice Bustillo faced a long recovery following a stroke at age 40. After a week in the hospital and a month at a rehabilitation center, she continued to have trouble with vision and motor functions.

Even more difficult for Ms. Bustillo, the owner of a consulting business and the mother of a son who was 3 at the time, was overcoming aphasia, a language disorder that is a common aftereffect of stroke.

Aphasia impairs the ability to process and understand language, including speaking, reading and writing, while leaving intelligence unaffected. Recovery can require intensive therapy including hours of practice to repair and reorganize damaged language functions in the brain.

Encouraging new evidence is emerging to suggest the brain's plasticity, or its ability to change and heal, may last many years after injury—far longer than the commonly assumed plateau for speech recovery of about six months to a year after stroke. Insurers, for example, may only cover the cost of one-on-one speech therapy sessions for the first few months.

"The conventional wisdom has long been that after a year post-stroke, you aren't going to get any better," says Cynthia Thompson, director of the Center for the Neurobiology of Language Recovery at Northwestern University. "But the brain continues to change until you die."

The new federally funded center is studying aphasia's different forms, such as the inability to understand and form sentences or to recover spelling and writing. The center also is studying factors, like blood flow in the brain, that may affect language recovery.

Growing numbers of younger people are suffering from strokes linked to diabetes, obesity, high blood pressure and high cholesterol. Strokes also may occur from uncontrollable factors such as a rupture of the blood vessels in the brain—the cause of Ms. Bustillo's stroke in 2003.

For young patients, the obstacles to recovery from a stroke may seem magnified by their youth. They often face the potential for a lifetime of disability including aphasia. As a result of her stroke, Ms. Bustillo lost the ability to read Dr. Seuss books to her son. She was too embarrassed to take him to the park because she couldn't summon the words and sentences to speak to other mothers.

Nearly 20% of stroke victims are under 55, compared with fewer than 13% in the early 1990s, according to a 2012 study in the journal Neurology. By 2020, as many as two million Americans who have suffered a stroke or brain injury will be living with aphasia, according to the American Speech-Language Hearing Association.

More centers and clinics are recognizing aphasia as a chronic condition that can be managed and improved over time, like asthma or diabetes. They are offering long-term group therapy that is far less costly than one-on-one sessions. And they are turning to technology, such as virtual speech coaches that interact with patients on computer terminals, with several patients monitored by one therapist.

At the Rehabilitation Institute of Chicago, researchers are studying whether treatment outcomes of such therapy can be improved with use of certain medications or small amounts of electrical stimulation. Chicago and other clinics also offer more-costly monthlong intensive language-recovery programs that can be repeated regularly.

Studies show that group programs help patients recover language in part by providing a supportive environment. Many use a strategy known as the Life Participation Approach to Aphasia, which encourages patients to set their own goals, express themselves in different ways such as drawing and writing, and return to activities they enjoyed before the stroke.

"Aphasia is one of the most isolating conditions, but in group treatment people who may have been sitting at home alone for four or five years suddenly find there are other people out there just like them," says Roberta Elman, who helped to establish the life-participation and group-treatment approach and who is president of the Aphasia Center of California, in Oakland. The center matches patients to weekly communication groups based on the type of aphasia they have.

The Adler Aphasia Center, in Maywood, N.J., offers a life-participation approach to speech recovery with activities such as acting workshops, debate clubs and craft classes in three 15-week semesters annually. Most members attend twice a week and pay $25 per day. Executive director Karen Tucker says the center provides scholarships and turns no one away. Patients can join at any point in their rehabilitation process.

Adler also trains medical interns, residents and other health-care workers "so they can communicate with aphasic patients and see how people can improve given the right supports and opportunity," Ms. Tucker says.


Ms. Bustillo was referred to Adler in 2005 by the rehabilitation center where she was treated after her stroke. She was helped early on by occupational and speech therapy but still had trouble speaking, reading and writing and was unable to return to her consulting business. She also was unable to drive and felt she had lost her independence and ability to help her family.

At Adler, she was relieved to meet others with the same challenges, she recalls. She took a communication strategies class that taught her how to deal with people in stores or on the phone, such as by asking them to slow down and explaining her problem with aphasia.

Adler staffers encouraged her to take a jewelry-making class, which helped her regain dexterity and vision, and she now volunteers at Adler teaching other members how to make gifts and jewelry for a store to benefit the center.

"I still often go home so tired, and I have to think before I talk and make sure I say the right thing," she says, stumbling only slightly with her words. She continues to improve with the help of Adler speech therapists and interaction with other members. "You still mourn the person you were before, but this has been like dying and getting a new life," Ms. Bustillo says.

Intensive one-month aphasia programs are available at a cost of $8,500 to $20,000. The Rehabilitation Institute of Chicago program, started five years ago, has shown measurable improvement in more than 80% of participants, according to Leora Cherney, director of its Center for Aphasia Research. Some patients return three or four times to continue building skills.

The Chicago center also offers less-expensive options, including community group therapy. It developed a program called ORLA—which stands for Oral Reading for Language in Aphasia—a therapeutic approach in which patients practice reading sentences aloud repetitively.

A computerized version uses a virtual therapist, in the form of a computer avatar. A CD version, minus the avatar, can be purchased for $85 by patients or therapists, and an app for mobile devices is in the works.

Dr. Cherney is testing a more-advanced online version with an avatar whose mouth moves, like that of a real person, to help patients pronounce words. She is recruiting volunteers for a study of six weeks of intensive therapy that can be done at home. Also available with the avatar: AphasiaScripts, a $110 player with 20 practice scripts, or a $229 version which allows a therapist or family member to customize scripts.

"With money in the health-care system getting tighter, we can use technology to help patients with aphasia practice speaking, listening and reading skills several hours a day while minimizing costs," Dr. Cherney says.

Write to Laura Landro at laura.landro@wsj.com




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Stem Cell Therapy May Help Liver Disorders

Stem Cell Therapy for Liver Disorders
Added by gricelda7 on July 7, 2013.
Saved under Health


A new study in United States has shown that in the near future stem cell therapy may provide the cure for liver disorders. Until now liver transplantation has been the most effective treatment for patients who suffer a high level of liver damage.

Researchers have been able to obtain liver progenitor cells from embryonic stem cells (ESC). Progenitor cells are similar to stem cells but they are already slightly differentiated cells for specific tissues and organs that can only divide a certain number of times. Through an in vitro process of differentiation the scientists have grown them out as mature liver cells that are functional.

The investigation was completed in the Department of Developmental and Regenerative Biology, Black Family Stem Cell Institute, at the Icahn School of Medicine at Mount Sinai.

Its senior researcher Valerie Gouon-Evans and her team explained in their paper, KDR identifies a conserved human and murine hepatic progenitor and instructs early liver development, published in Cell Stem Cell in June 2013, “Understanding the fetal hepatic niche is essential for optimizing the generation of functional hepatocyte-like cells (hepatic cells) from human embryonic stem cells (hESC).”

The Importance of KDR

KDR was discovered on the cell surface of liver progenitor cells. This is a receptor protein with a very important task. Scientists thought that this protein was only present in progenitor cells that form vessels and blood cells. But the team of researchers at the Icahn School of Medicine at Mount Sinai demonstrated that they could “switch on” the liver progenitor cells by activating the KDR protein, a feature that contributed to converting them into mature liver cells ready to use for liver repair.

To test if these cells were optimally functional a further experiment was carried out by the Department of Microbiology at Icahn School of Medicine at Mount Sinai, they were infected by hepatitis C virus and they “responded” to such stimulus, an exclusive feature of original mature liver cells.

In a second stage of this study, the investigators will try to use the regenerated cells (in vitro) in experimental animals to verify if their liver damage can be repaired with these cells made in the laboratory.

This treatment is a step further in the evolution of medicine and there are chances that one day this type of stem cell therapy will reduce or eliminate the old organ donation system, dramatically increasing the survival rate of millions of patients worldwide.

By: Dinah JL Novak



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Pot-Smoking And the Schizophrenia Connection

OPINIONJuly 1, 2013, 7:13 p.m. ET
Samuel T. Wilkinson: Pot-Smoking And the Schizophrenia Connection
Medical research shows a clear link between marijuana use and mental illness.

By SAMUEL T. WILKINSON
Recent legislation has permitted the recreational use of marijuana in Colorado and Washington state. Those who support legalization often tout the lack of serious medical consequences associated with the drug. Most of us know people who used marijuana in high school or college and seem to have suffered no significant medical consequences. As the medical and scientific literature continues to accumulate, however, it is becoming clearer that the claim that marijuana is medically harmless is false.

There is a significant and consistent relationship between marijuana use and the development of schizophrenia and related disorders. Schizophrenia is considered by psychiatrists to be the most devastating of mental illnesses. Patients who suffer from it often experience auditory or visual hallucinations, severe social withdrawal and cognitive impairment. Many require frequent and prolonged hospitalization in psychiatric wards.

Schizophrenia affects almost three million Americans—more than six times the number of people with multiple sclerosis, two and a half times the number of people with Parkinson's disease, and more than twice the number of people with HIV/AIDS. Less than one-third of patients with schizophrenia can hold a steady job or live independently. A large portion (about one-third) of homeless people in the U.S. suffer from the disease.

Though they receive little attention in the legalization debate, the scientific studies showing an association between marijuana use and schizophrenia and other disorders are alarming. A 2004 article in the highly respected British Journal of Psychiatry reviewed four large studies, all of which showed a significant and consistent association between consumption of marijuana (mostly during teenage years or early 20s) and the later development of schizophrenia. The review concluded that marijuana is a "causal component," among others, in the development of schizophrenia and other psychotic disorders.

A 2007 study in the Lancet, a British medical journal, concludes that using marijuana increases the risk of young people developing a psychotic illness, such as schizophrenia. This risk is greatest—up to a 200% increase—among those who use marijuana heavily and who start using at a younger age.

Those not familiar with epidemiological causation may wonder how cannabis could "cause" schizophrenia if so many people who smoke marijuana or hashish don't develop the disease. As an example, medical researchers have known for several decades that smoking causes lung cancer, yet over 80% of smokers do not develop lung cancer.

As research accumulates, the emerging picture is that marijuana precipitates schizophrenia or related psychotic disorders in people whose brains are inherently vulnerable to psychosis. All of us who do not regularly experience hallucinations or delusions reside on what may be called a "cliff of sanity." Some of us, for reasons still unclear (thought possibly to be genetic), are closer to the edge of the cliff than others.

Marijuana may push everyone a few feet closer to that cliff. For those who were already close to the cliff, the drug pushes them over the edge into the chasm of insanity, hence precipitating the development of schizophrenia.

The association between schizophrenia and marijuana is not the only issue at play in the debate over marijuana legalization. If legalization is certain to decrease the power of drug lords in Mexico and other countries, then this is certainly a favorable outcome. However, if the trade-off is that more people suffer from schizophrenia—and thus more Americans are homeless and debilitated—then this must be recognized and discussed by the general public. This association between marijuana and serious and devastating psychotic disorders has been absent or under-recognized in the public debate.

Despite (or perhaps because of) the unwarranted stigma that surrounds their illness, individuals with schizophrenia are vulnerable and in need of advocacy. We owe it to them, and to society in general, to consider all the facts, risks and potential benefits before we embark on this drastic social experiment. If the end of Prohibition offers any historical precedent, once marijuana is legalized it will be all but impossible to undo.

Dr. Wilkinson is a resident physician in the Department of Psychiatry at The Yale School of Medicine. His opinions do not necessarily reflect those of The Yale School of Medicine or its Department of Psychiatry.

A version of this article appeared July 2, 2013, on page A13 in the U.S. edition of The Wall Street Journal, with the headline: Pot-Smoking And the Schizophrenia Connection.


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Age related medical exams

Great lifehack article on age related medical exams.
http://lifehacker.com/the-medical-checkups-you-should-get-for-each-decade-of-724463649


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Cell Whisperer: Lasers Unlock Secrets of the Blood

Cell Whisperer: Lasers Unlock Secrets of the Blood
An advanced form of ultrasound may help researchers assess the health of blood and diagnose disease without breaking the skin

By Dina Fine Maron



Healthy red blood cells are shaped a lot like lifesavers, just with more of a dimple than a hole in the middle. But red blood cells that are sick or damaged often change shape, becoming bloated when infected by the parasite that causes malaria, for example. Quickly detecting that irregular shape might one day speed up identification of blood diseases, certain kinds of cancer or even tell blood banks when red blood cells sitting in storage are past their prime—all without breaking the skin or spilling a single drop of blood.

A new imaging approach called photoacoustics may one day help that dream become a reality. The procedure, which harnesses the power of light and sound, is akin to laser-induced ultrasound. A team of investigators at Ryerson University in Toronto used high-frequency sound waves to create new, detailed images of red blood cells, bringing science one step closer to that future. The findings are published in Biophysical Journal today.

With photoacoustics, a drop of blood is placed under a special kind of microscope that picks up sounds produced by the cells themselves. Researchers then shoot a very focused laser beam at the samples. As the blood cells absorb energy from the laser pulse, they release some of it in another form—sound waves. Because blood’s composition allows it to absorb light in different ways at varying wavelengths scientists can work out various details about the shape of the cell using photoacoustics. “Think of it like a microphone,” says study author Michael Kolios, a physics professor at Ryerson and Canada Research Chair in biomedical applications of ultrasound. “We are just listening to what’s happening.”

The catch is that detecting changes in the shape of red blood cells at the level necessary to indicate the cells might be sick has not yet been possible via this kind of imaging.

Kolios and his colleagues at Ryerson tweaked a customized photoacoustic microscope to detect very high frequencies. Now they can recognize red blood cells’ shapes and sizes with greater definition than ever before. Their success opens the door for a future that could one day include handheld medical scanning devices that could map out cell shapes.

Previously, researchers could only use a frequency under 100 megahertz for their photoacoustic experiments because it is difficult to obtain sensors strong enough to work with larger frequencies. Images made from such low frequencies did not reveal much, allowing investigators to see that there was a cell there—but not much more. The Ryerson team was able to use much higher frequency sound waves thanks to a special ultrasound sensor that can pick up the higher frequencies. This improvement allowed them to “see” red blood cells in enough detail so that they could begin to tell how healthy the cell was.

They still had to look at red blood cells under a slide, however, because sound travels so unpredictably when it enters into bodily chasms. When a pregnant woman has an ultrasound, for example, medical professionals employ a very low frequency to get images of her fetus because a high-frequency wavelength would arrive at the fetus but then would quickly scatter and be absorbed by surrounding tissue before leaving the woman’s body. Similarly, using high frequencies in photoacoustics would not elicit a detailed image on something that exists in the body’s recesses.

While there are still a number of technical issues to work out, researchers are encouraged by the clarity of the images that are now available with photoacoustics. The next step, says Lihong Wang, a biomedical engineer at Washington University in Saint Louis, is to think about culling information from places where blood vessels are relatively accessible, like the arm. “This will inspire some new work, and we may start looking at photoacoustic information for the purpose of quantifying the shape of a single blood cell.” Wang says.
A more immediate application for photoacoustics may be scrutinizing blood in hospitals and blood banks that is about to be administered. Red blood cells have a shelf life of 42 days. “Unlike milk, where it’s really good one day and you pour it on your cereal the next and it’s sour, blood products start deteriorating right away—from zero to day 42,” says Jason Acker, who assesses new technology for Canadian Blood Services as its associate director of development. Although blood is assessed for contaminating bacteria, white blood cells and hemoglobin, the quality of the blood is never measured, he says, and it may deteriorate faster or slower depending on a variety of factors. “It could be valuable to have tools just prior to transfusion or prior to issuing blood to a hospital about the quality of the product.” Kolios has begun talks with Canadian Blood Services about partnering on research for adapting this technology to be used to help assess blood in blood banks.

Another long-term application of this work could be in detecting something like melanoma. “I’m most excited about the potential of this work for in vivo detection of circulating tumor cells,” because this technology could identify cancer cells more quickly than current methods, Wang says. To adapt this technology to do something like that, scientists would need to further calibrate the wavelengths they would use—red blood cells are red and most melanoma cells carry melanin, which is black, and thus would absorb light differently. But the possibilities from this breakthrough have scientists eyeing a brighter future for earlier and less invasive disease detection.


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Wii (game console) May Help Balance in Parkinson's

Wii May Help Balance in Parkinson's
By Ed Susman, Contributing Writer, MedPage Today
Published: June 24, 2013
Reviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

SYDNEY -- An exercise program that included the use of the Nintendo Wii virtual reality video game appears to have improved balance, reducing the risk of falls among patients with Parkinson's disease, researchers reported here.

On the Tinetti Total Score 18, the patients in the study who used the Wii plus treadmill and cycling exercise routines increased from 22.3 at baseline to 26.6 (P=0.002), according to Antonella Peppe, PhD, research professor at the Fondazione Santa Lucia in Rome.

"The ability of the Wii Balance Board to stimulate the central nervous system makes it potentially useful in the rehabilitation of balance problems in patients with Parkinson's disease," Peppe said in her late-breaker poster presentation at the annual International Congress on Parkinson's Disease and Movement Disorders. "Our results allow us to confirm that the Wii is an excellent tool that can compete with other devices in the rehabilitation of Parkinson's disease."

The researchers also showed that the patients who exercised 60 minutes a day -- 20 minutes playing three different Wii games; 20 minutes on the treadmill, and 20 minutes on the cycle -- appeared to improve balance and gait as measured by both the Tinetti and Unified Parkinson's Disease Rating Scale (UPDRS) Part II and Part III and the Part III balance and gait section scores. At baseline:

Tinetti balance score was 13.83 and that improved to 16 (P=0.002) after patients completed the exercise program. Patients completed 1 to 26 sessions, with the mean of 10.66 hour-long sessions.
Tinetti gait score was 8.5 and that improved to 10.58 (P=0.007) post-treatment.
UPDRS part 2 score was 12.83 and that improved to 6.25 (P=0.002) post-treatment.
UPDRS part 3 score was 31.13 and that improved to 14.08 (P=0.002) post-treatment.
UPDRS part 3 gait and balance score was 6.73 and that improved to 2.0 (P=0.003) post-treatment.
Peppe and colleagues also reported that after treatment patients had improved outcomes on the Global Mobility Task, on the Parkinson's Disease Questionnaire-39 and on the 6-Minute Walk Test.

"Our results with the Wii Balance Board are encouraging," Peppe wrote in her presentation. "In fact, after the rehabilitation trial Tinetti's scale showed a statistically significant decrease in the risk of falling and the Global Mobility Task showed better stability, reflected in decreased time and increased functional ability highlighted by the 6-Minute Walk Test."

The researchers noted, however, that their research was limited by lack of a control group in their pilot study.

Participants mean age was 63.33; their disease onset occurred at a mean age of 51-and-a-half; their disease duration was 11.75 years. Patients' only treatment was levodopa at a mean daily dose of 526.71 mg.

"Peppe et al. demonstrate that therapeutic interventions utilizing the Wii Fit Balance Board show promise in improving symptoms related to Parkinson's disease," said Jennifer Trilk, PhD, clinical assistant professor of biomedical sciences at the University of South Carolina School of Medicine in Greenville.

"The study is interesting and could potentially add to a growing body of evidence for nonpharmacologic therapies related to management of Parkinson's disease," Trilk told MedPage Today.

She said that the use of Wii equipment -- especially the narrow configuration of the Balance Board and the subsequent constraints of foot and leg movement for therapy -- might limit its general use among Parkinson's disease patients.

She also suggested that treadmill walking and cycling were more likely to be associated with gait improvement rather than the Wii-based exercises.

Overall, however, Trilk said she agreed with the researchers "that the Wii Fitness Balance Board could be used, as a component of therapy, for managing symptoms related to Parkinson's disease."





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