Saturday, September 24, 2011

Really: What is New In Alzheimer's Research?? Diagnosing AD

Well here we are in late 2011. One of the things that is astounding to me is the disconnect between the research  experts and those in the daily grind. If you are the caretaker of a loved one or live with someone with AD you are the real expert in my opinion.
So we have no cure, we have  no definitive way to treat  it and we have no definitive way to diagnose it with 100% certainty except brain biopsy or autopsy of brain. I need to re notify and present those grave and awful facts to give an understanding and perspective of where things are at and break it down for the general public, so we can understand exactly where the current efforts to combat the disease are at. I suppose a lot of websites and organizations try to do that, but it is not always easy to follow what the heck is going on with AD.
The hottest research,  at least what is put out to the media outlets, and available to you and me is in diagnosis. In terms of treatment or cure, one of the things you have to understand is that a lot of the medicines and treatments and funding for studies comes from the private sector IE. big old pharmaceutical companies. I think you know as well as I do that drug companies are considered sinister, evil and only concerned about the bottom line. Everyone likes there funding though. But with the Obamacare crisis- the acceptance and positive regard  for drug companies is probably at an all time low. That actually hurts research efforts for things like Alzheimer's disease. -(swear to God)
In Duluth, MN- a city and state that arguably, collectively loves to hate physicians as much as any place: I can barely even talk to drug reps anymore. I almost don't let them in my office. If a doctor around these parts does interact with a drug company representative, then his or her name may be smeared all over the local fish wrapper newspaper for being bad as a doctor and moreover as a human being and everyone believes it.
Who is going to pay for the research. Just dont' hear much about the plight of AD with the health care antics, do you?
So take it up with the publicly funded agencies like the NIMH and the NIH. Very politically correct since they are "PUBLIC". Publicly funded research is up there with the perceived unconditional altruism of the "non-profit" tax status entity. Whatever way you look at it, they are all politically correct right?
I am not going to even get into the funding for AD research relative to many other diseases, but lets just say by looking at the numbers, we can draw an easy conclusion that AD research may be underfunded in the public sector.
So the thought leaders: those in the Research trenches while  liasoning up with the Alzheimer's Association, want to figure out a better way to diagnose AD other than a brain autopsy. We want to diagnose it early. Really really EARLY. Early diagnosis without question is good-clinically and  humanely it is ALWAYS good. I will not consider the economic, bio-ethical and therefore political implications- the liberal weasels will talk care of that, and it won't be pretty for  those whom care about the sanctity of human life- like myself and perhaps most readers of this blog.
Now let's think about the AD process. It is a two-fold process: internal and external.
There is something internally going on at the brain cellular level and also something externally going on with the victim- the behavior, the memory, the personality changes-you caregivers are the experts on the external manifestations of the disease. You live it everyday.
Now consider this-A person does not wake up one day and have Alzheimer's. We all know this  and it is established that there are changes at the brain cellular level and gross physical biological changes to the brain. Amyloid and such- the battle cries and buzzwords we have all heard before. plaques and tangles amyloid and tau
It should not be a leap of faith to say that the internal changes to the brain start before the external changes. That's just how the brain and the disease works. Remember we have millions and millions of  brain cells, and if you kill one cell nobody is going to notice too much. The disease has to destroy a lot of brain cells to notice externally, that can take years.
Researchers want to make the diagnosis early in the process, really early. Once again, what is happening internally to the brain and the cellular level in an AD victim may start years and years MAYBE even decades before the external change start when victim starts showing the signs of Alzheimer's all of you are so familiar with. If you get it early there might be something more we can do about it. Maybe some day at least stop it before it advances.This is a good thing. It is why we want to find it early, before the external manifestations start.
Now how do you do that. Basically we can look at pictures of the brain, through neuroimaging, CT MRI, PET SPECT all kinds of elaborate scans. We can tag certain cells to go to certain parts of the brain that might be showing changes in Amyloid composition per say. not new to medicine but in terms of radioactively tagging cells to look at the brain, it is not as common and established as say a scan of the heart using tagged cells.
So there is a big area-Advancing Neuroimaging, sophisticated picture of the live human brain and its real time functioning. in PET scans, one of the really expensive but promising radio tracers is called (PiB)  which is short for:
Pittsburgh Compound B This can help trace and assess Neocortical amyloid Burden or how much amyloid is accumulating in the brain, with pretty good accuracy.
The second diagnostic tool we have is laboratory tests either blood or cerebrospinal fluid. Biomakers Biomakers and Biomarkers. BIOMARKERS.
So that's it. We have blood (and spinal fluid) and neuroimaigng to work with, and that's about it. Not too much else these days. Those are the main things we have to work with in terms of diagnosing that disease when it is still internal and otherwise invisible, years before it externally manifests itself. Yes of course we have genes to look at and work with, but we have been barking up that tree for a few decades now, and it really isn't totally panning out for everybody across the board as a gold standard to definitively make the diagnosis or rule it out in anyone and everyone. So take some of those better studied genetic markers like ApoE, (well discussed everywhere now)  and lets clump them into blood work studies.
Now is there a way we can combine all the bloodwork and biomarkers and Amyloid Burden in the Brain by imaging? Is there???
Well it just so happens that the AIBL (Australian Imaging, Biomarkers and Lifestyle Study) is working on doing just that.
Basically they took 273 people , performed the expensive PiB-PET scans and then also took bloodwork from them. Studying the blood they used 9 different biomarkers in a panel, thing like cortisol and ApoE were tested in the blood panel. They figured out the biomarkers that would correlate with the different amounts of amyloid burden in the brain that would predict and be consistent with developing AD.   Basically not an easy thing to do.
Then they took another 817 people or so and didn't do a scan. They clumped these people into clinical diagnosis: AD (external Alzheimer's); MCI (mild cognitive impairment); healthy individuals.
!00% of the Alzheimer's victims had a  high neocortical burden based on the blood panel with the 9 biomarkers, (remember the panel correlated with the neuroimaging originally that showed the brain amyloid.
Okay so what does it all mean?
Basically it is moving us a little closed to developing a blood test to allow us to diagnose AD much earlier before it externally manifests. No we are not there yet.
The idea is neuroimaigng is too expensive, getting a spinal tap is too invasive , and we need a good blood test that will work for everyone to make the diagnosis before the disease outwardly manifests.
Remember all the research is happening around the world not only America. As I said in previous posts, it is collaborative and competitive. Everyone wants to be the first to make that discovery. No one openly admits it. That just would not be altruistic. '
So that's where the efforts are. If we can get it diagnosed early, have a mainstream blood test that you can get at the primary care clinic, then perhaps we can find more effective treatments earlier on inn the disease process. . If we don't have meaningful  treatments, but we can diagnosis it  really years earlier... well the way American society it acting,  We will be in really big trouble.

Monday, September 19, 2011


Wow, what is it? Last I checked physicians were not allowed to "burnout".  Burnout is even somewhat poorly defined, since it is not a clinical concept. Everybody knows what it is but it looks different in different people. Consider it a chronic state of emotional, physician, intellectual and spiritual exhaustion-In this case induced by ones job, or occupation or in this sense I still use the term profession. It can manifest with more cynicism, physical health problems, addictions, calling into work sick-(doctors don't get to), anger, irritability, slowed cognition, anxiety, marital and relationship problems and of course the catch all term "depression". Sometimes the depression is a clinical depression.
People end up hating their work, retiring early (if they can) switching careers( if they can) and a whole host of other consequences.
The fact of the matter is just a few years ago, almost all physicians wanted their son(s) or daughter(s) to become doctors. Now only some 30% encourage their children to go into medicine. Most docs over fifty years of age want out ASAP.
There are lots of little initiatives to help physician burnout, often run by para-professionals, psychologists, nurses, you know people that didn't go to medical school, didn't give up all of their adolescence and most of their adult lives to serve. Interestingly enough many of the physicians who lecture about physician burnout have gotten out of the game, they have gotten out of direct patient care.
Now I will tell you the rest of the story, that no one seems to comprehend, even most physicians, the anti-physician New York Times media type outlets, and the general anti-physician mainstream society. make that ALL doctors who make it (WHO MAKE IT) IE gotten through school, residency etc. want to serve others, they want to help patients. They are also as a whole very self-punitive, very even shame based, we are our own harshest critics. Most take it very very hard and suffer in silence when things do not go well with a patient. Moreover we are not allowed to whiners, it is politically incorrect, and just plain wrong if you are a physician, this blog is just plain wrong- because it talks about the things the smiley faces whom have gotten out of the clinical world and make a decent living, as well as all the physician despisers annoyed-  it is uncomfortable to think about.
Most docs are perfectionist by nature, everyone whom isn't this is WEEDED OUT in the 12 year process. The integrity and commitment is phenomenal, and yet their is something profoundly masochistic and self-punitive about the culture and very nature of the indoctrination of becoming a physician. In other words you pretty much give up yourself, it is selfless. That is in the backbone of any good physicians, and most are good. The not so good one 'wannabes', did not have the intellectual or spiritual or emotional commitment.

So here is a secret, maybe not a secret but a taboo statement within society.- a lot of physicians want out of direct patient care, this is where the stress and burnout comes from. Why? There is more pressure than ever, to see patients- as many as possible, that pressure comes from payers, administrators etc.
There is literally a bulls eye on physicians backs in regard to litigation, when we don't get the outcome we want we immediately want to sue the doctor. We want retribution, accountability. We want our doctor to be perfect, to know everything and have a wonderful bedside manner.
But nowadays we live in such a physician-hostile climate, we are ready to sue if something does not go our way. It is another pressure. Also we really place no actual value on the doctor. We know how much it costs to get our oil changed in our car or to get a crown on our tooth at the dentist, but we never really know how much a doctor's appointment costs. Moreover we get huge uncovered bills from institutions and the general assumption is that all that money is going into the doctors pocket. I will never be able to convince anyone outside of medicine that the doctor does not see that money. It helps us devalue and hate the physician even more.
And here is another concept- there is generally a breakdown of the family more social media, less human contact and intimacy and perhaps as a society we treat each other with less respect than ever. Call it a post-war pervasive narcissism except know we are about 5 generations post war, and have been busy indulging ourselves for decades, feeling good putting ourselves first, convincing ourselves that the destruction of the nuclear family is cool and politically correct. what does this have to do with physician burnout???
NO ONE WANTS TO PAY TO BE CARED ABOUT. The physicians office is one of the few institutional bastions left in our ever-advancing society where a person is supposed to and can feel cared about.
With that said a person can never feel cared about from the nurture they didn't get from their fragmented family of origin.   Now couple that with a doctor whom you don't pay- (insurance does or does it?) and that doctor is working hard to be good enough and help you as much as they can, but it will never quite be enough given the combination of factors conscious and unconscious between patient and doctor. It is a perfect storm for an -anti-physician society to advance their distaste towards doctors and an even more perfect storm for physicians whom actually take care of patients all day, to become really really burned out.
But since we are so shame-based, it is completely taboo to say we dont' like treating patients anymore. That is a sign of being bad, and that is the LAST thing a doc wants. So we burnout or quietly switch careers, except most docs have no marketable skills outside of medicine.
Physician burnout is more complex than eating right, balancing work and play, getting enough sleep, prioritizing family, exercising. Yes all that stuff is crucial to avoid burnout but it really needs to be understood, from a developmental and personality-character perspective to be able to do something more about it. One must also consider what has happened to society in the last four generations, to understand why there is more physician burnout.
I would love to see a doctor that still takes care of tons of patients all day speaking on burnout, except they don't have the luxury. Sorry I'm just whining, I must stop. I know like all good docs all over this great nation of ours, I will just keep trying harder every time.

Tuesday, September 6, 2011

WAM Match Appeal #1: Advocates 9-2-11

WAM Match Appeal #1: Advocates 9-2-11:

'via Blog this'

caring for those with Dementia.

God Bless,

Eternal Peace or endorphin release, or God, religion, afterlife, the divine

Well it has been a really long time since I blogged.  The summer is officially gone by us as we just finished labor day.  It is coming up on two years sincee I fell off a scooter and broke my face in 4-5 places. I have ringing in my ear and a tumor called an acoustic neuroma, which Mayo clinic can do nothing about except watch it and charge me lots of money that my insurance won't totally cover to pay for staging it once a year. It is on my cochlea which is sort of the end of the eight cranial nerve the other end connects up to your brain.
Also loosing my hearing in that ear. Because of location that won't operate. More later on this.
Not too much new on the AD front. Australian study and Mayo looking at a bunch of blood markers, a whole panel of tests to try and identify Alzheimer's in people before it becomes clinically apparent and obvious.  So earlier recognition is where it is at. Testing and findingg it before it becomes apparent, maybe years before. No clear treatments emerging. 
So this summer I went to a Benedictine Monastery for a few days in St. Leo Florida mostly to pray for healing for my ear. I ended up praying for my enemies and people I can't stand. My ear did not get cured but me stress level went down considerably.
I also ran my first 5k marathon this summer, ironically with the exception of the cancer in my ear, I am in probably the best shape of my life at nearly 50 years old.
I had a bit of a spiritual moment.  I was with my son and a climbing friend. We climbed the South Sister in the Cascades in Central Oregon. The summit is about 10,500 feet or so. We started at 5AM and completed the summit about 12 noon. Note that this is a climb I never completed in 1994 when I was 33 years old. I started out to late in the day on that one. Now at almost 50 I completed the climb.
On the way down we rested a few times. At one point, I sat down then layed back. The sun shined on my face and warmed me on the side of the mountain.  I said aloud, "this is what it must feel like to be dead." I didn't mean it in a bad way, but it upset the friend my son and I were climbing with. He said, "don't talk like that." What I meant what I felt so incredibly at peace, I wished for nothing, felt no stress or worry, just the beautiful sunshine warming me. It was so incredibly comfortable. I corrected my self and said, "No I mean this is what heaven must be like." I felt really peaceful and loved and even connected to God. Nothing hurt, I can't remember my ear ringing or throbbing, just peace.
This happened a couplee weeks before I went to the monastery.
It is unusual to have an experience like this. One could say I was exhausted from climbing for 8 hours and it was cold and brutal winds at the top of the mountain but on the way down it was sunny and nice. Perhaps it was endogenous opioid release,  a similar feeling a person may get from taking opiates.
On the other hand it simply could have been God and a peaceful loving content and fulfilled feeling.
You see how I struggle between the science and the spiritual. 
At any rate I was lucky to have this moment, this time where I felt close to God.
After loosing my parents at an early age, a lot of life has been filled with a certain stress, sometimes an anguish, (read the book) like everyone I have my struggles. As a doctor and a psychiatrist, a lot of my life is surrounded by the worst pain and evilness known to mankind and the terrible things that human do to one another and how it affects them. So if I get a moment on the side of a volcano and it is complete with human fulfillment I have to take it as a sign from God. I wish I had more of those signs, but we take what we are given. It was a good thing, perhaps a divine thing.

Talking about the book with the Lake Superior wind....... a calm day