Author Archives: michelesullivan

H5N1: Keep That Genie in the Bottle

Throw out a hint of some meaty research and say “Don’t Ask! Don’t Tell!”  You might as well draw a map to the Christmas cache and tell the kids, “Don’t follow this trail!”

The U.S government seems to be engaging in the worst kind of this delusion by asking the journals Science and Natureto withhold the methodology sections of two important papers on H5N1 viral mutation.

Michele G. Sullivan/Elsevier Global Medical News

The papers, one by University of Wisconsin-Madison veterinary virologist Yoshi Kawakoa and one by Dr. Ron Fouchier of Erasmus Medical Center in Rotterdam, Netherlands, detail their work on avian flu H5N1 mutation. Each describes genetic engineering that created a new strain almost 100% lethal to ferrets — generally considered the best animals to model a human respiratory infections.

Presumably, Drs.  Kawakoa and Fouchier conducted their experiments with the goal of helping to protect mankind against the virus’ inevitable change. But the National Science Advisory Board for Biosecurity sees a dark side. The agency’s official plea to both journals suggests that publishing “the  methodological and other details … could enable replication of the experiments by those who would seek to do harm.”

Their concern is not unfounded: It goes without saying that an individual, or even  a country, could use this with evil intent.  A weaponized bird flu with a 90% or higher mortality rate would make the anthrax letters of  2001-2002 look like a scuffle in a kindergarten sandbox.

But is censoring going to keep this knowledge hidden?

Scientific discoveries almost always build upon prior knowledge in a long, nearly unbroken, chain of meticulous research. Researchers publish long strings of studies on the same topic, each one evolving just slightly from the last. Others with a passion for the same topic climb on board as well, so that eventually everyone benefits.

A clear representation of this? At least some of the research that so troubles our government has already been disseminated.

Colorized transmission electron micrograph of Avian influenza A H5N1 viruses (seen in gold). Courtesy the Centers for Disease Control and Prevention

Last year, Dr. Kawakoa described his lab’s creation of an H5N1 mutation almost universally lethal to ferrets.  The study describes his work with the two most virulent forms of H5N1, both isolated from humans and both with a human kill rate of up to 80%. Dr. Kawakoa and his colleagues manipulated the genes in both to create a novel virus that appeared even more lethal, killing all of the intranasally inoculated ferrets.

The paper not only identifies the genes — hemagglutinin (HA) and nonstructural protein (NS) — but the method of reverse engineering and  the modifications’ chromosomal positions. Its purpose was not to create a super-pandemic among humans, but to identify the genes and loci that most contribute to H5N1’s uniquely dangerous potential.

His new paper, according to the National Institute of Health’s  comment,  shows “that  the H5N1 virus has greater potential than previously believed to gain a dangerous capacity to be transmitted among mammals, including perhaps humans.”

Last September, Dr. Fouchier presented his now-to-be-edited work at the Fourth ESWI Influenza Conference. During an oral presentation, he described work that resulted in some potent H5N1 mutations. According to the conference daily, the researchers infected ferrets with the new H5N1, also formed by plasmid reverse engineering and also manipulating hemagglutinin.  The infected ferrets died, but didn’t transmit the virus.

The team then let the virus do its own thing,  just moving it repeatedly from a sick ferret’s nose to a healthy nose without tinkering – the way a virus would naturally mutate by adapting to each new host.  Dr. Fouchier found a new H5N1 with new mutations: It became an airborne form after 10 transmissions, suggesting that avian flu can mutate within one species, rather than requiring a “mixing bowl” animal, like a pig.

“This virus is airborne and as efficiently transmitted as the seasonal virus,” the paper quoted Dr. Fouchier as saying. “This is very bad news, indeed.”

The meeting wasn’t secret. Journalists were there, and some even wrote about it. New Scientist ran a piece about the research, as did Scientific American.

If this much information is already out there, might it just be possible that a “rogue scientist” could come up with much, much more? And is the National Science Advisory Board for Biosecurity really suggesting that only two scientists in all the world have so advanced this virus?

It might even be possible that there are labs in other countries working on the same thing. And that some of those countries might want to suppress important findings — holding them close the vest to “protect” the populace.

We wouldn’t want that now. Would we?

—Michele G. Sullivan

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Filed under Epidemiology, Genomic medicine, Health Policy, IMNG, Infectious Diseases

For Baby Beds, It’s Back to Basics

(Full disclosure: As a grandmother of two I have gone bonkers at every baby store in Northern Virginia. And the first night after baby Allison came home, I kept her in my own bed … allegedly so her mom could get a good night’s sleep.)

You’re an OB. You love pregnant women and babies and all that this wonderful time entails. And since you’re a good OB, you listen to your moms and relish their nesting behavior. It’s a good sign when they begin talking about Baby’s room and bed, all the cute stuff they’ve gotten from loving family and friends.

Now you – and your pediatric colleagues – are  going to have to let your moms down gently.

To prevent SIDS, AAP recommends against newborns sleeping in cribs set up like this. Sarah G. Breeden/Elsevier Global Medical News (2)

Bumper pads, stuffed toys, crib canopies (made popular by Jennifer Lopez’s royal nursery pictures), and even the fuzzy baby blanket Grandma crocheted – none of it belongs in a newborn’s bed.  And experts at the American Academy of Pediatrics (AAP) are targeting the issue in big way. On Oct. 18, the group issued a new policy statement on safe sleep for infants.

It turns out that the newest  best place for a baby to bed down is totally retro: a nearly bare (but consumer-safety approved) crib with a firm mattress and a single tight-fitting sheet.  PJs should be  a sleeper appropriate to the room’s temperature without a chance of overheating Baby, who should be sleeping on his back without so much as a blankie. And that’s it.

Virtually every OB and pediatrician discusses the topic of Sudden Infant Death Syndrome (SIDS) and supports AAP’s  17-year-old “Back to Sleep” campaign. The push resulted from research that pinpointed stomach- and side-sleeping as significant risk factors for SIDS. Since its adoption, there’s been up to a 66% decrease in SIDS deaths in the U.S.

But, Dr. Rachel Moon said at AAP annual meeting, this encouraging trend has a dark twin – a quadrupling in the number of infants who’ve died from suffocation and entrapment. And many of these deaths have been linked to getting stuck in loose bedding, or even from stuffed animals who topple over in the night and obstruct breathing.

Sleeping with parents is a big problem too, Dr. Moon said. Many groups – and not a few doctors – have promoted bed-sharing as the most natural way to care for a newborn, especially facilitating breastfeeding, a mighty defense against SIDS. But unfortunately, cross-eyed lethargy – a state familiar to every new parent – does not a safe bedfellow make.

And it goes without saying that a parent on pain meds  (any of your patients ever have an episiotomy or C-section?), or who is using other drugs or alcohol, is more likely to roll over on Baby. Deaths don’t necessarily have to be dramatic – like being crushed under adult weight, squashed between parents, or dropped on the floor. Even an arm that moves over a newborn’s mouth can obstruct breathing enough to kill.

Make sure family caregivers and daycare providers know the rules too, AAP advises.  Infants in child care settings are significantly more likely to die from SIDS,   perhaps because providers aren’t following the advice for safe sleep

Babies who sleep in plain cribs with firm mattresses and tight-fitting sheets are at a lower risk of SIDS.

More AAP advice? After the 4 a.m. feeding, stress that Baby goes back to her own crib, positioned safely  supine, uncovered, and hopefully with a pacifier.

Yes, the much-loved binkie now has a justified place in the scientific literature. It seems that pacifiers help reduce the risk of SIDS, probably by occasionally arousing the baby during sucking frenzies.

So tell  your patients’ thrilled Grandmas to relax  and rejoice by contemplating  how many pacifiers they can buy for the price of just one coordinated Peter Rabbit crib set.

—Michele G. Sullivan

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Filed under Emergency Medicine, Family Medicine, Health Policy, IMNG, Obstetrics and Gynecology, Pediatrics

Chew on This!

Grandmothers the world over are the same when it comes to some things.

Sneaking candy behind mom’s back.

Big cuddly hugs.

Best. Cooking. Ever.

And advice about how to eat said cooking.

A slow eater. Credit: Håkan Svensson, Xauxa/ Wikimedia Commons

“Slow down! This isn’t a race you know! Chew each mouthful 100 times!”

Japanese grandmas are no different – and even the Japanese government has jumped on the chewing bandwagon, Dr. Masaaki Eto said at the annual meeting of the European Association for the Study of Diabetes.

Dr. Eto described his study of 9 obese – but not diabetic –  subjects with a mean body mass index 27 k/m2 (in Japan, obesity begins at a BMI of 25 kg/m2). At baseline, the volunteers’ mean fasting plasma glucose was 99 mg/dL. They all ate the same 630-calorie meal on two separate days: bread, butter, a hard-boiled egg, steamed vegetables, a banana, and milk.

On day one, they had to finish it in 20 minutes, chewing each bite 5 times. On the second test day, they ate the same meal, also in 20 minutes, but chewed each mouthful 30 times.

Dr. Eto and his colleagues measured two satiety hormones – glucagon-like peptide (GKP-1) and peptide YY (PYY) before and after each meal.

The results will please grandmas worldwide.

Chewing each bite 30 times significantly increased the levels of both hormones over chewing 5 times, said Dr. Eto of Ohu University, Fukushima, Japan.

Among the 5-chew gulpers, plasma PYY increased from 36 pg/mL to 41 pg/mL – not a significant change. But the slow chewers had quite a different outcome. “The 30-times chewing group had a significant increase in plasma PYY,” Dr. Eto said. Their levels jumped from a mean of 36 pg/mL to 66 pg/mL.

The story was repeated with GLP-1. The fast-chewers did have an increase – although not significant (5 pmol/L to 17 pmol/L).  But the slow-chewers had much better results, increasing their GLP-1 from 5 pmol/L to a whopping 29 pmol/L.

“This is the first report that thorough chewing stimulates postprandial increases in the two hormones,” Dr. Eto said. “These hormones reduce appetite and food consumption, so thorough chewing may help obese subjects to lose weight.”

Besides, he said, Japanese grandmothers “since the old days” have advised kids to do a lot of chewing.  So much so, he added, that the Japanese government has issued a recommendation to  chew each bite of food 30 times – to help avert the country’s growing obesity problem. “That is why we picked 30 times chewing,” for the study, Dr. Eto said.

Some audience members weren’t completely convinced that the good results are related to the combination of chewing and food intake. One questioned whether the mechanics of chewing was key benefit, stimulating the vagusl nerve to release GLP-1. “For instance,” he asked, “what if the subjects chewed the food and then spat it out? What would the results be then?”

To which moderator Dr. Davide Carvalho replied, “I believe chewing and spitting out the food could be the best diet we could invent.”

—Michele G. Sullivan

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Breakfast in Bed, Anyone?

What do beds and pancakes have in common?

Nothin' says lovin' like dust mites from from the... frying pan? Photo by Flickr Creative Commons user Kalavinka

A: Romantic interlude

B: Snuggly Sunday treat

C: Wonderfully considerate partner

D: Potentially lethal mites

Answer:  All of the above

If you’re lucky in love, you get some romance along with your hot pancakes, propped up on your comfy mattress and fluffy pillows.

If you’re not so lucky, you suck in a lungful of Dermatophagoides pteronyssinus from your comforter and slug down a syrup-coated helping of its wheat-loving cousin, Dermatophagoides farina. And if your immune system is easily triggered, this relaxed repast can turn into a choking, wheezing trip to the hospital.

The tiny (300 micron), translucent house dust mite frequently haunts human beds, thoughtfully cleaning up mold, fungi, bacteria, pollen, your dead skin cells, and maybe that other white sock you lost a couple months ago.

Dermatophagoides pteronyssinus - a species of house dust mite. Photo by Flickr Creative Commons user Giles San Martin

Because of their tiny size and adaptive nature, these guys traveled with us from our damp, dark caveman homes to our modern hang outs and creature comforts:  beds, blankets, sofas, rugs, and cuddly stuffed animals.

For most of us, house dust mites cause no problem. They’re so tiny we can’t see them. They don’t sting or bite. And even if 100 were creeping up your leg – which they will probably do tonight – you would never know.

But unfortunately, they can seriously bug people with atopy. It’s not the mite per se, but its numerous droppings that cause issues among the allergic.  Inside those tiny poo balls are bits of undigested food and the digestive enzymes meant to break them down. All it takes is a breath of air – or a dip in pancake batter – for the “stuff” to melt away,  activating these enzymes.

Inhalation reactions start when the molecules come into contact with lung epithelium. Scavenger cells get the inflammatory process up and running, aggravating asthma and other allergic reactions, like atopic dermatitis, allergic rhinitis, conjunctivitis, and otitis media.

Pancake syndrome is a variation of the inhalation reaction. Whenever cooks use mite-infested flour, there is potential for danger. The medical literature contains case reports and series of both children and adults who experienced an anaphylactic reaction after eating mite-infested wheat-flour based foods. The reactions varied from mild to lethal.

In all cases, the flour used was replete with dust mites of several species – and full of the cell-destroying Der enzyme, cysteine protease. Among its many talents: direct damage to airway epithelium; destruction of the body’s epithelial tissue damage defense system; disruption of intercellular junctions; and of course, stimulating those pesky proinflammatory mediators.

Infested flour is more likely to be found in temperate, humid areas, and in poorly stored wheat flour or flour-based mixes – or products that have been opened for a long period and never used. In 2009, the World Allergy Organization published a dust mite oral anaphylaxis paper, suggesting that all grain flours be stored in airtight containers in the refrigerator or freezer.

So the next time a half-empty box of pancake mix gets you in the mood for some snuggly breakfast in bed – try switching to eggs. – Michele G. Sullivan

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Filed under Allergy and Immunology, Blognosis, Dermatology, Family Medicine, Gastroenterology, Hospital and Critical Care Medicine, IMNG, Infectious Diseases, Internal Medicine, Internal Medicine News, Pediatrics, Primary care, The Mole, Uncategorized

The Little Ant With the Big Bite

Just speaking with Dr. Ronald Rapini during the summer meeting of the American Academy of Dermatology  is enough to make you itch. That’s how good he is at describing the vicious attack of the fire ant – as it bites and stings its way northward from its Southern roots.

A native of South America, this aggressive invader established the first Fire Ant Town around Mobile, Ala., in the early 1900s. Rumor has it that the little buggers were stowaways on steamers. Apparently they found American soil so friable (and American flesh so tender) that they have engaged in a relentless northern march, traveling first throughout the southeast and now up both the Eastern and Western seaboards.

Fire Ant

Fire ants belong to the same species as wasps and bees. (Photo courtesy Agricultural Research Service, USDA)

Fire ants sport a chillingly descriptive Greek name – Solenopsis invecta, “Unvanquished Channel-Faced.” I leave it to you to decide if the imported red fire ant is “channel-faced,”  but I defy you to deny that it is unvanquished.

These are a species of the Hymenoptera, the insect order that includes wasps and bees, and they share some basic characteristics. Unlike their cousins, fire ants are only winged during the spring, when the await Eros’ call to fly from their nests in a mating frenzy – after which their diaphanous wings drop away and they build ever-more-complicated colonies that can spread throughout entire fields.

They also adhere to their order’s inclination to live in large, hierarchical societies arranged around a queen, with armies of workers bent on aggressive nest defense — much to the dismay of bumbling human feet.

If you invade their space, the ants swarm out with a
double-ended defense, Dr. Rapini, chair of dermatology at the University of Texas Medical School, Houston, said in a video interview.

“Unlike most ants, which just bite you, these guys bite with their huge jaws and then pivot around and sting you,” with a venom filled dagger.

The resulting wounds are painful, itchy, and full of pus.  Although familiar to Southern physicians, who have seen the problem for years, Northerners are just coming to grips with these tiny purveyors of pustular pain.

“Sometimes doctors will even get a biopsy on this because they’ve never seen it before,” Dr. Rapini said.

Because a fire ant bite/sting feels pretty much like someone burning you with a lit cigarette, most  humans are cognizant enough to run hysterically away from a fire ant encounter, doing the “fire ant dance” to shake the critters off their legs and shoes and out of their trousers. But like drinking and driving, drinking and fire ant hills are not a good mix, Dr. Rapini said.

An inebriated man fell asleep on a fire ant hill with dire consequences. (Photo courtesy of Dr. Ronald Rapini)

“My worst case was a guy who got drunk and passed out on a fire ant hill and came in with hundreds of stings,” he said. The patient wound up in the hospital, desperately ill with a bacterial superinfection; treating him required both antibiotics and high-potency corticosteroids.

There have even been reports of fire-ant deaths.

For most folks, though, the bites are painful, but few. A prescription-strength corticosteroid cream will at least help get patients through the worst stages. “It basically is a self-limiting issue; the bites just go away over a week or two,” Dr. Rapini said. “You really have to try not to scratch, though. That’ll make a scab. And pickers get scars.”

And by the way, humans aren’t the only creatures to suffer at the jaws and stingers of fire ants. They can cause terrible injuries in reclining baby animals.

Pets can also be at risk.

As are, apparently  cute little caterpillars and tweeting birdies.

— By Michele G. Sullivan (on Twitter @MGSullivan)

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Filed under Allergy and Immunology, Dermatology, Emergency Medicine, Family Medicine, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Internal Medicine News, Pediatrics, Primary care, The Mole, Video

Not This Life, Dear — I Have a Headache

A headache specialist's meeting doodle - is this picture worth a thousand words?

A headache is a mighty pain

That changes the defenseless brain,

It may go away.

It may come and stay.

Or rear again, again, and again.

Maybe not great poetry.

But certainly a statement – especially when we assume the author is a headache specialist.

I found this poem on a note pad left in a lecture room between sessions at the annual meeting of the American Headache Society, right after a talk on the genetics of migraine.

After a  lecture on the increased incidence of migraine in young soldiers with posttraumatic stress disorder, I found another note pad. This one depicted a stick-person, helplessly splayed across a tangled spider’s web.

Both, I think, represent the feeling of frustration that bonds headache specialists with their patients.

“We know what can turn it on, but how do we turn it off? That’s the question,” said Dr. Till Sprenger of the University of California, San Francisco. “We still don’t know.”

Headaches unremitting in the face of any treatment strategy are by no means a rarity. Medicines that benefit one may be useless to another. And drugs that can help can also hurt.

Almost anything used for a headache, from acetaminophen to opioids, can backfire if used often enough. Medication-overuse headaches are harder to treat and can start a cycle of using more and more drugs that become less and less effective. Triptans, the mainstay for many migraine patients, are most successful when used at the earliest signs of a headache. But they’re expensive, up to $32/dose, and most insurance companies impose a monthly limit. To save their pills for their worst moments, patients delay the dose, trying to figure out how bad the headache will be. The longer they wait, the less effective the medication.

The physicians at the American Headache Society know this. A number of speakers expressed frustration, not only at their inability to really help some patients but also at the still-rudimentary understanding of headache etiology – the only foundation upon which more effective treatments can grow.

The doctors at this meeting were a sympathetic lot or, perhaps more accurately, an empathetic lot. About half of the physicians I chatted with during breaks and in interviews said their own chronic headaches motivated them to specialize in treating others. They described their job as a mix of satisfaction and exasperation – because they know all too well the blessing of pain relief, the fear of impending pain, and the panic of unremitting pain.

Studies back up my very nonscientific observation of headaches among those who treat them. The most recent appeared in Headache, the American Headache Society’s own journal. It suggested that up to 40% of neurologists who treat headache suffer with their own.  Another 2010 study on migraine management noted that 48% of the  neurologists surveyed were themselves migraineurs.

While there no patients spoke at this meeting, Dr. Dawn Buse became their voice. Despite continuous evolution in headache medicine, her study showed that many continue to suffer.

“Forty percent have at least one unmet need regarding their headaches,” said Dr. Buse of the Montefiore Headache Center, New York.  The top reasons for continued problems? Dissatisfaction with current treatment. Continuing headache-related disability. Overuse of opioids or barbiturates. Other issues that presented in the survey were excessive visits to the emergency department or urgent care center and cardiovascular disorders, which can turn physicians off to the idea of a triptan-based migraine program.

The literature is replete with data confirming what headache physicians confront every day – migraine and other cephalgias worsen almost every quality of life measure.

A 2009 meta-analysis, coauthored by Dr. Buse and Dr. Richard Lipton, past president of the AHS, perfectly captured headache’s often all-consuming impact. Patients with a high headache burden “had higher lifetime rates of depressive disorders, panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, specific phobias, and suicide attempts than controls, were more likely to have missed work in the preceding month, to assess their general health as ‘fair’ or ‘poor,’ and to use mental health services.”

The relationship between headache and mental disorders is a complex one, not entirely understood, Dr. Buse told me during an informal chat. She likened it to the famous chicken-or-egg conundrum. “There is some evidence of bidirectionality – that each one predisposes to the other,” she said. “But if you think about it, it makes intuitive sense. If you are afraid of your next headache, you’re likely to be anxious,” which makes a headache more likely and can increase its severity.

The same thing goes for depression, she said. The neurotransmitter dysfunction associated with depression may predispose to headache, but months – or years – of intermittent pain very probably increase the risk of becoming depressed.

It was easy to see the concern in her eyes, and the caring of everyone who spoke at the meeting. Many of them, I suspect, have seen the doodle come to life …  Caught in that spider’s web, knowing that something bad is coming, but having very little power to stop it.

– Michele G. Sullivan

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Dermatologists in NOLA? … Eat!

Any dermatologist whose appetite is more than skin-deep is going to L-O-V-E next week’s American Academy of Dermatology meeting. New Orleans and food. They go together like fried chicken and waffles, praline bacon and stuffed French toast, beignets and chicory coffee.

Hot beignets are just a healthy jog away. Photo by Flickr user jyshun

Although there’s no shortage of tables in the Big Easy, reservations could be in short supply by now, with thousands of docs ready to pounce on the city’s specialties. So be a smart tourist and get on the phone, or hit opentable.com and line up your plan of attack. 

Breakfast

Most derms are probably going to hit the AAD’s breakfast tables before hitting the morning sessions. But if you just can’t take one more muffin-and-coffee meal, consider the following: 

Cafe du Monde. Do we really need to talk about this spot? Just do it.  It’s easy to incorporate into an early morning jog and the jog back eliminates any guilt (and all calories) about downing two or three sofa-pillow-sized pieces of fried dough.

You also might want to hop on the St. Charles Streetcar and head up to the white-colonnaded Camellia  Grill. The streetcar ride is a pleasure in itself, a leisurely trip through a grand old neighborhood of enormous moss-draped live oaks, Audubon Park, and some incredible old homes. Get off at Carrollton Avenue and open the door on the past – a long lunch counter served by (mostly) men in white uniforms and bow ties. Banter with the grill cooks and enjoy an enormous plate of eggs, waffles, French toast, or omelets. Since Camellia serves breakfast all day, you can still enjoy the experience at night, with the added bonus of a piece of pecan pie grilled in butter. Or what the heck – just have that pie for breakfast (626 South Carrollton Ave.; 504-866-9573).

Brunch

Brunch at the Court of Two Sisters in the French Quarter is a frustrating mix of dreamlike atmosphere in a vine-draped courtyard, and throngs of hung-over tourists lining up at the trough, um,  buffet line. The food is decent, but the courtyard not quite as lovely in February as it is in June. And, well, it can be a mob scene (613 Royal St. 504-522-7261).

How about a real surprise – something elegant, discreet, and lovely in the racy French Quarter? For about $60, you can listen to soft jazz and blues by the James Rivers Movement and relax in the Roosevelt  Hotel’s velvety Blue Room. For that price , you’ll get endless champagne and mimosas, one entrée off the brunch menu (anything from eggs Sardou to prime rib), and access to buffet of gumbo, chilled seafood, and a dessert table of mini-pastries, speciality cakes, and bananas foster – flamed tableside. For cool cocktails and hot jazz, check out the hotel’s Sazarac Bar, decked out in devilish red velvet for a devilish evening out. (123 Baronne St.; 504-648-1200).

Oysters

I know, I know – everyone will tell that Acme is THE place to go. But while 50 people are shivering in the outside line, facing an hour wait, you can saunter right across the street to Felix’s,  grab a bar stool, and have them shuck you out a dozen fresh, sweet oysters for $10.75. Manager Adrian Zado assured me that Louisiana oysters are still coming in, although the beds around the mouth of the Mississippi remain off-line. “Some were shut down for protection,” because authorities didn’t know how oily oysters would affect diner safety. Other beds died off when the state released more fresh water into the gulf to try to keep oil offshore. Slip  in on a Wednesday from 5-10 p.m., and you’ll get a free beer (the local Amber Abita is great) with every dozen oysters, although I like mine with one of those cute demi-bottles of champagne (739 Iberville St.; 504-522-4440).

Lunch and Dinner

Mother’s, close to the convention center, is a controversial place. Tourists love it because it’s in all the books. Locals come for a few specific things –the roast beef with debris particularly. But mostly it’s a long wait in a lunch line, followed by big servings of mediocre food (401 Poydras St.; 504- 523-9656).

Both Antoine’ s and Galatoire’s are old NOLA institutions, these two grand monsieur of the French Quarter offer a similar experience – a time trip back to the genteel era of ladies with feathery hats and the men who coddle them. Antoine’s  is the elder brother, established in 1840; Galatoire’s a mere 106-year-old. Antoine’s is heavily French-influenced; Galatoire’s proudly claims “The menu doesn’t change.” Aficionados of lighter, New American-style cuisine might be disappointed in the presentation and the flavors, but both draw devotees of these classic dishes (Antoine’s: 713 Saint Louis St., [504] 581-4422; Galatoire’s:  209 Bourbon St., [504] 525-2021).

In the Commercial District, my favorite place is still Herbsaint. It’s small, with a vest-pocket-sized bar, but survived Hurricane Katrina with most of its well-loved offerings, and some darn good new ones. My favorite meal? Shrimp and grits with Tasso ham, any of the pork dishes (the menu changes seasonally), and, for dessert, the brown sugar banana tart with fleur de sel caramel. Reservations all gone? Try the tart anyway; the recipe appeared a few years ago in Bon Appetite (701 St. Charles Ave.; 504-524-4114).

If you want to venture uptown, Brigtsen’s  is a great bet. Housed in a charming turn-of-the century wooden home, it serves up Creole classics with a little modern twist. Anything with pork, quail, or rabbit is a can’t miss (especially the panéed rabbit and spinach with the Creole mustard sauce). The “Shell Beach Diet” gives you six different little seafood  jewels, for $32. And what’s not to like about banana bread pudding with banana custard sauce? (723 Dante St.; (504) 861-7610).

For a local’s take on food, I turned to my colleague Alicia Ault, who has a long-standing love affair and virtual residency with NOLA. Here’s what she had to say:

Dick & Jenny’s has  become somewhat well-known over the years, and a big plus is that they are open on Mondays – there are few fine dining establishments open on either Sunday or Monday (4501 Tchoupitoulas St.; 504-894-9880).

Three Muses.  A new-ish place on Frenchmen Street, very small, good chef, has music sometimes. Small plates-type food. It’s getting a lot of hipster buzz  (536 Frenchmen St.; 504-298-TRIO).

Patois.  This is an old New Orleans place, too, also  uptown.  Fabulous food, almost impossible to  get in. Alicia – is that a challenge (6078 Laurel St.; 504-895-9441)?

Boucherie.   In the Carrollton area, it features very highly rated New American/New Orleans food, farm-to-table stuff. I can never get in here, partly because it’s small. And I’m  talking even when there’s nothing special going on in town (8115 Jeanette St.; 504- 862-5514).

Coquette. Fabulous cocktails (I had bacon-infused bourbon), some outside tables, nice atmosphere, very good food (2800 Magazine St.; 504-265-0421).

Ralph’s on the Park. A Brennan’s restaurant, Ralph’s is a locals-type special-occasion place on City Park. Service and food are great. A $35 three-course pre-theater menu and a $19 two-course lunch are on offer (900 City Park Ave.; 504-488-1000).

Ye Olde College Inn. Very solid New Orleans food with a noisy, party-type atmosphere. Locals love this place, and I end up eating here a lot because it’s easy and not too expensive (3000 S Carrollton Ave.; 504-866-3683). Also it’s right next to the Rock ‘N Bowl   so you can eat and then stumble over for music.

Well, that’s it. And now I’m calling my editor to complain because I’m being sent to cover a stroke meeting in L.A. next week – instead of delicious NOLA.

— Michele G. Sullivan (on Twitter @MGSullivan)

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Renegade Science

I’m not going to sugar-coat it, because Dr. Mark A. Smith never would.

He was a no-BS guy.

Dr. Mark A. Smith spent his life looking for the answers only science can provide Photo by Renjith Krishnan

When he died in a hit-and-run accident just before Christmas, the Alzheimer’s research world lost one of its most outspoken leaders – the author of more than 800 scientific papers, most of which challenged mainstream thought about the disease.

The accident that claimed his life happened around 2 a.m. on Dec 19.  Dr. Smith – professor of pathology at Case Western University and the director of basic science research at its Memory and Cognition Center – was walking home from a local bar. Another man, driving home from the same bar, struck Dr. Smith, apparently killing him on impact, according to a police report quoted in the Chagrin Solon Sun, a local newspaper.

The driver, Daniel V. Neesham, didn’t stop. Instead he drove home. Ironically, he apparently died in his house soon after. A preliminary coroner’s report suggested that he might have died from a drug overdose, but the final results may not be known for months, Solon Sun reporter Joan Rusek told me.

When we put questions about his death aside, when we put the tragedy aside, when we put aside sympathy and sadness – what remains of Mark A. Smith?

Science.

In 2005, when I started to report on the snowballing of antiamyloid drugs, Dr. Smith was one of a tiny handful of researchers who weren’t jumping on the amyloid bandwagon. “There are a few of us who don’t worship at the Church of the Holy Amyloid,” he said in an interview that year. “There is a thought that amyloid plaques are a response to the disease, rather than the cause of the disease, and that they could even be performing some kind of protective function. It’s certainly less sexy theory, but it’s out there.”  He was always good for a quote – some witty, some funny, and some perhaps not entirely suited for publication.

As enthusiasm for antiamyloid drugs gathered steam, he stuck to his scientific guns, continually pointing out studies hinting that beta amyloid might not be the be-all and end-all of Alzheimer’s. His own research suggested that getting rid of amyloid plaques might even do more harm than good – a theory that may have played into the failure of an experimental immunotherapy. Testing stopped abruptly in 2002, when about 6% of those receiving it developed encephalitis, despite later autopsies that clearly showed decreasing amyloid load.

Swimming upstream won Dr. Smith his controversial reputation – something he took not only with good grace, but a certain amount of pride. Last summer,  Forbes reporter Robert Langreth called him a “renegade” over his stance that antiamyloids could actually harm patients.

And despite the 2005 predictions of nearly every top researcher – that we would have Alzheimer’s “licked” within 5 years – the disease rages on. In the last 4 years, four highly anticipated antiamyloid treatments failed their phase III trials. Nor could Dimebon, a drug presumed to stimulate failing neuronal mitochondria, live up to its promising phase II data. All along the way, Dr. Smith pursued his own line of inquiry, focusing on oxidative stress as the disease’s initiating event.

One of his most recent papers suggested that preventing Alzheimer’s with antioxidant therapy could be much easier than curing it with antiamyloid therapy.  Reactive oxygen species damage metabolically active cells – like neurons – the quickest, he said, sparking a cascade of self-perpetuating events that cause even more oxidative stress and the inevitable mental decline of Alzheimer’s. Treating early with potent antioxidants might avoid the downward spiral , he theorized.

Even if Dr. Smith’s ideas ultimately prove incorrect, his consistent pecking at the amyloid theory, coupled with the multiple drug failures, are nudging Alzheimer’s research onto a different path. The idea of preventing neuronal damage before it occurs is quickly overriding the drive for an antiamyloid disease-modifying drug.

Which brings us back around to science, and our most basic question: What exactly is it?

Science is faith, backed up by fact. Belief buttressed with data. Like democracy, it can be loud and messy. Dissenting voices clash, but ultimately work together to uncover reality. World-changing discoveries can’t be made without mistakes along the way, without collisions of opinion and thought, without “renegades” who refuse to jump on the latest research bandwagon – those who pursue, instead, their own ideas.

Ultimately, as generations of parents have warned, “The truth will out.”

And dissenters like Dr. Mark A. Smith will help make that happen.

– Michele G. Sullivan (on Twitter @MGsullivan)

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A Little Mohs Respect

The Mohs technician – a non-physician (often even a non-healthcare worker) – occupies a unique place in the medical pantheon.

The Mohs surgeon’s right hand must be as steady as the surgeon’s own, capable of working with the most minute wafers of tissue, just a cell or two thick. A natural tinkerer who can adjust a highly complicated machine whenever its temperamental temperament gets out of whack. A perfectionist whose urge for the precision can never be shaken by deadlines, fussy patients, or cranky docs who just want to get out of here already.

At a Mohs surgery training course, sponsored by the American Society of Mohs Surgeons,  I learned first-hand (no pun intended) about what the tech brings to this fascinating area of surgery.

Alexander Lutz, the owner of Travel Tech Mohs Services, Inc., Carson, Calif., put it well during his talk on the issue: “It’s a rare relationship between and physician and non-physician, even more so than a surgeon with his surgical nurse or tech. The nurse might be helping the surgeon, but you aren’t depending on them to complete the surgery. With a Mohs technician, you are.”

A physician who wants to learn Mohs surgery can choose to hire and train a formally educated lab tech or histotechnician – or pick a staff person to train. It can be a nurse or medical assistant, or even the office manager. 

Knitting could be a sign of tech talent.

Photo courtesy Loggie-log/Wikimedia Commons

Mr. Lutz gave some pointers on picking the right trainee. Two characteristics are key: manual dexterity and a perfectionist personality. “In my experience, good Mohs techs have these things in common. I always ask if they have a hobby that shows dexterity-like knitting, musical instruments, or even juggling.”

And though the perfectionist personality part might drive the doc nuts in a personal relationship, it  will serve both well in the surgical suite. The success of Mohs surgery – and even the life of a human being – depends on those beautiful clear margins. The surgeon can only create those margins if there are plenty of beautiful slides to guide the surgery. And only a dedicated, skilled technician can make those beautiful slides.

— Michele G. Sullivan (on Twitter @MGSullivan)

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Mom and Dad – Still Active After All These Years

I’ve always suspected it, but a week at Disney World has convinced me – my parents could be some sort of super-humans from another planet.

To celebrate their 67th wedding anniversary, my 90-year-old dad and 87-year-old mom took their five adult children (and two of the 27 grandkids) to Disney World for a week.

Barbara and Al Guay at Disney World

Mom and Dad are old in years only. Dad has some idiopathic neuropathy in his lower legs and feet, so he now uses a cane and was in a wheelchair for most of the theme park walking. But Mom proceeded to – how can I put this nicely – kick our butts.

She walked all day, every day, pushed my dad part of every day, and demanded that we meet for breakfast at 8 a.m. each day to organize our transportation to the next park. Wheelchair notwithstanding, Dad was right there with her, complaining if we were late or whining.

My parents are a model of what the research community now calls “successful aging.”  They are fortunate enough to have had the same family physician for more than 20 years, who’s monitored their health (including Dad’s serious hypertension and Mom’s mild emphysema) and made a few suggestions, but who generally sits back in amazement while they forge ahead.

In the spirit of this week when we give thanks for simple things, I’ll share some of Barbara and Al Guay’s secrets for keeping young – and the evidence that proves Mom’s advice can be very good indeed.

Mental activity

What they do: Mom is an artist who finds constant joy in creating new works in ceramic. Dad went back to college after retirement to study music. Now he’s writing his memoirs of an early 1900s childhood in Montana. Both of them are usually juggling two or more books at a time.

The evidence: A 2009 study looked at 4 years of data among 1,477 Japanese elders (66 or older). Increasing exposure to intellectual activities was significantly associated with an increased chance of maintaining and even increasing their ability to live independently. “This study … provides preliminary support for promotion of exposure to intellectual activities among older adults as an opportunity to prevent disability in the older segment of the population,” the authors said (Int J Geriat psych 2009;24:547-55).

Physical activity

What they do: Go to the gym three times a week. Because of his lower extremity neuropathy, Dad concentrates on leg strength training rather than cardio, while Mom does the weight circuit and the treadmill. They bowl once a week, walk around the block, stroll the easier trails in Shenandoah National Park. And drive themselves (and their kids) to Disney World once or twice a year

The evidence: A study in press right now examines physical activity in a population of 629 Korean adults aged 65 and older. Reduced physical performance and muscle strength were significantly associated with reduced cognitive flexibility and self-efficacy. “Clinicians need to consider the association between executive function and physical performance when working to improve physical functioning in an aged population,” the authors said (Arch Geront and Geriat 2010; doi:10.1016/j.archger.2010.10.018).

Diet and smoking

What they do: Very little meat; fish several times a week; lots of fruits and vegetables; nuts, dark chocolate ,and a small glass of wine or cocktail several times a week; daily omega-3 supplements. Neither has ever smoked a cigarette.

The evidence: A 2009 review found numerous studies suggesting that diets rich in antioxidants and anti-inflammatory components – such as those found in fruits, nuts, vegetables, and spices – may lower age-related cognitive declines and the risk of developing neurodegenerative disease (J Nuerosci 2009;29:12795-801).

Social activity

What they do: Church every Sunday. Bowling with buddies every Thursday. Visits with their children and grandchildren at least once a week. Although he no longer flies a plane, Dad’s friends at the local flight club keep him aloft with short trips up and down the Eastern Seaboard.  Mom attends art shows where her pieces often take center stage.

The evidence: In 2009, a study examined the associations between social relationships and positive perceived health among almost 25,000 Thai elders. Friendship networks, informational and emotional support, and social engagements were positively associated with good perceived health. “Healthcare professionals should target the promotion of friendship networks, social support, and health-promoting behaviors, especially focusing on the oldest old, uneducated, poor, and elders with a disability,” the authors said (Nurs Health Sci 2009;11:144-149).

Sexual activity

What they do: I can’t hear you – my fingers are in my ears. Let’s just say there is still some giggling going on.

The evidence:  Just last month, a South Korean cross-sectional study found that elderly married people (mean age 72 years) who maintained an active sexual life had significantly higher self-esteem than those who did not (Arch Gerontol Geriatr 2010; doi:10.1016/j.archger.2010.08.011 ).

Among the 156 subjects interviewed, 78% reported an active sex life, with nearly half engaging in sexual activity 2-3 times each month. “Health experts need to educate and counsel the elderly about their sexual lives to foster high-quality, healthy elderly lifetimes,” the authors said.

 But the authors said much more research is necessary, especially given the “Elderly Boom” going on worldwide. Since I wasn’t able to find many studies on sexuality in the aged, I must agree that this is a topic ripe for scientific exploration. But if you study my parents – please don’t let me know.

– Michele G. Sullivan (on twitter @MGSullivan)

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