Guest blog post: Let your diet be Mediterranean

Do you want to live to be 100 or older? Today’s experts agree that if were born in 2000 or after, you have a good chance of living to be 100. Many of the world’s experts in this field believe that the Mediterranean Diet is the answer.

The Life expectancy chart has risen in the United States, most of Europe, Japan and Canada and if this trend continues, centenarians will be the norm. Researchers in Denmark predict that society will look at old age differently. Instead of the current three phases, which are children, adults and old age, there will be four stages. These stages would be childhood, adulthood and then old age divided into two segments, the third stage being young old, and the fourth stage oldest old.

Japan is the leader in life expectancy. If you were born after 2007, then you are expected to live to be at least 83. In the United States the expected age is 77. The number of people in the United States over age 100 has doubled in the last 15 years.

People debate whether it is healthy to live this long. Studies on people older than 85 are minimal, but evidence seems to be that centenarians are more mentally alert and more independent than ever before. Much of this success is due to early detection of illness and early treatment.

Some of the characteristics that most of these centenarians share are the FOX03A gene, (which we cannot control). Also other important factors include emotional resilience, self sufficiency, intellectually activity. You should have a good sense of humor, involvement with other people, low blood pressure, and a healthy diet. An interesting fact is that 80% of the centenarians in American are women and most of them gave birth after age 40.

Many experts agree that the diet is the most important factor to a long, healthy life, Most of these people recommend the Mediterranean Diet. This diet includes many fruits and vegetables along with pasta and rice. Red meat is not considered as important. Fish should be eaten twice a week. Red wine in moderation is considered healthy and olive oil is consumed daily to cook and flavor foods. This diet includes nuts, usually unsalted, because salt should be limited. The Mediterranean diet is considered an anti-inflammatory, heart-healthy diet. Daily, moderate exercise should be incorporated with this diet.

About the Guest Blog Author

Valery Fortie is the National Awareness Coordinator of Mediterraneanbook.com. As the editor of the Mediterranean book blog, she focus her efforts on providing scientifically driven information to help people eat to lower
high blood pressure and live a longer and better life.

Mediterraneanbook.com is a non commercial website created to preserve the Italian Healthy Eating Traditions. Founded in 2004 in Italy, Mediterraneanbook.com feels very strongly about having informed consumers
on duty in all healthy eating fields.

The Dementia Concussion Link?

Has the media brainwashed you into believing that suffering a concussion or two is going to cause you to develop Alzheimer's disease? Think again and get the facts at my other website, MTBIFacts.com. Below is a link to a story I just posted on-line tonight.

The Dementia Concussion Link?

Per the corporate medical policy

If you are considering undergoing an expensive medical procedure such as an MRI or a neuropsychological evaluation, be very careful when the insurance company states that the service will be covered 100% “per the corporate medical policy.” Those five words are they key…per the corporate medical policy. When patients hear this, they tend to think that this means the medical procedure will be paid in full and proceed with the evaluation. What is actually means is that a decision to pay for the service will not be made by the insurance company until after the evaluation takes place. What this often translates into is the insurance company finding every reason in the world not to pay for the service.

As an example, I was once evaluated a child who suffered a brain injury four years prior to the evaluation. There was a question as to whether the brain injury affected his development. The insurance company stated ahead of time that the service would be covered 100% per the corporate medical policy. The evaluation was completed and then the insurance company refused to pay because they said the brain injury occurred too long ago. This is frustrating because this information (the date of the brain injury) was well known in advance and the insurance company could have easily made a determination beforehand. Instead, the patient’s family was told they would need to pay thousands of dollars for the service, which they cannot afford.

Given the above, my advice is as follows. Press the insurance company to provide something in writing saying that the procedure is pre-authorized or not pre-authorized. If the company refuses, you may want to consider switching insurance companies at some point. Make sure the words “per the corporate medical policy” are not included because this only serves as a way for the insurance company to wiggle out of not paying. Secondly, be sure to appeal such cases to the insurance company. If that does not work, contact your state insurance committee. Insurance companies do not like to be bothered by state regulators. If \ this does not work, contact your local congressperson and have that individual call the insurance company on your behalf. You would not believe how effective this can be. Remember, the insurance company needs the help of lawmakers to pursue their agendas and does not want to make any legislative enemies. If the local congressperson does not work, call your state U.S. senator.

Improving your memory

As a neuropsycholgist, people often ask me if there are techniques they can use to improve their memory. Or course, there are basic things you can do such as write yourself lists, keep a portable memory notebook, use a daily planner, and put your keys in the same place every day.

However, if you want a formal system (particularly one that will help with school), my opinion is that Harry Lorayne takes the cake. When I was in HS, we all had to take a class with a religious teacher who made everyone try to memorize every book of the Bible in order. I knew there was no way I could do that with rote memory skills. So then I saw Harry Lorayne on TV and couldn't believe what I was seeing this guy do (memorizing entire magazines and he could say what page # the information was on!).

So I figured what the heck and purchased his memory power tapes. It was amazing. In the first week of the class, the teacher sarcastically asked if anyone has memorized all the books of the Bible yet. I raised my hands and said, "Not only have I memorized all the books of the Bible, but I'll say them backwards. Or, if you'd like, you can name a book of the Bible and I'll tell you what number it is. Or you can name a number and I'll tell you the book."

Everyone looked at me like I had some kind of super power when I did just that but I didn't. It was also based on an associative memory technique that Harry came up with that involves pairing numbers with phonics. It truly works and to this day I still remember that the 33rd book of the Bible is Ezekiel. You can use it for almost anything. This was just one example. Anyway, for those interested, information is available here, including some old clips of the master in action. I make no money off the sal of this product.

http://www.harrylorayne.com/

World's LARGEST Medical Message Board Created

MedFriendly is back. Well, the site never actually went away but during the time that I was preparing for board certification, the site was on a definite hiatus, without many updates. After becoming board certified in November 2008, I decided to take a few months off to decide what I was going to focus on. I wanted to continue MedFriendly, but it was clear that the site needed to be overhauled to a database-run system for the advertisements that I have on the site, which would prevent the unattractive appearance of dead links. As a result, I began the process of making this transition, but it will take some time. For now, if you click on a link and it does not work, try changing the extension from .html to .php5 or vice versa.

To commemorate the re-birth of MedFriendly, I have been working for months on creating the world’s largest medical message board which you can now find here:

MedFriendly Message Board

On this message board, you will find a wide array of topics and forums unlike any other on the internet. The message board has the advantage of consolidating an enormous amount of information in one convenient point of access. No longer do you need to skip from website to website to visit different medical forums when they are all in one location. The message board will help build a sense of community and has many fun aspects to it such as the ability to create your own avatar (personal picture to identify you). Topics and forums can be added simply be emailing me through the contact page.

Please take the time to sign up for the MedFriendly Message Board today and tell your friends and family about it as well. The only way a community of members can be built is by signing up. There are few members at the moment because the message board was just launched today. Registration is free, quick, and easy. Be sure to check your junk email box to make sure that the confirmation email was not sent there. As soon as you respond to the confirmation email, you are all set to post.

As to the blog, that will be continuing as well. Not every day, but there will be more frequent posts beginning today on diverse topics that are sure to inform and entertain. Please keep checking back for updates and remember, sign up for that message board. 

The Myths of Mild Traumatic Brain Injury: the 15% number

One of the most popular myths perpetuated by the media and some in the scientific community is that 15% of patients who have suffered a mild traumatic brain injury (MTBI) do not recover by one year and may even experience permanent symptoms. An important point that I try to teach people is to always obtain the original article that is cited in support of such claims so that the validity of the claim can be examined. In this case, the reference often cited is a 1995 study by neurologist, Michael Alexander. In his paper, he wrote the following: "At one year after injury approximately 15% of MTBI patients have not recovered’’ (p. 1256).

When researchers cite Alexander's study as the only reference for this figure, it casts the impression that he is the person who collected the data to support it. However, if one reads Alexander's paper, it is seen that Alexander based his 15% figure on two earlier studies: McLean and colleagues (1983) and Rutherford and colleagues (1979). To begin with, McLean and colleagues only followed 20 patients for one month not one year. In addition, his study consisted of 11 patients with MTBI, 8 patients with moderate TBI, and one patient with a severe TBI. One can hardly use a study of all severity TBI patients at one month post-injury to argue for the chronic effects of MTBI.

The main source of the myth, however, comes from Alexander's summary of the Rutherford article. Rutherford followed 131 MTBI patients for a year and he did indeed find that 19 (14.5%) complained of symptoms at that point. A detailed analysis of Rutherford's patients, however, reveals some interesting details. First, there were actually 145 patients in the study and of these, only 131 followed up. Assuming the missing 14 did not have symptoms one year post-injury, that changes the number to 13.1%. Of the 19 patients who were still reporting symptoms at one year, 8 were involved in lawsuits and 6 (5 of whom were in lawsuits) were suspected of malingering six weeks post injury. Malingering was defined in this study by: bizarre and exaggerated descriptions of symptoms and strange responses during routine examination. Can we really trust the self-report of symptoms in these individuals to be reliable and valid? The answer should be obvious.

In addition to the numbers above, 10 of 19 patients reported one new symptom at one year post-injury that was NOT reported at six weeks post-injury. If the symptoms were brain injury based, they should not appear at one year post injury when not present at six weeks post-injury. More information is that 6 of the 19 patients had only ONE symptom at one year and 7 of 19 patients had two symptoms at one year. This is not enough to classify patients with what is sometimes referred to as "post concussion syndrome" which is traditionally described in the literature as the presence of three or more symptoms at three months post injury. In the end, we are left with 6 subjects who endorsed between 4 and 9 symptoms. And when we take 6 and divide it by 131 we get 4.5%. If we use the entire sample of 145 patients, the number drops to 4%. This is consistent with the estimate (<5%) provided by Iverson in his 2005 review of MTBI. In sum, by simply checking the original sources, one can easily see than the 15% estimate is a truly a myth.

REFERENCES

Alexander, M. P. (1995). Mild traumatic brain injury: Pathophysiology, natural history and clinical management. Neurology, 45, 1253–1260.

Greiffenstein, M.F. (2008). Clinical Myths of Forensic Neuropsychology. The Clinical Neuropsychologist, 10, 1-11.

Iverson, G. L. (2005). Outcome from mild traumatic brain injury. Current Opinion in Psychiatry, 18, 301–317.

McCrea, M. (2007). Mild traumatic brain injury and postconcussion syndrome. The new evidence base for diagnosis and treatment. New York: Oxford University Press.

McLean, A., Temkin, N. R., Dikmen, S., & Wyler, A. R. (1983). The behavioral sequelae of head injury. Journal of Clinical Neuropsychology, 5, 361–376.

Rutherford, W. H., Merrett, J. D., & McDonald, J. R. (1979). Symptoms at one year following concussion from minor head injuries. Injury, 10, 225–230.

The U.S. healthcare system has been undermined by not assessing for symptom validity

These days, many (but not all) health care providers are becoming less and less like scientists and more and more like blind patient advocates. While it is natural for treating providers to advocate for their patients, and in fact, part of their role in many cases, what many appear to have forgotten is that advocacy needs to be based on reliable and valid data. For example, let us say that a patient walks into your office and subjectively reports a plethora of diffuse cognitive and somatic complaints after what appears to have been a relatively mild injury. What is the provider to do? Let us further stipulate that the patient shows up with these same complaints and informs you that he or/she is involved in personal injury litigation or a workers compensation dispute. Should this information be considered in the case formulation and should it potentially alter the plan of care? Or, should these contextual factors all be ignored and shoved aside in the interests of patient advocacy and being nice? Far too often, I see health care providers do the latter and it often causes great harm, despite good intentions by some.

While all ethical health care providers want the best for their patients and do not want to have conflict with them, it is also important to draw boundaries and remember that the patient is not your friend. Trying to become friends with your patient constitutes a multiple relationship that can cloud objectivity, which is so important to the assessment process. Another important factor to remember is that simply because a patient walks through your office doors does not automatically create a situation where you must show 100% allegiance in believing everything the patient says or doing everything they ask of you. While there is nothing wrong with having an allegiance to your patient and being a strong patient advocate, the degree of such advocacy should be modified based on an objective determination of the validity of the patient's clinical presentation.

While many patients present to the clinician's office with an accurate portrayal of their symptoms and problems, there are other patients who exaggerate their presentation for a whole host of reasons. Some exaggerate because they want to convince you that something is wrong, because they want attention for being in the sick role (i.e., factitious disorder), or because they seek some type of external gain such as money in a lawsuit, disability, medications, or avoidance of responsibility. The latter is known as malingering. Patients who exaggerate their clinical presentation may have valid symptoms inter-mixed with exaggerated symptoms. Less common is the patient who has made up a story about a personal injury and is feigning the entire clinical presentation (sometimes referred to as pure malingering).

If the patient's symptoms are purely based on self-report and you have no objective data to support your conclusions, you can potentially fall victim to patient exaggeration. Why is this so important? Improper identification of symptom exaggeration leads to a waste of health care services such as referring patients to needless and endless therapies, tying up access for those patients who legitimately need such services. Furthermore, patients are often granted disability (sometimes for years) or accommodations in school or work that they do not deserve. Many systems that provide disability services or accommodations have quotas on the number of people they will grant such services to. Therefore, granting access of such services to patients who are willfully distorting there clinical presentation is a disservice to those patients presenting in a reliable and valid manner who legitimately need such services.

In my line of work as a board certified clinical neuropsychologist, I frequently encounter situations where symptom validity is not assessed by the health care provider. In many cases, this is because assessment of symptom validity sets the stage for a potential conflict with the patient. In other words, if the provider determines that the symptoms are not valid, this will need to be communicated with the patient in some way, which can upset the patient. The very possibility of conflict with a patient is something that many health care providers do not want to deal with because it can be socially uncomfortable and potentially lay the groundwork for a patient complaint or possible lawsuit. As a result, health care providers tend to give patients the benefit of the doubt and accept self-report at face value. This is a tremendous mistake.

For example, I recently published an article in the journal, Brain Injury, (reference below), showing that 21% of adults who reporting suffering a mild head injury or mild traumatic brain injury failed a very simple test designed to assess the degree of effort they were putting forth on the evaluation. When later asked to rate how difficult this task was, this group of adult patients rated it to be 5.6 out of 10 (with 10 being the most difficult). By contrast, I found that only 5% of children with moderate to severe neurological conditions (e.g., strokes, traumatic brain injuries) failed this same test and that the entire group of children rated the same test as very easy (1.35 out of 10). It is not neurologically possible for a mild traumatic head or brain injury in an adult to cause worse performance on a simple test compared to little children with moderate to severe brain injuries. The only logical conclusion is that the adult group of patients exaggerated their presentation.

Without the use of objective measures such as the one used in my study above, clinicians will find it very difficult to assess for the validity of a patient's presentation -- although they may have suspicions. Objective data helps supplement the confidence one has in those suspicions. Tools are available to assess for validity of cognitive performance as well as the validity of physical, cognitive, and emotional complaints. I will not describe the methods behind these instruments in a public forum, but they are well researched and validated and are very important to utilize.

By not assessing symptom validity, one increases the risk of blind patient advocacy. This can cause one to fall into very bad habits such as not obtaining or reading through the patient's medical records. By not doing so, the clinician misses reviewing important information that may provide an alternate explanation of the patient's presentation or may raise red flags of suspicion. Another bad habit is the willful suppression and omission of information in the clinical note that would show that the patient's problems may be related to factors other than those related to their disability claim. For example, I recall working on a case where a provider omitted that a recent hospitalization concluded that the patient was experiencing pseudo-seizures because this finding highlighted that there was a psychological component to the patient's problems, which conflicted with the claim that all of the problems were neurological. As a result, the tendency is to try to fit a square peg in a round hole and continue to attribute the clinical presentation to a medical cause that does not really exist. Another bad habit is allowing patients to tell you what information goes in their reports, what stays out, and how to write it.

Lastly, it is important to note that the assessment of symptom validity is designed to improve patient care and utilization of the health care system. In many instances, patient exaggeration is related to psychological factors that would be better addressed by referring the patient to psychotherapy rather than tying up medical resources in the community. In this way, patients are better served because the real factors driving their clinical presentation can be addressed, helping them move on to living more productive lives. Of course, not every patient will be happy to learn that there are doubts as to the validity of their performance or symptoms, but I have found that patients are often accepting of such feedback if care is taken to listen to their self-report in a non-judgmental manner during the clinical interview so that a strong rapport is established. This allows the patient to be much more accepting of such feedback because the patient feels that you have listened. Also, the presentation of the feedback is crucial. Rather than calling the patients liars, it is important to emphasize how the information you have gathered can help guide their clinical care. By showing that you listened to the patient, performed a thorough evaluation, and used objective data to make your conclusions, patients tend to be very understanding of such feedback.

With that said, there is no full-proof way to insulate yourself from a patient complaint or conflict. This is most likely to occur with patients who blatantly distort their presentation and have alot to lose by not being able to access the external gains that they seek. However, dealing with these issues is part of the job when evaluating the validity of a patient's presentation, particularly in those with vague medical complaints and controversial medical diagnoses. However, being able to cite objective data to support your conclusions greatly helps in insulating you from a complaint leading anywhere.

In summary, although you may be reducing the chance for any conflict with a patient by not assessing for symptom validity, you can also be making the patient sicker by not doing so. In medicine, this is known as iatrogenic illness -- when the "treatment" makes the patient worse. If you are not assessing for symptom validity, it is important to learn more about the topic and to begin integrating this into your clinical practice.

To learn more about this topic and to schedule Dr. Carone to lecture to your clinical practice, university, or in other settings, contact him at lectures@MedFriendly.com for information on available dates and speaking fees. Dr. Carone is also available for legal consultation (e.g., assessment of case viability, independent opinion of neuropsychological reports) although he does not test patients referred by lawyers or independent medical exam companies at this time.

Reference:

Carone, D., (2008). Children with moderate/severe brain damage/dysfunction outperform adults with mild to no brain damage on the Medical Symptom Validity Test. Brain Injury, 22, 960-971.