Monday, May 24, 2010

Just a bump on the head?

My heroine from last week is a fourteen year old soccer player from Virginia who sustained a concussion--one we would have previously considered "mild"- five weeks ago. Sarah Rainey told the congressional committee that has previously seen the NFL and a host of medical experts testify: "I sometimes now have to use a calculator to do simple arithmetic." She made it painfully clear that head injuries might appear insignificant ("dings" in old parlance) but that the seriousness and consequences of such an injury might be quite subtle and interior to the patient.

After relatively minor head injury, difficulties with math are legion, not to mention emotional instability, memory dysfunction, and slow processing speed. Some teens will describe that their minds feel as if they are on dial-up instead of DSL. Hard to get through an SAT with that sort of problem. Because these symptoms are so subjective and depend on the student reporting them, the entire diagnosis can be missed. Add to that the pressure to get back to the game from coaches, teammates, parents and friends, and it becomes even harder to protect concussed brains.

One thing Sarah Rainey boldly spoke about on May 20 was the notion that sitting out a game or two will be enough. Before the august panel she argued about the Centers for Disease Control's
concussion slogan 'It's better to miss one game than a whole season.' She went on to say according to the New York Times report of the hearing: "I understand their intent, but I think they minimize the seriousness of concussions by making it sound like you just need to take a game off and then you'll be good to go."

Having seen a number of patients in the last few months who have truly been sidelined by concussions with marked behavioral, academic and medical consequences, I can only hope that these public reports will help to educate our coaches, parents and students about the subtle and important nature of this issue.

Watch Sarah Rainey here as she recently testified before congress about her experience with a concussion. Here on Youtube

Monday, May 17, 2010

Predictors of Internet Addiction

Seems the problem of internet overuse and addiction is a global one. A recent prospective study in Taiwan published in the Archives of Pediatric and Adolescent Medicine in 2009 showed that two characteristics could predict the seventh graders who would become addicted to the internet when screened two years later. These characteristics are Attention Deficit Hyperactivity Disorder (ADHD) and hostility.

As described in Pediatric News, internet addiction is characterized by a "preoccupation, uncontrolled impulses, more usage than intended, tolerance, withdrawal, impairment of control, excessive time and effort devoted to the Internet, and impairment of decision-making ability.

The researchers, working under Dr Chih-Hung Ko, followed over 2000 seventh graders in order to determine that ADHD was the strongest predictor of Internet addiction among girls and that hostile boys (defined by the Buss-Durkee Hostility Inventory--DO NOT TRY THIS AT HOME!) were more likely than others to develop the addiction.

Dr Ko hypothesizes that kids with ADHD can master fast-paced internet games readily and their success at this is "addictive" as their brains release dopamine during the intense online activity. Hostile boys, on the other hand, may allow themselves to express their otherwise anti-social behavior and aggression in a relatively safe way by gaming on the internet

My concern as an adolescent physician is that the ADHD and hostility may lead to more harmful consequences when the online activities go beyond games to involve social networking sites. Impulsive teens with ADHD may "go places" they shouldn't or say things that are dangerous or harmful when they hit "Send" prematurely. Hostile teens may in turn find solace on any number of websites that encourage and nurture the kind of anger that we have all seen turn into treacherous life threatening pursuits or even terrorism

On a more creative and optimistic note, I hope that game designers will work with mental health professionals and use this information to create therapeutic games and activities to treat these hurting kids.

image from www.crenk.com

Tuesday, May 11, 2010

How Stress CAN Make You Sick

A lot of really cool information is coming out of a variety of sources that I think will help explain and prove phenomena that we have observed for a very long time. Take for instance the idea that traumatic events (The Four D's:death, divorce, debt, and disease) or War experiences, for that matter, can leave long term effects including an increased likelihood of illness following any of these traumas. Generations have known this to be so--"Don't get so upset, you'll make yourself sick" I used to hear. Now research from the Columbia University School of Public Health has come up with scientific explanations for why this is so.

Dr Sandro Galea and colleagues at Columbia were able to correlate Post Traumatic Stress Disorder (PTSD) with measurable changes in the genetic regulation of the immune system. Through a process of demethylation, cetain areas of the DNA that affect the immune system were found to be compromised in PTSD patients. Demethylation may cause genes to be unregulated and in this case, it may make a person more prone to disease. These findings were reported in the Proceedings of the National Academy of Sciences and are described on Scienceblog.

This is fascinating research because it begins to clearly link mental processes (PTSD) with those that have been traditionally considered physical (bodily illness). The lines are increasingly blurred between these two phenomena as we learn more about neuroscience and are able to quantify heretofore mysterious brain phenomena. It also helps to explain why some conditions-addiction, eating disorders, self-destructive behaviors, to name a few are really "wired" in the system at the level of the genes. As we continue to understand these connections better, diagnosis, treatment and prevention will improve. But perhaps most of all we will achieve a higher level of understanding of and compassion for conditions that we have deemed "all in our heads."

Tuesday, May 4, 2010

Painters, Plumbers, Roofers, Doctors

For months I have been bothered each time I hear the radio ad for Angie's List, an online review mechanism for all sorts of local "service providers." I have struggled to understand what it is that perturbs me about being grouped together with technicians of this sort when I consider what I do as an adolescent doctor something very different and more complicated to judge than the results of a repair to a leaky roof or faucet.

Well today, I got some experience to help me sort it out. For a few days my bathroom hot water faucet has simply not let any water out. All the other faucets work fine so I figured it had to be some odd sort of blockage...maybe the kind they could have used in the pipes of the oil rig in the Gulf coast. Anyway, I couldn't see where the problem might be so I called my local plumber. Within minutes of looking he found a kink in a metal tube high up under the faucet. What happened next?

He told me to take down the name of the manufacturer and go on line, order the part and call him back once I had it. Sure I would order the wrong thing and making a quick calculation as to what my own time is worth compared to a plumber, I told him I really couldn't do that, that I considered it his job. "That's sort of like a doctor telling you to go order your heart valve and then they can schedule surgery." He just looked at me, relented and then told me he would take care of it, probably making his own calculation about how much he could charge for this.

But he went on to explain that he doesn't normally do parts any more. Since the advent and rise of the "big box stores" plumbers no longer are the experts on this or make any money when they deal in anything but repairs.

OK, so that's where we had a meeting of the minds. He's got Home Depot and other megastores; I've got Aetna and other insurance companies. We are both diminished in our ability to do the right thing and the whole thing with respect to our customers and patients. Nevertheless, I remain hopeful that with the wink of an eye and a please and a thank you and maybe an extra charge here or there, we can preserve the dignity of our mutual professions. Maybe Angie is on to something afterall.