Unusual Enhancing Foci

Pressure to treat can discourage physicians from carrying out the careful investigations needed for correct diagnosis. Here, we describe a case in which the correct diagnosis took several years, and became apparent only after a review of patient records revealed a decade-old surgical history of laparoscopic cholecystectomy performed for acute calculous cholecystitis.

The patient, a hypertensive 78-year-old man, presented with fevers and increased abdominal pain 4 weeks after beginning chemotherapy for the presumed recurrence of a gastrointestinal stromal tumor. Three years previous to this presentation, he had undergone endoscopy during an evaluation for melena; the procedure had revealed a 1-cm submucosal abdominal mass that was identified by pathologic analysis as a low-grade gastrointestinal stromal tumor. The tumor had been removed by a partial gastrectomy without any further imaging studies, and because it was small and low-grade, with non-malignant surgical margins, no chemotherapy had been prescribed. The management plan had been to follow the patient by periodic abdominal imaging with computed tomography (CT).

To read this article in its entirety, please visit our website.

-- Abhishek Agarwal, MD, Meghana Bansal, MD, Rebecca E. Martin, MD

This article originally appeared in January 2012 issue of The American Journal of Medicine.

Is Beauty a Good Career Choice?

The beauty industry as a whole is ever increasing, even in the recent years of recession and economic halt in growth. Whilst other sectors are facing tough times, beauty businesses are in comparison not as badly affected. This is somewhat down to today's media driven society, which encourages personal well being and appearance. When shopping for the essentials, many choose to cut back on items to spare money for their beauty regime.

This is great news for those that work within the beauty sector as it means increased job security. This is a well sought after commodity at the moment.

There is a certain amount of escapism in being pampered and making yourself look beautiful that attracts a growing number of women to consistently spend money on treatments and products. Making yourself look good on the outside can leave you feeling happy and refreshed.

This can boost inner confidence and self esteem, but if not used wisely could lead to an unhealthy addiction. Many women seem to be addicted to the sun bed, fake tan or at the end of the scale, cosmetic surgery these days! Like anything it is important to maintain a healthy balance. Too much of what we like is often not good for us and no amount of buffing and pampering will solve any underlying issues we may have.

'Metro Sexual' men are also on the increase. It seems that a large number of men are now spending longer getting ready to go out than their female counterparts! Gone are the days when it was OK to walk out of the house looking a bit rough around the edges. Men must now appear to be well groomed and care more about their appearance than ever before.

Celebrities such as David Beckham have helped lead the way in how men should look. It's now more 'cool' to be trimmed, waxed and bronzed than ever before. The Ex England football star has carved a niche in men's fashion and appearance. He has endorsed many products for huge international brands, which have raised awareness for men's grooming worldwide.

As a result of increased awareness in society to always look your best, beauty jobs and occupations are now well sought after. Beauty currently offers a solid career choice. A path that is less unstable than other areas. Hair stylists, beauty therapists and nail technicians are all required to keep the nation looking beautiful!

Diagnostic Imaging: Powerful, Indispensable, and Out of Control

Reality is never quite as simple as it seems. For all the good that imaging has done, it has come with significant costs: exorbitant financial costs to individual patients and society, and personal health costs to patients through over-diagnosis, over-radiation, and over-treatment.

At issue in any review of the appropriateness of imaging utilization are the various interests of the stakeholders. The primary stakeholders are the patient and the physician. Their motivation to acquire as much information as possible through imaging is laudable but is, in fact, misguided. The core of the dilemma is that our ability to diagnose subtle findings far exceeds our knowledge of what to do with the information: advanced diagnostic studies have led to an epidemic of indeterminate incidental findings that physicians and patients often find at least as troubling as the events that triggered the initial imaging study. In a sense, imaging has become too powerful: it frequently identifies subtle, questionable, unrelated, indeterminate pathology that it cannot characterize any further, leaving both stakeholders up in the air regarding what to do next. This often leads to a vicious cycle of more and more imaging and testing.

To read this article in its entirety, please visit our website.

-- Robert G. Stern, MD

This article originally appeared in February 2012 issue of The American Journal of Medicine.

Sex & Satisfaction in Women

Sexual Activity and Satisfaction in Healthy Community-dwelling Older Women

Do you have to have sex to be sexually satisfied? Apparently not, if you are a woman over 40.

Abstract

Background
Female sexual dysfunction is a focus of medical research, but few studies describe the prevalence and covariates of recent sexual activity and satisfaction in older community-dwelling women.

Methods
A total of 1303 older women from the Rancho Bernardo Study were mailed a questionnaire on general health, recent sexual activity, sexual satisfaction, and the Female Sexual Function Index.

Results
A total of 806 of 921 respondents (87.5%) aged 40 years or more answered questions about recent sexual activity. Their median age was 67 years; mean years since menopause was 25; most were upper-middle class; 57% had attended at least 1 year of college; and 90% reported good to excellent health. Half (49.8%) reported sexual activity within the past month with or without a partner, the majority of whom reported arousal (64.5%), lubrication (69%), and orgasm (67.1%) at least most of the time, although one third reported low, very low, or no sexual desire. Although frequency of arousal, lubrication, and orgasm decreased with age, the youngest (<55 and="" oldest="" years="">80 years) women reported a higher frequency of orgasm satisfaction. Emotional closeness during sex was associated with more frequent arousal, lubrication, and orgasm; estrogen therapy was not. Overall, two thirds of sexually active women were moderately or very satisfied with their sex life, as were almost half of sexually inactive women.

Conclusion
Half these women were sexually active, with arousal, lubrication, and orgasm maintained into old age, despite low libido in one third. Sexual satisfaction increased with age and did not require sexual activity.

To read this article in its entirety, please visit our website.

-- Susan E. Trompeter, MD, Ricki Bettencourt, MS, Elizabeth Barrett-Connor, MD

This article originally appeared in January 2012 issue of The American Journal of Medicine.

'Imaging for the Clinician' premiers in AJM's February issue (video)

Imaging for the Clinician-- a special section in The American Journal of Medicine-- will premier in the February 2012 issue of the Journal. In this video, AJM Editor-in-chief Joseph S. Alpert, MD, discusses diagnostic testing and the February issue.

Ancient Way of Living - The Warrior Diet

Are you tired of being on diets that make you feel like your whole life is revolving around food? Or maybe you have been having energy crashes throughout the day -especially after lunchtime meals.

These problems are common and can actually be solved by questioning the mainstream advice of eating breakfast like a King, lunch like a Queen and dinner like a Pauper.

The Warrior Diet is a radical regime of under eating for 20 hours followed by overeating for 4 hours. This might seem like one extreme lifestyle choice that is just crazy to even consider. However this model actually mimics how the majority of people used to live throughout history up until the human race began making significant technological advancements, which inevitably lead to an abundance of food. People would typically carry out chores, go hunting or do manual labour work whilst eating very little during the day. Then late in the evening once all the work for the day was done the family would feast together consuming the majority of their daily calories in one sitting.

How does it work and why is it beneficial?

This diet was devised by Ori Holmekler who suggests that it is not for body building, but instead for a way to develop a lean muscular body while at the same time keeping your size and weight down, in essence giving you a Bruce Lee look.

This diet works because of how your nervous system is set up to handle the digestion of food and funnelling of available energy. During the 20 hours that you are under eating; the Sympathetic Nervous System (SNS) is responsible for your ability to deal with stress, physical activity and periods of intense concentration. Basically anytime you need energy or cohesive body function it is the responsibility of the SNS to provide you with it. Whenever you eat, the SNS gets turned off as the parasympathetic nervous system (PNS) gets turn on, which is responsible for the digestion of food. This is why after having a big lunch it is common to have energy crashes and feel like taking a nap as opposed to carrying on with the day. Taking a nap anytime you eat a meal or a snack does sound nice, but who in this day and age has the time for that?

The overeating phase of the Warrior Diet will typically be during 4 hours of the evening. The PNS will be maximized during this time and will aid in resting, digestion and detoxification among other things. All food groups will need to be consumed during this period of time, however it does not mean that you should binge on junk food and sugary snacks. Usually this will not be a problem because a person on this diet will crave the foods that the body actually needs as opposed to the foods that one might crave if they want to indulge their taste buds only. Of course during the first few weeks or even months there will be a transition period where you will need to condition yourself to lose the cravings for your old eating habits. This can be particularly difficult if you have a strong reliance on sugary foods and drinks. It has been said that a persons desire for food is the hardest to suppress, this diet really does put this statement to the test.

It is not complete starvation during the undereating phase

You might be relieved to learn the there are certain foods you can eat during the undereating phase. These will typically have a low glycemic index such as fruits and vegetables. Eating small amounts of these foods does not compromise the PNS because of how lightly they burden the digestive system. Smoothies are also allowed as long as you use a blender, investing some time to learn a few recipes will really reduce the difficulty of the under eating phase.

Improved quality of life in addition to weight loss

What other dieting regime offers a direct increase in body functionality in addition to weight loss? This diet is really designed for anyone seeking to get the most out of their bodies on a daily basis in a way that works with the body "energy delivery systems" and not against it. Additionally - a process known as recycling is activated during the undereating phase which is responsible for replacing the old, sick and dead cells of your body with news ones. This keeps you looking younger, feeling stronger and gives you the ability to develop the muscle composition that you require for peak physical performance.

Well that is great, but how does this help me lose some weight? Recycling requires energy, which is derived from the food that you eat. Typically when you consume more food than you need, the excess goes into your fat stores. However, the Warrior Diet allows for those fat stores to be depleted to more healthy levels thereby decreasing your weight and exposing your muscles from underneath the fatty tissue.

The choice is extreme but so are the stakes

The overall premise of the Warrior Diet goes against how most people live and what most dieting professionals will tell you. But you also know that a lot of people are overweight, suffer from energy crashes and fail to lose weight using the advice given by professionals. So my message would be to consider your own situation and whether this diet can work for you specifically. The differences to what you may have been taught all your life are extreme, but the stakes here are huge. If this turns out to be a success you could potentially have a rock hard muscular body, the energy levels of an ox and the health levels of a Tibetan monk (their average life expectancy is around 100). Giving this diet a try for a few weeks is the least you can do, what is the worst that can happen? You will lose some weight, save some money on the groceries and gain a new experience you can tell your friends about.

Choosing the Right Daily Multivitamin Supplement

Are you searching high and low for the best multivitamin around? Choosing the right multivitamin can be very tricky as there are products of every kind in the market all claiming to be the best. I'm quite sure, many of you don't know how to distinguish between marketing fact and marketing fiction, thus I've made an extensive research on this topic. I just wanted to make this clear, what you are about to read is for informational purposes only. They are not intended as a substitute for advice from your GP or medical professional.

Now, lets get started but before I do so please bear in mind that when a multivitamin is swallowed in any other form other than the food-form the body will expel the majority of it because it registers them as foreign therefore, you are not getting 100% absorption of the vitamins you are taking. With that said, I don't shun taking vitamins. The good news is a multivitamin even if it is not all absorbed is more than enough for most of us, especially if we are eating relatively healthy the rest of the time. As said previously, you can only get this much vitamin from the supplement as the body doesn't absorb as much as it's given therefore choosing the right daily multivitamin supplement is really important.

Do you really need to take multivitamins?

The answer is no, that is if you are eating a well-balanced diet. Well, do not take unless you know you need the vitamins. Taking more than what your body needs will do more harm than good. I reckon, doing a blood test will help you determine if you need supplements.

What form of vitamins should you choose?

There are three forms: tablet, capsule, and liquid

Tablet -The least expensive among the three. Easy to store. Have a long shelf life. These hard pills are the worst performing as only 10-20% of the supplement's content gets into the bloodstream meaning every $100 spent on these $80 is wasted.

SoftGel Capsule - Easy to store. Softgel capsules have a better absorption rate than tablets but lower absorption rate than liquid multivitamins. Unlike the tablets, they have a shorter shelf life.

Capsules come in vegetable-based or gelatin-based form. Gelatin-based caps are derived from animals like cows and pigs and had been great concern over about its susceptibility to pass the infection (such as bovine spongiform encephalopathy (BSE) which is found in cows and is often referred to as "mad cow" disease) to man. Vegetable-based (cellulose) caps are made from Hydroxipropyl Methyl cellulose (HPMc) which is derived from woods and cotton fibers and is generally recognize as safe by FDA. HPMc derived capsules can meet all requirements of current USP and FCC.

Liquid - The most expensive and the shortest shelf life among the three. Liquid multivitamins have the best absorption rate with 95% of the vitamins and minerals making it into the bloodstream.

I personally prefer the veggie or Kosher gel capsules (2nd choice) as tablets are virtually indigestible while choosing the liquid form is a way too high for my budget. If you've been reading my blog, you'll know that I always aim to look for the best value for my dollar. What do I mean by this? Let's say there are four kinds of multivitamins for me to choose from and as follows: low affordability, low quality brand X; medium affordability, high quality brand XY; medium affordability, extremely high quality brand Y; and high affordability, extremely high quality brand Z. I will go for the medium affordability but extremely high quality multivitamin. I will never go for inferior quality nor willing to pay twice as much just to get 30% improvement in the quality of the ingredients. As mentioned above, there are benefits to each kind, as well as drawbacks. Why will I settle for a costly liquid form wherein I couldn't even get 100% absorption either and vitamins like niacin is better much absorbed in the mouth. Consumers need to spend their hard earn money wisely. Don't be swayed by sales talk, don't be victimized by false claims, you just need to do a little bit of research on the supplement that you're eyeing at.

How may multivitamins should you take each day?

It's up to you. Multivitamins come in various serving sizes or dosages. Some multivitamins try to cover all the nutrients in a single capsule per day. Others require 3, 6 or even 12 capsules per day. The only problem with the one a day capsule is it cannot possibly provide you with sufficient quantities of micro-nutrient nor can it fit in all the extras like herbal extracts, superfood powders, active enzymes, and other essential nutritional elements. No single multivitamin can provide all that you need, otherwise it will be too big to swallow. Most health consumers, however, are taking at least 3 capsules a day. As I've said, it's really up to you. The most important issue is choosing a supplement that you will incorporate to your daily routine. If you're willing to take just a capsule each day, that's fine. Simply look for a multivitamin that packs as much as possible all the vitamins, minerals, and herbal extracts into a single cap.

Just like to mention that the calcium content in all the multivitamin supplement available in stores or online are less than 45% of the suggested daily value because it's a bulky nutrient. You may want to add a calcium supplement if you don't consume enough dairy to reach 1000-1200mg daily value. If I were you, the calcium found in our multivitamin is good enough as a study conducted in Australia on white women over the age of 65 for six and a half years has found that the use of calcium supplements was associated with increased risk of hip and vertebral fracture of the proximal humerus.

In taking multivitamins, it's important that you select the formulation that's right for the quantity of capsules you plan to take. Getting too much of a particular vitamin or nutrient is bad for your health. Watch for Daily Values or US Recommended Daily Allowance on labels to help guide you, especially if you are taking more than one vitamin.

What to look for a in a good multivitamin?
It should have the following components: Vitamin C(in the form of Ascorbate), Vitamin D-3 (Cholecalciferol), Vitamin E (in the form of d-alpha tocopherol), Vitamin K-2, Folic Acid, Lutein, Calcium (in the form of Calcium Citrate or Malate), Magnesium (in the form of Magnesium Malate or Glycinate), Selenium, B Vitamins [B-1 (Thiamin), B-2(Riboflavin), B-6 (Pyridoxine), and B-12 (in the form of Methylcobalamin), Alpha Lipoic Acid (if possible), herbal extracts, enzymes Please take note of the form being used as this will help you distinguish from those cheap ingredients that you'll see in cheaper brand of multis. The forms of vitamins mentioned above have high absorption rate or should I say in their most absorbable form thus I specifically mentioned them to you. For a multi to be classified as best supplement it ought to contain a balance mixture of vitamins, minerals, herbal extracts, enzymes and other specialty nutrients as these work synergistically and many enzymes and herbs can immensely enhance the efficacy of vitamins.

It should be Iron free. Most of us do not need this. We can easily obtain 10mgs (for men and women who are not menstruating) or 18mgs (for menstruating women) )of iron we need from food and if taken in excess can damage the liver.

Vitamins that need precautions: Zinc (<15mgs), copper(<2mgs), Vitamin A(<5000 IU), and Chromium(<120mcgs). These should be taken only in considerable amount as indicated in the parenthesis.

It should not contain adders or fillers esp. synthetic and toxic fillers like hydrogenated oil, dyes, coal tar, etc. as these may hinder absorption and in general are undesirable in dietery supplement.

It should have a best by date. Without a best by date, there is no guaranteed potency by the time of consumption. Vitamins by nature are reactive. That's a simple chemistry taken from a BS Chemistry graduate like me. The quantities listed on the label will change over the course of its shelf life. Therefore, it's important to not take vitamins/supplements that past their expiration date.

The shorter the shelf life the better. If they use cheap ingredients, the shelf life will obviously be longer.

It should be manufactured under strict GMP (Good Manufacturing Practices) compliance. This ensures the quality and effectiveness of the ingredients.

It should be nutraceutical-grade,scientifically formulated. It must be absorbable/soluble.

It should be a unisex customized formula.

It should improve your health and wellness. You alone can tell if a multivitamin really works. If you don't feel any difference after taking the supplement after a month or so, it's time to find a better one. This statement only holds true if you are eating nutritious food to complement your supplement intake. Make sure to take your multi with a meal that contains a little fat as certain vitamins like K, D, and E need a little fat to be effectively absorbed by your body.

Always remember that your best defense is to buy the supplements from a nationally-recognized, reputable source with an interest in protecting its good name. Look for a manufacturer who does extensive research and publishes it's clinical studies. Be wary on labels as most supplements out there contain large quantities of inferior grade nutrients/ingredients and toxic fillers and try to put in only a few amount of the superior ones just so they will be allowed to be added on the label. The consumers then will think that this supplement will be doing them some good well in fact they're just buying a bottle of junk and what's even worse it's harmful to their health.

Violence Against Women - Do They Like/Encourage It?

There are various situations that result in violence against women. There is the type of violence that is what I would call "spontaneous", is an attack on any woman in the street.

That kind of violence is not what I will be dealing with, but the kind that manifests itself with results of hospital visits or the law officer's intervention.

Let me state upfront that I am against ALL forms of violence, whether it be political, child, IPV, verbal, economic or otherwise.

IPV [Intimate Partner Violence] is prevalent in all stratum of society. One's income streams does not exclude the gravity of the problem.

Some years ago my next door neighbour's son was married in a beautiful Hindu wedding ceremony. She was a stay-at-home wife typical of the tradition that obtained at the time.

Soon one could hear the sounds of beatings as if the wonder-bride was relegated to being a "tassa drum." This continued for some months until the wonder-bride jumped through the bedroom window during a beating, landed on the kitchen roof, and made good her escape. I have not laid my eyes on her since.

The causal factor in the relationship I later learnt was the gentleman's mother. His working in the grocery all day and the daughter-in-law not bowing to her mother-in-law's every whim and fancy had her "carrying news" on the wonder-bride. These tidbits the mother told her son of which he believed, hence the severe beatings.

A female calypsonian once used these lyrics in her ditty. "Dog does run away, cat does run away, so woman put some wheels on your heels". I endorse that point 100%. A woman is God designed and God created to be a HELPER for man. Not a servant but an equal partner to assist him and he her in THEIR journey across the lifespan.

I grew up in an era where male dominance was still being promoted. But my father said to us his offspring that our mother was the Queen of the home. At that time I did not sense it but it grew on me when I had my own home.

Some women that are in a IVP situation are bound in her space by the cultural patterns that obtain in their society. Who can she turn to if she vacates her space? But I say this the economic potential of these countries could explode once these women are freed from their chattel existence.

The major factor in the IVP thing is man's longing to be "macho". But that "macho" lifestyle goes against all forms of co-habitation.

I lived with a lady who bore four children for me who was in a IVP situation before we met. I later learnt from her during our many bedroom talks [she was afraid to speak elsewhere of it] of the many atrocities that was she submitted to.

I will draw one example from our journey together to illustrate how devastating an effect on a woman's psyche or for that matter anyone IVP effects.

I was a cigarette smoker at the time, and while lying on the bed together having a casual conversation I would obviously reach to the head-board to get my smoking paraphernalia. Every time I did this she would flinch. It took her about five years to release from her mind that whenever I raised my hand was not to hit her.

We underestimate as men the effect that IVP has on our ladies and by extension our offspring. This fighting to control is never healthy.

I once read a case history of a couple having problems and one night the husband choked and raped her in the presence of their 12 year-old son. He took up a poker and struck him on the head she got up and kicked him all over, grabbed her purse and boy an ran.

I sense you will say that women are IVP perpetrators too. It is on both sides of the divide, but it leans heavily in favour of the woman. Protect them and our children. I will write on female partner violence down the road

Time to stop the violence.


I once read a case history of a couple having problems and one night the husband choked and raped her in the presence of their 12 year-old son. He took up a poker and struck him on the head she got up and kicked him all over, grabbed her purse and boy an ran.
I sense you will say that women are IVP perpetrators too. It is on both sides of the divide, but it leans heavily in favour of the woman. Protect them and our children. I will write on female partner violence down the road.
Time to stop the violence.