By Richard P. Holm, MD
The other day, I was on a run with a scientist friend who recently had suffered a small heart attack. During our run, we talked about cardiac rehabilitation and safe running practices that could help his recovery. He was happy to be back running, and as I was recovering from cancer surgery, I was also happy to be back running. If not over-done, we know that those with or without heart disease benefit from regular exercise. I could feel the run was rebuilding my strength and savored the social time with my friend. When we finished, energized and happy, a short cool-down walk brought us to his home.
There, his wife prepared a light morning breakfast of two eggs, nicely spiced with salt and pepper, a small patty of pork sausage, sliced fried bell-peppers, pieces of fresh melon on the side, and coffee. It was delicious and just the right amount. Twenty years ago, having eggs and sausage for breakfast was thought to be a big no-no. Now, new science has discovered it is NOT the fat and protein in a diet that causes atherosclerosis, but rather the excessive calories. What is more treacherous than the type of food is actually the quantity. If this doesn’t shake your world enough, we have also learned that processed carbohydrates are bad, while a balanced diet of proteins, fats, and small amounts of non-processed carbohydrates are good. For example, large helpings of carbohydrates like potatoes, pasta, pancakes, bread, or donuts can be harmful. Smaller amounts of foods like eggs and sausage are safe. That morning, the calorie count for each of us was about 300 and we both felt great.
Every day there seems to be another study that advises the opposite of what we used to think: eat less salt, now salt to taste unless the heart is weak; don’t eat butter, now butter is caloric but safe; don’t exercise too much, now do it every day; don’t drink alcohol, now a daily glass of wine is good; don’t eat fatty meals, now eat fewer calories and avoid processed carbohydrates. That being said, we have always known about the health benefits of friendship, and no one has refuted that.
In summary, researchers have made headway in understanding what is good for us. May we embrace the science that supports eating fewer calories, less processed carbohydrates, and more fruits and vegetables. If we can also find time for 30 minutes of daily exercise and some quality time with friends, then we have the perfect formula for good health.
by Richard P. Holm
The adage “don’t look a gift horse in the mouth” means to not find fault with something you have been gifted. It refers to the fact that a horse’s age can be determined by looking at their teeth. If the gum has receded and the horse is “long in the tooth”, then it is an old horse. Like an old horse, my teeth and I have been around for a while, and I always get a bit nervous when I drive up to the dentist’s office, concerned about what problems they might find.
There are several things that can cause dental troubles. A common, frequently overlooked cause is dry-mouth. Experts in the field of geriatric dentistry say that saliva is an important and complex fluid that is taken for granted when it comes to dental health. Without spit, teeth fall out in short order, the gastro-intestinal tract becomes troubled, and the overall quality of life diminishes significantly. Certain autoimmune conditions can reduce saliva, but a more common cause of dry-mouth are medications. Dry-mouth is a common and unassuming side effect of many prescriptions. Pills that can cause dry mouth include those used to treat bladder and bowel-spasms, nasal congestion, depression, anxiety, psychosis, acne, epilepsy, pain, high blood pressure, diarrhea, asthma, and nausea.
Although dry mouth is a challenge for many, it is fortunately not my problem. My dental hygienist said, after a thorough look, “Good news: your gums look pretty darn good for a 68-year-old. I see no problems.” After reviewing the X-rays, she said, “You must be regularly cleaning the areas between your teeth. Whatever you’re doing, keep it up.”
It is important to care for your teeth throughout your life so that your gums stay healthy and teeth stay strong. Aside from brushing twice-a-day, and a visit to the dentist twice a year, my efforts include removing food particles at the end of the day with a water-jet-washing device, similar yet more effective than flossing. It surprises me, every night, how many pieces of meat, corn, or broccoli can be stuck up in-between my teeth. Also, over the last ten years, I’ve been using those special disposable tooth-pick flossing tools that come in a bag which I place in a spot I notice and can reach into every day.
With daily jet-washing, picking and flossing, and avoiding medicine-induced dry mouth, I have been rewarded with good dental health. I still have my own chompers, and I’m not quite so “long in the tooth” as could be expected. Hopefully this advice can help you be as equally blessed.
By Richard P. Holm, MD
This morning, a 40-year-old woman called a question into my radio talk show complaining of a bunch of tight blisters under her right shoulder blade. She said, “The skin is red underneath and the whole area is quite painful.” Her question was, “What kind of bug bites could have done this, and what should I do?”
In reality, these were likely not bug bites, but rather the manifestations of the alphaherpesvirus varicella-zoster virus (VZV). This virus is more commonly referred to as “chickenpox” early in life and “shingles” when it reemerges in older individuals. Though we typically acquire chickenpox at a young age, the virus sets up shop in peripheral nerves for the lifespan of the host and can raise its ugly head many years later, resulting in shingles. It is fortunate that vaccination of the young, or those over 60-years-of-age, can help prevent chicken pox and reduce the severity of shingles if the virus ever reactivates.
A similar type of skin infection can be caused by herpes simplex virus (HSV). Infection with HSV commonly results in fever blisters, also known as “cold sores”. These are larger, painful, blisters which cluster around the infected area, typically the mouth or the genitals (depending on where the virus was initially acquired) that can reemerge when the immune system is weakened by illness or stress. There are two types of HSV, I and II, that can be both directly and sexually transmitted. Like VZV, HSV type I and II are alphaherpesviruses, meaning they also exist for the lifespan of the host. Antiviral medications like Acyclovir can help abate symptoms and prevent reactivation, but there are currently no vaccines or cures available for HSV.
Blisters can also result from contact dermatitis, a condition where the body reacts negatively to an irritant or allergen, resulting in a skin rash. These irritants or allergens can be anything, like poison ivy, antibiotic ointment, or even fabric softener. We also see blisters pop-up when unprotected hands are traumatized by raking the yard, burned by grabbing a hot pot handle, or frost-bitten on an ice-fishing expedition. A life-threatening blister condition can also occur when a person has an allergic reaction to some pill or intravenous medicine and blisters start spreading over extensive amounts of skin and into mucous membranes. When this occurs, stopping the culprit medicine and providing emergency medical measures can save the patient’s life.
A few years ago, a 99-year-old patient started suffering from blisters over her lower legs. I first tried stopping every unnecessary medication, then a topical treatment, but to no avail. I reviewed causes for blisters and once again realized how many different reasons there could be for blisters on the skin. After biopsy, her diagnosis came back as a mysterious autoimmune disorder called pemphigoid. The dermatologist treated and cleared the blisters with just the right medicine, and my patient had relief.
The more I learn, the more I am humbled.
My Father was in his 50's when his retina, the lining which provides a blanket of vision on the inside back of one of his eyes, started separating from its base structure. Called a 'detached retina', this condition occurs in 3 people out of 1000; more often in men, in certain families, in those with near-sightedness, in obese hypertensives, and in those who have had cataract surgery.
Dad's first symptoms included floaters, quick flashes of bright light, and blurred vision starting in the peripheral part of his vision, gradually moving toward his central vision, like a gray veil falling across his line of sight. There was no pain with this, however he became understandably fearful as his vision deteriorated.
I remember my father having open-eye surgery at a University Center in Minneapolis; it was a cutting-edge treatment at the time. It required two weeks of hospitalization with both eyes patched closed and with absolutely no head motion while sandbags pushed into both sides of his head. His constant companion and only entertainment was a radio plugged into his ears. I remember when he finally came home, he was overjoyed to see us, seemed to have a renewed appreciation of life, and was happy that his vision seemed to be gradually returning. That was the late 60’s, and I don’t think his appreciation for life ever waned after that.
Modern treatment for detached retina may include reattachment of the retina with a laser (like spot-welding) or freezing small areas (cryotherapy). Sometimes the walls are squeezed together by a band the surgeon wraps around the sphere of the eyeball. In other cases, the vitreous jelly, or the bag of fluid that fills the eyeball, is removed and the fluid is replaced with a gas bubble to push the retina back in place. Each case is different and the treatment approach may vary depending on the severity and type of detachment.
Fortunately, modern-day treatment for detached retina no longer requires two weeks of eye patches and sandbags holding the head perfectly still.
Nurture versus nature is a question often bandied about. Is it the environment in which the child is raised, or is it the genetics provided by the biological parents, that most influences what kind of person a child will grow to be?
We have known for a long time that if a parent is depressed, their children are at higher risk for having anxiety, depression, and disruptive behavior. Indeed, the offspring of depressed parents have up to a three-times higher risk of these problems when compared to the children of parents who are not depressed. So, is it because of the environment; or is it genetics?
Research published in the Journal of the American Medical Association brings us closer to an answer. It is important to note that the study consisted primarily of mothers with depression, as they are far more likely to report symptoms and come in for treatment than fathers with depression. However, researchers believe that their discovery applies to whichever parent has depression, regardless of whether they are male or female. The results were fascinating: effective treatment of the mother lead to resolution of psychiatric problems in the child.
Study author Myrna Weissman, professor of psychiatry and epidemiology at Columbia University, said “while depression may be a genetic disorder, [this study showed that] a parent’s illness has a very strong environmental
effect on her child.” In other words, when mama’s not happy, nobody’s happy. Weissman also pointed out “if you have a depressed mother, you ought to do everything you can to get her better, because there’s a double effect that will impact their children.”
I think the message from this research is very powerful, and should be taken to heart by any mother or father. If you as a parent are having psychological trouble, get help and your child will be better for it. If you won’t do it for yourself, do it for your kids.
By Richard P. Holm MD
When should one worry that he or she might be having a heart problem?
Unfortunately, heart symptoms can be all over the board, and sometimes there are no indications for trouble until very late in the game. On top of this, classic heart-problem symptoms can just as easily be due to something not heart-related, like an esophageal spasm or musculoskeletal strain. That said, there are clues for heart trouble that help us know when to seek help.
It is helpful to take into consideration the age, gender, size, life-style, and situation of the individual in question. In general, there is a higher incidence of heart problems in people with a history of smoking, a family history of heart disease, older age, and if that person is male. But heart problems can occur in anyone, so never cover-up or ignore symptoms. Heart disease in some people, especially diabetics and women, can present with unusual or very minimal symptoms. Hypertensive and overweight snorers should have an inexpensive night-time oxygen test to see if a full sleep study is needed. Sleep apnea is a dangerous and important cardiac risk-factor, and I believe way more worthy of attention than cholesterol. If suspicious, talk to your doctor, since discovering sleep apnea could add years to your life.
A middle-aged or older person having a heavy sensation in the chest, neck, jaw, shoulder, or arm that comes with exertion and is relieved with rest, should be suspicious of a blockage in their coronary arteries. Called angina pectoris, this condition alone may not be dangerous unless coming on with progressively less exercise. Still, if you experience angina you see your doctor. If these symptoms come on suddenly, severely, and do not go away with rest, then you have a very urgent problem, so call 911.
Heart weakness, also called congestive heart failure, or CHF, can be caused by heart-valve disease, long standing high blood pressure, chronic alcohol use, certain viral infections, and more. The most common symptom of CHF is shortness of breath, but almost every illness, especially lung disease, can cause this too.
Heart rhythm problems are sneaky. Many of us, including me, have benign sporadic palpitations that are not dangerous and mean nothing, but still worth discussing with your care provider. If you have runs of heart rate in the range of 150 beats per minute, or rates so fast or slow as to cause weakness or passing out, you should go the emergency room.
As complex as all these warning signs may seem, the most important way to diagnose heart disease starts with paying attention to symptoms.
By Richard P. Holm MD
The other day an 80 plus year old woman came into my office asking if she could get off some of her pills. “I take too many,” she said, and I agreed with her. We were able to consolidate her medications and reduce her total number of pills from 14 to only 4.
We live in a pill-taking society. Some of this probably comes from the human tendency to find an easier way to do things. If we have a choice between walking or riding to work, we will likely ride. Similarly, if we have a choice between exercising or taking a pill to lower our blood pressure, we will likely take the pill. A pill is easier than a lifestyle change, and pharmaceutical companies are all too willing to sell us more pills.
Make no mistake, there is nothing wrong with taking certain medications; some significant medical conditions just call for it. However, as the conditions pile up, so can the medications. Sometimes it takes 2-5 different drugs to get a blood pressure down, or to control a diabetic’s blood sugar, or to help a weak heart pump better. If you happen to struggle with a combination of these or other conditions, you can end up taking a smorgasbord of pills.
Many drug companies work very hard to convince doctors and patients that there is a drug for almost every ailment. Think about how providers are asked to solve a new problem each time a patient comes in, and how simple and pleasing it would be if there was a pill to satisfy their every need.
We live in a culture that is inclined to over-rely on drugs and over-play their benefits; what’s worse is that we under-play their risks. This is a fact: the more drugs, the higher the likelihood for a significant side effect or a dangerous interaction between medicines. Additionally, there are many conditions that can be improved, or even reversed, with positive life style changes like diet and exercise. A pill might seem like the better and easier choice initially, but with the multiple side-effects and potential interactions, as well as the expense of multiple medications, it can end up costing you dearly in the long run.
I am not saying that all medicines are bad, and I’m not encouraging you to stop taking your medicines without careful direction by your doctor. I’m simply asking that you be aware of the number of medications your taking and the potential risks and interactions associated with them. The next time you see your provider, however, ask her or him to review the pills you take and try to get the number reduced. That would be good medicine.
By Richard P. Holm MD
Caring for the elderly my whole clinical life has been an honor and a pleasure, but some experiences have been terribly heartbreaking. Elder abuse is one of the saddest, and it can come in the form of physical harm and neglect, emotional cruelty, or financial exploitation.
A couple of years ago a frail, confused, elderly person arrived in the emergency room with a fractured bone, bruises, sores, and was quite unclean. His family described that the patient had fallen multiple times recently, and I could see his needs were overwhelming his care providers. If there hadn't been physical abuse, there was at least neglect. After surgery and hospital care, we were able to send the patient to a nursing home. We all need to be aware when there might be possible physical abuse, and call for help when we see it.
Another case was one of emotional abuse with much blaming, shouting, and anger put upon an incapacitated elder. It was by a visiting, emotionally-ill family member who had arrived from afar and was unloading his own emotional baggage upon their frail and defenseless parent. The patient had been admitted for a medical issue, and the nurses were the first to recognize the emotional abuse. Police were notified and the visitor was banished from visiting the patient in the hospital during their stay or at their home after they were discharged.
On instance of financial abuse was evident in another case, when a son informed me that his 80-plus-year-old mother and her new boyfriend had recently been going to the bank and removing large sums from the mother’s savings account. The son believed his mother was “losing it”, and informed me that she had been spending thousands of dollars for herbal and supplemental cures for her memory problems She had several unpaid bills and was now was being manipulated by an opportunist. He asked me how to protect his mother’s money.
I saw the patient in my office; obviously the mother was demented and incapacitated. A judge confirmed her incompetence and determined the son was to have power of attorney. Problems could have been avoided had the son been more watchful, had the mother made financial plans before her mental health problems, and had a bank’s trust department or a bookkeeping business been asked to pay bills.
None of us are safe from abuse. When people become frail or lose their mental capacity, then bad people can take advantage of them. Elder abuse can come in the form of physical harm and neglect, emotional cruelty, or financial exploitation, and is more common than you would expect.
Be aware, and take precautions.
On the way home from Rochester I wrote an absolutely beautiful and humble comment here, and lost it when I sent it not connected, and could not seem to recover it. You are going to have to be satisfied with a shorter and less beautiful and less humble message... sorry.
We stayed at Dave and Joleen Nelson's home, and had brunch with Phil Lombardo. We couldn't be more thankful for the support that we had from the Lombardos and the Nelsons during this ordeal.
It was good news from Dr. Truty on Tuesday afternoon, who explained no evidence for spread, infection, or problems. He said measure improvement by the week not by the day... expect 2-3mo... and he added pancreatic digestion enzymes before meals of snacks. And then he removed the feeding tube. Said exercise and nutrition...
The next morning we met with Oncologist Thor Halfdanerson, (Icelandic) who explained that the neuro-endocrine part of the tumor is low grade tumor and not a great threat. The accinar part of the tumor, however, is something had we know in advance we would have treated exactly the same way with the same chemo and radiation that I had. He said there is no scientific data to treat at this time, leaving me with no further plans except follow-up. He said I have a 50-50 chance for cure, better than lots of other options out there.
As I was thinking about the meaning of all this yesterday, I settled in on "FRIENDSHIP." That includes the love within family members. It is the spiritual sharing one has with another that seems to give everything color, humor, joy.
Here's to our friendship. Love you.
By Richard P. Holm
There is something about that word “cancer”; the big C.
When the pathology report displays those abnormal type cells on biopsy and the report spells out those six black letters, then, whether it is a simple treatable condition or one that will most certainly predict an earlier death, the patient hears cancer and it changes everything.
Through the years, I have had to inform too many patients about a diagnosis of cancer. I have learned there is often a paralyzing fear that comes with the word. Due to advancements in science, many more people are winning the fight against cancer compared to when I first started practicing medicine. Still, whenever I have to say, “you have cancer", often the word “cancer” is the only thing they’ll think about for next several days.
Unfortunately, some people who hear the word come to face their mortality for the very first time, even when the chance of cure is good. I dare say this goes for too many of us, resulting both from unrealistic expectations in this scientifically advanced world, and the cover-up of the dying process in this everything-is-going-to-be-alright society.
This week a friend told me she and her husband were preparing to sell their house by thinning out their stuff collected over 15 years and remodeling with that new carpet they've needed for a long time. It reminded me of a how a realtor friend of mine once told me how he keeps his house ready for sale at all times, even if he has no intention of selling it. Why not put in the carpet, paint the bedroom, and fix the steps so that he can enjoy it right now? Why put off until tomorrow what can be done today?
In a similar vein, I have heard it said that every once in a while, perhaps yearly, we should all have some kind of significant brush with death and then be rescued. Maybe that would help us to remember how impermanent life really is; maybe that would help us to get and keep our house in order. Then, when each of us has our turn to cross the river into that land of the Sweet Bye and Bye, we can feel what the young neurosurgeon, Paul Kalanithi, said before dying of cancer, "(I have found a joy)...unknown to me in prior years... a joy that does not hunger for more and more, but rests... satisfied in this time, right now..."*
We shouldn't have to come down with cancer to get our house in order.
*Paul Kalanithi MD, Before I go: A Stanford neurosurgeon's parting wisdom about life and time. The Washington Post, March 12, 2015