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Monthly Archives: June 2014

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Bo Li looks closely at red and green colors. He is not preparing Christmas decorations, but rather is looking at the way different neurons in a region of the brain light up in response to an increase or decrease in fear.

An associate professor in the Neuroscience Department at Cold Spring Harbor Laboratory, Li is studying a small area in the mouse brain called the amygdala. His results may help guide pharmaceutical companies and other researchers as they look for ways to help people suffering with post-traumatic stress disorder.

In the central amygdala, he found two cell populations that likely play some role with fear. One of those cell populations promotes fear. He believes the other suppresses fear. Ongoing studies, he said, will provide answers about the other cells soon. Once he understands both, he will look for ways to affect their activity.

Understanding fear responses is just one of the areas where Li studies neurons in the brain. He also does research on animal models of depression and schizophrenia, hoping to find differences researchers can exploit to provide early detection, treatment and prevention.

Fritz Henn, a visiting professor at Cold Spring Harbor Laboratory who collaborated with Li when Li was a post-doctoral fellow, said he is a “rising star in neuroscience research.”

In post-traumatic stress disorder, people who witness or experience stressful and potentially life-threatening experiences develop a sustained level of fear, even after removed from stresses like the life-and-death struggles of war. This trauma can diminish the quality of life as people struggle with emotional scars that don’t seem to heal.

By looking at the neurons of mice, Li is able to use genetic technology to explore an area that contains about 10,000 neurons. He uses scientific advances that enable him to separate neurons in different categories. These different types of neurons are labeled by a marker, which glows in green, yellow or red. He can also use viruses that specifically recognize these neurons and enable him to see a higher or reduced activity level for these neurons in a fear response.

Using an optical fiber that is about 150 microns, which is about the thickness of a human hair, Li can shine a light on the amygdala to see signals that are then collected through a computer. His analysis allows him to record changes in the signals sent by these different types of cells. Henn called Li’s research “state of the art.”

By collaborating with other scientists at Cold Spring Harbor Laboratory to do gene sequencing, Li can look at what other proteins are expressed by these different cells.

“It’s just a matter of time to gather the data and come to conclusions,” he said. He believes this research will make substantial scientific progress in the next five years. The clinical applications will likely take longer, he predicted.

The amygdala is an area that scientists have known for a long time controls emotion and emotional memory. As a result, researchers on Long Island and elsewhere in the world are putting considerable energy and time into understanding the specific cellular functions in this region.

His work on schizophrenia presents other challenges because it’s difficult to mimic the kind of symptoms humans exhibit, including hallucinations and reasoning problems.
Li is looking at the genes linked to schizophrenia and finding similar genes in mice.

“Going from genes to behavior is a big gap,” he said. “We need to fill that in.” He is working on genes in his lab that he knows cause problems in some brain circuits to understand depression as well.

“We know a particular circuit in the brain [called the lateral habenula circuit] is important for reward, learning and punishment,” he said. “When this circuit is impaired, it can cause depression.”

Li lives on campus at Cold Spring Harbor with his wife, Shirley Guo, who is also a scientist and works for Kadmon, a biotechnology company in New York City that is developing medicines for a range of diseases and provides treatment of hepatitis C. The couple have an 11-year-old daughter, Serena, who is an avid tennis player.

Li called Cold Spring Harbor a “fantastic environment” and said it is “one of the best in the world for doing science.”

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Should we be getting our fat from butter?

Fat in the diet is a highly complicated issue. For decades, we have adopted the notion that fat may be the enemy and, therefore, we should eat a low-fat diet. But is this really true? The answer is that we all need fat, but the sources are important.

The cover of Time magazine’s June 23 edition exclaimed in big yellow letters to “Eat Butter. Scientists labeled fat the enemy. Why they were wrong” (1). It also included a picture of a curl of butter, in case you had forgotten what butter looked like. This cover is provocative and tantalizing. However, it does a disservice to the article itself and to the general population who may have seen it.

The article, itself, is well written. Its focus is not mainly on butter, but rather on different types of fats, saturated and unsaturated. The author Bryan Walsh does make salient points, but my objection is mainly that many of these points are buried deep within a five-page, three-column, single-spaced article among comments that are not necessarily substantiated. You have to wade through paragraph after paragraph to get to some these points. Reading the first page is not good enough.

Let’s look at a few studies presented in the article.

Study: Different types of fat — saturated and unsaturated with heart disease.

There was a recent meta-analysis (a group of 72 studies including both observational and randomized controlled trials) that looked at whether different types of fat had an impact on cardiovascular health (2). The results showed that saturated fats, omega-6 polyunsaturated fats and monounsaturated fats were most likely not harmful and that omega-3 polyunsaturated fats were potentially beneficial. However, trans fatty acids were shown to be potentially harmful, with a 17 percent increased risk of cardiovascular disease outcomes such as heart attacks and heart disease.

While this is an interesting study, there are some significant flaws that need to be highlighted.

1. The conclusions in the study don’t match or only partially match. Let me explain. There is a conclusion in the abstract (a synopsis or summary of the study) and a conclusion in the body of the study. The abstract concludes that polyunsaturated fats, including omega-3 fatty acids, are not necessarily beneficial while saturated fat may not be harmful. In the body of the study, the authors conclude that omega-3 fatty acids significantly reduce cardiovascular events. Why is this important? Many physicians are bombarded by studies and may only have time to read the abstract. Thus, this could wrongly influence the physician.

2. The source of fat is never differentiated in the study. In other words, the saturated fats which are deemed harmless may be from foods or supplements that contain both unsaturated fats and saturated fats or from foods that contain only saturated fats. We see benefit in plant-based foods that have multiple types of fats — saturated and unsaturated — such as olive oil, nuts, seeds and avocado. However, most animal fats, like red meat, pork and chicken, contain only saturated fats. The exception is fish, which contains multiple types of fats.

Also, unlike the Time cover story, the study NEVER mentions butter, cheese or red meat. Therefore, the commentary by the press is based on an extrapolation that cannot and should not be made: that eating butter, cheese and red meat maybe harmless and possibly beneficial.

3. The populations of the studies differed at the starts of the different trials. In other words, some were healthy participants, some were high-risk patients and some already had cardiovascular disease. The main thing these studies had in common was that cardiovascular disease outcomes were an endpoint, but it did not have to be the primary, or main, endpoint. Thus, cardiovascular disease outcomes may not have been the main thrust of all the studies that made up the meta-analysis.

4. A meta-analysis by definition is difficult to perform because researchers combine results from studies that were designed and performed differently from one another. In this meta-analysis, the authors combine the results of observational trials that may have used different types of fat intake from food or from supplements. Usually, supplements, like fish oil, involve both saturated and unsaturated fats, and they may have different effects than food.

5. Finally, the study does not tell us what those who ate lower saturated and unsaturated fats ate instead. For example, it compared those who ate high saturated fats to those who ate low saturated fats. What did the group who ate lower saturated fat eat instead of fat? Was it carbohydrates? If so, were they fries, whole grains or sweet potatoes?

The Time cover article goes on to mention the Mediterranean diet and its beneficial effects with heart disease. There was a recent randomized controlled study, the gold standard of studies, called the
PREDIMED trial, with results that showed that participants who ate a Mediterranean diet with added olive oil or mixed nuts had a 30 percent decreased risk of cardiovascular disease than those in the control arm who were advised to follow a “low-fat” diet (3). The Mediterranean diet emphasizes vegetables, fruits, whole intact grains, beans, legumes and fish, as well as olive oil and nuts. This was not a low-fat diet. It contained both saturated and unsaturated fats, including polyunsaturated and monounsaturated fatty acids. The caveat to these results is that the “low-fat” group was not actually able to maintain a low-fat diet, but instead ate more like the standard American diet with no restrictions.

Interestingly, researchers using the same Mediterranean diet study, PREDIMED, showed that higher dietary intake of magnesium reduced the risk of cardiovascular mortality risk by 34 percent (4). They compared those in the highest intake of dietary magnesium with those in the lowest. These participants had a high risk of cardiovascular disease. Foods rich in magnesium include dark green leafy vegetables, such as spinach, as well as nuts, seeds, fish, beans, lentils and avocados.

In conclusion, the sources of fats matter. To run out and eat a cheeseburger, without the bun of course, would be to have misunderstood this article and the flaws in the meta-analysis and to have focused only on the cover of the Time magazine article. The take-home message should be that we need some fats in our diet, but that the sources of these fats are critical. Diet quality is of the utmost importance in reducing disease (5), so put that cheeseburger out of your mind. Many studies have shown that the Mediterranean diet helps reduce the risk of cardiovascular events. For some, this may include the addition of more olive oil and nuts.

References:

(1) Time.com. (2) Ann Intern Med. 2014;160:398-406. (3) N Engl J Med. 2013;368:1279-1290. (4) J Nutr. 2014;144:55-60. (5) Lancet. 2014;383:1999-2007.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website medicalcompassmd.com or consult your personal physician.

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Getting a wallet out of a back pocket, reaching up to put luggage in an overhead bin on an airplane, or waving across a parking lot to a friend are all motions that can become almost impossible for people who have frozen shoulder.

A painful and motion-limiting problem, frozen shoulder occurs mostly in women between the ages of 40 and 60. The problem is that the body is depositing extra collagen, a binding material, over the shoulder capsule, limiting motion around the joint. Typically, treatment includes a corticosteroid injection and considerable amounts of physical therapy, to loosen up the joint. If that doesn’t work, patients have gone through a surgical procedure that includes months of physical therapy afterwards.

Edward Wang, associate professor of orthopedics who treats numerous cases of frozen shoulder each year at Stony Brook Orthopaedic Associates, and Marie Badalemente, a professor in the Department of Orthopaedics who has worked to develop an enzyme cocktail to relieve the pain of a disfiguring hand disease, have teamed up to create an injection that targets that extra collagen.

The treatment uses injections of an enzyme called clostridial collagenase. The tandem have patented the treatment and are entering phase 2b of the Food and Drug Administration’s clinical trials, which are ongoing at 25 facilities throughout the United States and five in Australia. Stony Brook is still looking for volunteers to participate in the drug trial.

Kim Russo of Holbrook had surgery for one of her shoulders when she noticed an ad for the study. The treatment she’d already received included four months of physical therapy, surgery and then another four months of therapy.

When she received her first treatment, she noticed a change almost immediately. “I could tell after my first [shot] that there was something just a little different,” she said. After the second shot, she was doing so well that she didn’t need a third one, she said.

Badalemente helped develop the treatment, called Xiaflex, for a condition that also involves the build up of collagen in the hand. In Dupuytren’s contracture, people struggle with limited finger mobility. The enzyme breaks down the collagen, restoring function and flexibility to the fingers.

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Insulin may increase the risk of death compared to sulfonylureas

When we refer to diabetes, we think of its complications. It may lead to microvascular maladies that affect vision (retinopathy), the kidneys (nephropathy) and the limbs (peripheral neuropathy), as well as macrovascular diseases such as heart disease and heart attacks. These are important reasons to prevent and treat it.

However, diabetes, in and of itself, is complicated. For example, in the ACCORD trial, we treated diabetes patients aggressively with medication trying to get their HbA1C (three-month sugars) to below 6.0 percent rather than the standard 7.0 percent, because we thought lower would mean fewer complications. According to the results, the patients who were treated more aggressively had a higher risk of mortality (1).

We know that in type 2 diabetes, the first line of therapy beyond lifestyle modifications is metformin. But when that is not enough, we also know that insulin is the most powerful treatment for decreasing glucose, or sugar, levels. But are insulin therapies the best drugs to use? Well, it turns out that they may have more risk of death compared to another drug class, sulfonylureas (e.g., Glucotrol, Amaryl). However, sulfonylureas, along with another drug class, thiazolidinediones (e.g., Avandia, Actos), may increase the risk of fractures. Sulfonylureas and insulin each have also been associated with increased risk of hypoglycemia (low sugar).

Diabetes is also associated with depression. The prevailing thought has been that having diabetes may contribute to depression. However, the association may be related to another common factor, inflammation.

If that were not enough to make your head spin, the Centers for Disease Control reports that one-quarter of patients don’t even know they have diabetes (2). And for people over the age of 20, 33 percent have prediabetes, defined as sugar levels between normal and diabetes, with fasting sugar of 100-125 mg/dl or HbA1C of 5.7-6.4 percent. However, there is good news as it relates to lifestyle modification. Let’s look at the evidence.

Medications: insulin versus
sulfonylurea

Two of the most common medications for the treatment of diabetes, referred to as second-line therapies since they would be used after metformin, are insulin and sulfonylureas. In a recent observational comparative effectiveness trial with patients already on metformin, results showed that  when insulin was added compared to when sulfonylureas were added, there was a 44 percent increased risk of all-cause mortality and a 30 percent increased risk of cardiovascular outcomes including heart attack, stroke or all-cause death (3).

Does this mean we should not use insulin? No. There were limitations to this study. Though it was more sophisticated with its comparative effectiveness design, it was still retrospective, which is not as strong as some other study types and may involve bias. The only conclusion that can be made is that insulin when used with metformin had an association with, but not a link to, significantly negative side effects versus sulfonylureas. These patients were followed for a median of 14 months. We need prospective studies, especially randomized controlled studies. However, the results are intriguing. It makes you think twice before reaching for insulin as a second-line therapy.

Medications: sulfonylureas and thiazolidinediones

Does this mean that we know what to use for second-line therapy? Not necessarily. In a recent study, both sulfonylureas and thiazolidinediones showed a significantly increased risk of fractures. There was a 9 percent increase in fracture risk with sulfonylureas and a 40 percent increased risk with thiazolidinediones when each was compared to metformin (4). The good news is that other drug classes were tested and did not show statistically significant elevated risk occurrences. This was also a retrospective observational study so the same study limitations apply, most importantly, bias and confounding factors.

Depression

To complicate matters further, diabetes and depressive symptoms are associated with each other, but not in the way you might think. According to a recent study, these two maladies may not be a classic chicken-and-egg argument, but rather a common denominator; inflammation may be the culprit that is at least partially responsible for both diseases processes (5).

The researchers found that six biomarkers of inflammation were increased in patients with both diabetes and depressive symptoms. These inflammatory markers include C-reactive protein, tumor necrosis factor alpha, triglycerides, white blood cells, interleukin 1 (IL-1B and IL-1RA) and monocyte chemotactic protein-1. Ultimately, if they are both caused by inflammation to varying degrees, then theoretically if we reduced inflammation it may give us beneficial results for both diseases. This is important, since those with both diseases may have a two times greater likelihood of death, according to the authors. They also note that lifestyle modifications, including diet and exercise, are the best way to reduce inflammation. The study involved 1227 newly diagnosed diabetes patients.

Heart attack

Both men and women with diabetes are at increased risk of heart attacks. However, in a recent meta-analysis (group of 64 studies) involving over 800,000 patients, the results surprisingly show that women with diabetes are at a significantly greater risk of having a heart attack than men (6). In fact, these women were at a 44 percent increased risk of having fatal and nonfatal cardiovascular events compared to their male counterparts. The reason for this, according to the authors, was that women may already be in poorer health before the onset of diabetes. What to do?

Exercise: games

We tell patients to exercise, but many of us know just how difficult it can be to motivate ourselves to do this. Video games may provide the needed spark. In a randomized controlled trial, the gold standard of studies, those who used Wii Fit Plus saw improvements in their diabetes parameters compared to those who were given usual care (7). Results included significant decreases in their HbA1C, fasting blood sugars and weight. These results were seen in just three months. There were also improvements in daily physical activity, quality of life and depressive symptoms that are so commonly associated with diabetes. Family members were also likely to get involved in the Wii with the patient, creating a natural support network. Interestingly, after 12 weeks, those in the control group were then given the Wii Fit Plus and followed for an additional 12 weeks. They saw similar benefits. The authors called this “exergaming.”

Ultimately, we should do a really good job with lifestyle modifications and if that is not enough add metformin, because we know that both have much greater upsides and very few downsides compared to many other diabetes treatments. Exercise can even be fun, as shown by the exergaming study. However, if insulin or other medications are needed, while there are treatment guidelines, it really comes down to a case-by-case decision to be made by the patient and doctor.

References:

(1) N Engl J Med. 2008;358:2545-2559. (2) cdc.gov/diabetes. (3) JAMA. 2014;311:2288-2296. (4) ADA 2014 Scientific Sessions;165-OR. (5) Diabetes Care Online. 2014 May 19. (6) Diabetologia Online. 2014 May. (7) BMC Endocr Disord. 2013;13:57.

•If you would like to see a specific topic covered in Medical Compass, please email [email protected].

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website medicalcompassmd.com or consult your personal physician.

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Like a philosopher, Marshall Newton ponders the journey and the destination. Except that what he’s pondering often has to do with the movement of energy rather than the circuitous path through life.

A professor emeritus of chemistry at Brookhaven National Laboratory, Newton retired on January 1, 2009, but, by several accounts, that hasn’t slowed him down. He said retiring freed him up from the “important but time-consuming departmental and lab-wide committee meetings,” enabling him to “get back in depth to some scientific issues which I never had time to fully pursue in the past,” he explained.

Newton tries to understand how energy moves from one place — often at the start of photosynthesis — to a form of energy stored or used in another place. “What I do,” he explained, “is formulate mechanisms for a key process that typically occurs in almost all energy conversion processes.”

Theorists like Newton want to assess the possible pathways “for the efficient capture and conversion of energy.” Part of this conversion involves electronic transfer, which is usually coupled to heavy atoms that must go over a hill or energy barrier as part of the overall transfer process. That process represents something of an energy cost, the way a local diner might incur costs paying for electricity or gas.

Newton develops quantum mechanical models to analyze the efficiency of such processes. He has investigated molecular processes that may serve as components of new artificial photosynthesis schemes, either photochemical or electrochemical.

In artificial photosynthesis, researchers try to mimic the energy generated by plants from carbon dioxide, water and the sun.
Newton is “recognized worldwide for his scientific contributions combining his knowledge of electronic structure, electrochemistry and a wide range of other chemistry,” said James Muckerman, a senior chemist at BNL who has known Newton for close to half a century.

Newton, who started working at BNL in 1969, said that chemists used to be “in the dark ages” about calculating what happened on an incredibly small time scale. Theory and experiment have “bootstrapped” each other in achieving finer and finer distance and time scale, he said.

The benefit of all the theoretical work with computer simulations and models is that it can help guide future design ideas for solar cells or other energy capturing and transferring processes.

Theorists can “turn over [their results] to engineers and say, ‘This is what you should do to make optimal energy material,’” Newton offered. That, he added, is easier said than done.

When scientists try to move energy or charge, the standard problem is the dissipation or loss of that energy along the way. It’s akin to carrying a bag of groceries home from the store and bumping into walls along the way. Each time you bumped into a wall, you’d lose something from your bags. Specifically, relatively high-electronic energy from photons runs the danger of being degraded to heat and transferring charge or excitations can get trapped by “defects.”

Newton said retirement has given him more freedom to indulge his intellectual obsessions, including theoretical chemistry and other fields — both scientific and non-scientific. He hasn’t had any urge to take refuge in fishing or golf.

“The beauty of today’s life is that retirement is whatever you want to make of it,” he said. “It’s much more common now to be active retired. For the last five years, I’m doing more or less than the same things as the first 40, due to the generosity of my department and my department head, Alex Harris.”

Raised in Boston, Newton, who prides himself on not having a regional accent, lives in Strongs Neck with his wife Natika, a philosopher who until last year was also a professor at Nassau Community College. In the fall, she will teach a course in the Osher Lifelong Learning Institute at Stony Brook.

His daughter, Erika Newton, is a staff physician at the Stony Brook Medical Center. Her husband, John Hover, is leader of the grid group at BNL, which is part of the Relativistic Heavy Ion Collider ATLAS computing facility.

Son Joel, who lives in Nyack, New York, is a guitarist who plays jazz and fusion with the Joel Newton Situation. The benefit of the collaboration between theoretical and applied chemistry becomes clearer over time.

“The interplay of theory and experiment is grist for historians and philosophers of science,” Newton said.

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Simple changes may improve diagnosis and outcomes

Last week, I wrote about heart disease and mentioned that hypertension, better known as high blood pressure, is one of its contributing risk factors. I would like to go into more depth on hypertension, for approximately 33 percent of Americans are afflicted, according to the latest statistics from the Centers for Disease Control. (1)

What could we possibly learn about blood pressure that we have not already heard? New information is always coming out on this common disease. Studies are teaching us about diagnostic techniques and timing, as well as consequences of hypertension and its treatment.

Let’s look at the evidence.

Technique

When you go to the doctor’s office, they usually take your blood pressure first. But do they take readings in both arms and, if so, have you wondered why? I take blood pressure readings in both arms, and when one of my longtime patients asked me why, I joked that I need the practice. In truth, it’s because there may be significant benefit from taking readings in both arms.

An analysis of the Framingham Heart Study and Offspring Study showed that when the blood pressure was taken in both arms, if there was a difference of more than 10 mm Hg in the systolic (top number) blood pressure, then there may be an increased risk for the development of cardiovascular disease — stroke and heart disease. (2)  This is a simple technique that may give an indication of who is at greater cardiovascular disease risk. In fact, when this interarm blood pressure comparison showed a 10 mm Hg difference, it allowed the researchers to identify an almost 40 percent increased risk of having a cardiac event, such as a stroke or a heart attack, with minimal extra effort expended.

So, the next time you go to the doctor’s office, you might want to ask if they would take your blood pressure in both arms to give you and your doctor a potential preliminary indication of increased cardiovascular disease risk.

Timing

When do we get our blood pressure taken? For most of us it is usually at the doctor’s office in the middle of the day. This may not be the most effective reading. Nighttime blood pressure readings may be the most accurate, according to a recent study. (3)  This was a meta-analysis (a group of nine observational studies) involving over 13,000 patients. Neither the clinical nor daytime readings correlated significantly with cardiovascular events when multiple confounding variables were taken into account, while every 10 mm Hg increase at night had a more significant predictive value.

Twenty-four ambulatory blood pressures readings were taken with these patients, which means these were standardized readings. Does this mean that nighttime readings are more important? Not necessarily, but it is an interesting finding. With my patients, if blood pressure is high in my office, I suggest that patients take their blood pressure at home, both in the morning and at night, and send me readings on a weekly basis. However, at least one of the readings should be taken before antihypertensive medications are taken, since they will alter readings.

Salt impact

There has always been a debate about whether salt really plays a role in high blood pressure and heart disease. The latest installment in this argument is a compelling British study called the Health Survey from England. It implicates sodium as one potential factor exacerbating the risk for high blood pressure and, ultimately, cardiovascular disease. (4)  The results show that when salt intake was reduced by an average of 15 percent, there was a significant blood pressure reduction and that this reduction may be at least partially responsible for a 40 percent reduction in stroke mortality and a 42 percent reduction in heart disease mortality.

The graphs of sodium reduction mimicked the line graphs for the reductions in deaths from stroke and heart disease. One potential study weakness was that physical activity was not taken into account. However, a strength of this study was that they measured salt intake through 24-hour urine tests. Most of our dietary salt comes from processed foods that we least suspect, such as breads, pastas, and cheeses.

Age-related macular degeneration

When we think of blood pressure-lowering medications, we don’t usually consider age-related macular degeneration as a potential side effect. However, in the Beaver Dam Eye Study, those patients who were taking blood pressure medications were at a significant 72 percent overall risk of developing early stage AMD. (5)  It did not matter which class of blood pressure-lowering drug the patient was using, all had similar effects: calcium channel blockers, beta blockers, diuretics, and angiotensin receptor blockers. However, the researchers indicated that they could not determine whether the blood pressure or the blood pressure medication was the potential contributing factor. In addition, another study that was presented at the Association for Research in Vision and Ophthalmology in May, 2013 actually suggests the opposite — that blood pressure medications may reduce the risk of AMD. (6)  However, this was a retrospective (backward-looking) study, and it has yet to be published.

This is a controversial topic. If you are on blood pressure medications and are more than 65 years old, I would recommend that you get yearly eye exams by your ophthalmologist.

Fall risk

As we age, falling risk seems to increase. A recent study shows that blood pressure medications significantly increase fall risk in the elderly. (7)  Overall, 9 percent of these patients on blood pressure medications were seriously injured when they fell. Those who were considered moderate users of these medications had a 40 percent increased risk of fall. But, interestingly, those who were consider high-intensity users had a slightly less robust risk of fall (28 percent) than the moderate users. The researchers used the Medicare database with 5,000 participants as their data source. The average age of the participants in the study was 80.

Does this mean that we should discontinue blood pressure medications in this population? Not necessarily. This should be assessed at an individual level between the patient and the doctor. Also, one weakness of this study was that there was no dose-response curve. In other words, as the dosage increased with high blood pressure medications, one would expect a greater fall risk. However, the opposite was true.

In conclusion, we have some simple, easy-to-implement, takeaways. First, consider monitoring blood pressure in both arms, since a difference can mean an increased risk of cardiovascular events. Reduce your salt intake; it appears that many people may be sensitive to salt, as shown by the British study. If you do take blood pressure medications and are at least 65 years old, take steps to reduce the risk of falling and have annual ophthalmic exams to check for AMD.

References:

(1) CDC.gov/blood pressure.  (2) Am J Med. 2014 Mar;127(3):209-15.  (3) J Am Soc Hypertens 2014; 8:e59.  (4) BMJ Open 2014;4:e004549.  (5) Ophthalmology online April 30, 2014.  (6) ARVO 2013 Annual Meeting: presentation.  (7) JAMA Intern Med. 2014;174(4):588-595.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website medicalcompassmd.com or consult your personal physician.

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By Linda M. Toga, Esq.

It is that time of year when many people make vacation plans that involve flying or driving long distances or engaging in activities that are risker than their day to day activities. Whatever their vacation plans may include, being in a different environment, coupled with the risks associated with travel and the possibility that something could go very wrong, often provide the needed impetus for people to think about and address their estate planning needs. The urgency to complete a comprehensive estate plan prior to heading to the airport, interstate or cruise ship is even more pronounced if the people who are leaving on vacation have young children.

Since there is no “one size fits all” when it comes to estate planning, the process is not something that should be rushed or taken lightly. While I have prepared and supervised the execution of a client’s Will, healthcare proxy, power of attorney and living will hours before he left on a trip and within 24 hours of first meeting with the client to discuss his needs and goals, I do not suggest that approach. Instead, before vacation plans are made, I suggest that everyone who does not have an estate plan in place or who does not have a plan that reflects his/her current situation and goals, consult with an attorney experienced in estate planning.

There are many things that need to be considered when developing an estate plan, including but not limited to, whether it is best to create a trust or a Will, whether estate tax will be an issue, how and when assets are to be distributed and to whom, and who will serve as executor, trustee and/or guardian. In addition to thinking about what will happen upon death, people engaging in estate planning should think about who will have the authority to make healthcare decisions and handle financial transactions on their behalf while they are still alive should the need arise.

The decisions that go into creating an estate plan are often difficult and emotions can run high. Since the individuals who serve as executors, trustees, guardians and agents assume a great deal of responsibility, it is important to discuss your plans with these people in advance. Coming up with a plan that meets your needs and accomplishes your goal takes time, which brings me back to the fact that the process should not be done as you pack your bags for vacation. Before booking a trip, schedule an estate planning consultation. The peace of mind that comes from knowing your affairs are in order will make your vacation that much more enjoyable.

Linda M. Toga, Esq. provides legal services in the areas of litigation, estate planning and real estate from her East Setauket office.

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Obesity, regardless of blood pressure or cholesterol, increases risk

In my May 22 article, entitled “Detecting various heart attack symptoms,” I wrote about unusual symptoms that may indicate a myocardial infarction (heart attack) and the importance of knowing these atypical major symptoms beyond chest pain. This is not an easy task. I thought a good follow-up to that article would be one that focused on preventable risk factors.

The good news, as I mentioned previously, is that we have made great strides in reducing mortality from heart attacks. When we compare cardiovascular disease — heart disease and stroke — mortality rates from 1975 to the present, there is a substantial decline of approximately one-quarter. However, if we look at these rates since 1990, the rate of decline has slowed. (1)

Plus, one in 10 visits to the emergency room are related to potential heart attack symptoms. Luckily, only 10 to 20 percent of these patients actually are having a heart attack. (2)  We need to reduce our risk factors to improve this scenario.

Some risk factors are obvious. Others are not. The obvious ones include age (men at least 45 years old and women at least 55 years old), family history, high cholesterol, high blood pressure, obesity, sedentary lifestyle, diabetes, and smoking. Less obvious risk factors include gout, atrial fibrillation, and osteoarthritis. Lifestyle modifications, including a high-fiber diet and exercise, also may help allay the risks.

Let’s look at the evidence.

Obesity

On a board exam in medicine, if smoking is one of the choices with disease risk, you can’t go wrong by choosing it. Well, it appears that the same axiom holds true for obesity. But how substantial a risk factor is obesity? In the Copenhagen General Population Study, results showed an increased heart attack risk in obese (BMI >30 kg/m2) individuals with or without metabolic syndrome (high blood pressure, high cholesterol and high sugar) and in those who were overweight (BMI >25 kg/m2). (3)  The risk of heart attack increased in direct proportion to weight. Specifically, there was a 26 percent increase in heart attack risk for those who were overweight and an 88 percent increase in risk for those who were obese without metabolic syndrome. This study had a follow-up of 3.6 years.

It is true that those with metabolic syndrome and obesity together had the highest risk. But, it is quite surprising that obesity, by itself, can increase heart attack risk when a person is “metabolically healthy.” Since this was an observational trial, we can only make an association, but if it is true, then there may not be such thing as a “metabolically healthy” obese patient. Therefore, if you are obese, it is really important to lose weight.

Sedentary lifestyle

If obesity were not enough of a wake-up call, let’s look at another aspect of lifestyle: the impact of being sedentary. A recent observational study found that activity levels had a surprisingly high impact on heart disease risk. (4)  Of four key factors — weight, blood pressure, smoking and physical inactivity — age was the determinant as to which one had the most negative effect on women’s heart disease risk. Those under the age of 30 saw smoking as most negatively impactful. For those over the age of 30, lack of exercise became the most dominant risk factor for heart disease, including heart attacks.

For women over the age of 70, the study found that increasing physical activity may have a greater positive impact than addressing high blood pressure, losing weight, or even quitting smoking. However, since high blood pressure was self-reported and not necessarily measured in a doctor’s office, it may have been underestimated as a risk factor for heart disease. Nonetheless, the researchers indicated that women should make sure they exercise on a regular basis to most significantly reduce heart disease risk.

Osteoarthritis

The prevailing thought with osteoarthritis is that it is best to suffer with hip or knee pain as long as possible before having surgery. But when do we cross the line and potentially need joint replacement? Well, in a recent study, those with osteoarthritis of the hip or knee joints that caused difficulty walking on a flat surface were at substantially greater risk of cardiovascular events, including heart attack. (5)  Those who had surgery for the affected joint saw a substantially reduced heart attack risk. It is important to address the causes of osteoarthritis to improve mobility, whether with surgery or other treatments.

Gout

When we think of gout, we relate it to kidney stones. But gout increases the risk of heart attacks by 82 percent, according to an observational study. (6)  Gout tends to affect patients more when they are older, but the risk of heart attack with gout is greater in those who are younger, ages 45 to 69, than in those over 70. What can we do to reduce these risk factors?

There have been studies showing that fiber decreases the risk of heart attacks. However, does fiber still matter when someone has a heart attack? In a recent analysis using data from the Nurses’ Health Study and the Health Professional Follow-up Study, results showed that higher fiber plays an important role in reducing the risk of death after a heart attack. (7)  Those who consumed the most fiber, compared to the least, had a 25 percent reduction in post-heart attack mortality. Even more impressive is the fact that those who increased their fiber after the cardiovascular event had a 31 percent reduction in mortality risk. In this analysis, it seemed that more of the benefit came from fiber found in cereal. The most intriguing part of the study was the dose response. For every 10 g increase in fiber consumption, there was a 15 percent reduction in the risk of post-heart attack mortality. Since we get too little fiber anyway, this should be an easy fix.

Lifestyle modifications are so important. In the Nurses’ Health Study, which followed 120,000 women for 20 years, those who routinely exercised, ate a quality diet, did not smoke and were a healthy weight demonstrated a whopping 84 percent reduction in the risk of a cardiovascular events such as heart attacks. (8)

What have we learned? We can substantially reduce the risk of heart attacks and even potentially the risk of death after sustaining a heart attack with lifestyle modifications that include weight loss, physical activity, and diet — with, in this case, a focus on fiber. While there are a number of diseases that contribute to heart attack risk, most of them are modifiable. With disabling osteoarthritis, addressing the causes of difficulty with mobility may also help reduce heart attack risk.

References:

(1) Heart. 1998;81(4):380.  (2) JAMA Intern Med. 2014;174(2):241-249.  (3) JAMA Intern Med. 2014;174(1):15-22.  (4) Br J Sports Med. 2014, May 8. (5) Presented Research: World Congress on OA, 2014.  (6) Rheumatology (Oxford). 2013 Dec;52(12):2251-9.  (7) BMJ. 2014;348:g2659.  (8) N Engl J Med. 2000;343(1):16.

• If you would like to see a specific topic covered in Medical Compass, please email [email protected].

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website medicalcompassmd.com or consult your personal physician.

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Plan calls for homes for older folks at Terryville course

The Heatherwood Golf Club. Photo by Andrea Moore Paldy

Word that a retirement community is being proposed for Heatherwood Golf Club in Terryville brought residents out in full force to last Wednesday evening’s Port Jefferson Station/Terryville Civic Association meeting, where they raised concerns about density, increased traffic, storm drainage and sewage.

Doug Partrick, an owner of multifamily housing developer Heatherwood Communities, was at the meeting to present the plan for a 200-unit housing complex on the 70-acre property at Arrowhead Lane and Nesconset Highway.

His family has owned Heatherwood Golf Club since the 1960s but it “is no longer viable as a standalone,” he said. With fewer people golfing, the company — which also owns Pine Hills golf course in Manorville — “no longer can carry the golf course as it is without consideration for development.”

Partrick, architect Steven Hanson and engineer Michael Marinis propose to turn the 18-hole course into one with nine holes that would wrap around two-bedroom rental homes. The residences would be a combination of ranches, townhouses and first- and second-floor flats.

Of the golf course’s 70 acres, homes would be built on 25 acres and 45 acres would remain open space, Partrick said.

Hanson said the new homes would offer direct access to the course, which would act as a buffer between the development and the surrounding community, but that the course would remain open to the public.

Developer Doug Partrick talks about his proposed development for the Heatherwood Golf Club at a recent civic meeting. File photo by Andrea Moore Paldy
Developer Doug Partrick talks about his proposed development for the Heatherwood Golf Club at a recent civic meeting. File photo by Andrea Moore Paldy

Of particular concern to residents at the meeting was the fact that development on the golf course could violate the 2008 Comsewogue Hamlet Comprehensive Plan, a study and land-use plan for the area. According to Lou Antoniello, the civic association’s treasurer and chairperson for that hamlet study, the large majority of Port Jefferson Station and Terryville had already been built up at the time of the study, and surveys indicated that residents did not want the few remaining open spaces to be developed.

The study laid out the type of development locals wanted to see, and was geared toward preserving the area’s open space and history while creating a balance of living, shopping and cultural areas, Antoniello said. He sees that balance in jeopardy, as there are several senior housing communities already built or proposed.

MaryAnn Johnston, president of the Affiliated Brookhaven Civic Organization, an umbrella group of about 30 civic groups, said it would be a “waste and abuse of residents’ time and energy” if local development did not follow the guidelines of the study.

Councilwoman Valerie Cartright (D-Port Jefferson Station), who attended the civic meeting, said in a written statement that the study was “a reflection of the community’s vision” and that she continues “to support the desires of these residents” in her role on the town board.

Residents at the meeting also said they were concerned that the new project could exacerbate traffic problems on the already congested Nesconset Highway and asked about storm drainage and sewage from the property.

Heatherwood representatives said they have yet to conduct a traffic study, but have plans to handle drainage through the construction of ponds, and the 200 housing units would be hooked up to a county-owned sewage treatment plant.

Winning support from residents is only one of the difficulties facing the developer — overcoming zoning hurdles could be another. The property is currently zoned as A Residence 5, which allows one housing unit per 5 acres.

Asked what he would do if the development does not move forward, Partrick said he’d have to ask himself if he would be “better off consistently losing money on the golf course or … just shutting the golf course down, leaving it dormant” and paying taxes on the land.

Civic association leaders said they needed more information on the Heatherwood proposal before deciding whether to support it. However, an informal vote showed that most of those who attended the meeting opposed the development as it was presented.

Cartright advised residents to “listen and reflect on each of these individual proposals to determine what is in the best interest of the community and in line with their vision.”

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Even when most electronics aren’t functioning or are in sleep mode, they consume power. Leaving an inactive laptop long enough without charging it causes the battery to drain.

That’s not the case, however, with a developing technology called spintronics. Researchers are developing ways to use the spin of particles to operate DVR devices, smart phones and space technologies.

“The hope with spintronics is that you save the state and you won’t consume energy,” explained Javier Pulecio, a research associate in physics at Brookhaven National Laboratory. “When you turn it on, it’s instantly on. It has everything saved in its current position.” It is, Pulecio explained, like a refrigerator magnet, which stays magnetized.

Spintronic technology is still in the early stages of development, said Pulecio, with some significant fundamental hurdles to overcome before it will have widespread application in consumer electronics. One of the challenges is figuring out how to transport an electron’s spin over a longer distance, enabling it to become a useful carrier of a signal.

If scientists put an electron with a particular spin through a copper wire, the approximate distance the spin will stay polarized (or in the same state it was in when it entered the wire) is about 2 nanometers. In a normal conductor, the electron scatters, which causes the spin to change state or “flip.”

For perspective, an inch is 25,400,000 nanometers. The distance for that signal is “really tiny,” Pulecio said. “Current transistor technology is much larger than that.”

One possible solution is graphene, which is pure, two-dimensional carbon that is one atom thick. Graphene enables an electron to stay polarized for longer distances — microns instead of nanometers. It allows electrons to move without scattering, an activity known as ballistic transport.

Pulecio recently led a team that published a paper in Nature Communications that described how they created nanodevices with magnetic vortices in them. The configuration of the vortex is like a hurricane. It has a core, like the eye of a storm, with a circular magnetization around the center, like the clouds circling the eye.

He used two discs of different thicknesses but similar diameter on top of one another. This created orbits of spinning electrons of different sizes.

Even though the two discs had orbits that wanted to move differently, they synchronized through strong interactions to create a new orbit size during the motion. The electrons from the disc with the smaller-sized orbit were pulled out to an orbit that was closer to the larger one.

Pulecio’s mentor Dario Arena, a physicist in the photon sciences directorate at BNL, described the results in this experiment as “very promising.”

While Pulecio is still “quite young by the standards in the field,” Arena said “colleagues from other institutions have commented on how impressed they are with his results.”

Pulecio is studying other magnetic quasiparticles, such as skyrmions, which could lead to a reduction of the energy necessary to excite them by six orders of magnitude (or by a million times). He is interested in trying to bridge the fundamental science to its application. He hopes to contribute to creating smaller, more energy-efficient devices.

Arena explained that spintronics has current applications.

“Spintronics is not an abstract curiosity in the lab,” Arena said. “It is the foundation underpinning our advanced hard drives on computers. Even as more and more personal computers are moving toward solid-state hard drives, magnetic hard disk drives are finding an even more important application in cloud-based services such as Netflix, Dropbox, iCloud and many others.”

Arena said spintronic devices are marketed by companies such as Freescale, a spinoff of Motorola. While it isn’t currently used in consumer electronics, spintronics has found application in “harsh” environments where traditional semiconductor memory may have deficiencies, he said.

A resident of Wading River, Pulecio and his wife Alexandra, who is a science educator at BNL, welcomed a son, Xavier John, to their family eight months ago.

Born in Chicago and raised in Tampa, Fla., Pulecio said he enjoys mountain biking and fishing in and around Long Island. Pulecio’s mother Catalina, who grew up in Colombia, came to the United States because she saw greater opportunities for her family.

She didn’t speak English well when she arrived and made considerable sacrifices, he said. For his siblings and him, it was never a question of if they were going to college, but when and where.

Pulecio said he appreciates the opportunities he has at BNL. “My group leader Yimei Zhu and mentor Dario Arena have provided me with amazing support and guidance,” he said. “Our ability to understand, alter and control material at the atomic level makes this a truly exciting time to be a scientist.”

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