Health

Al Kirby, right, and his wife, Dawn, look on as Dr. Henry Tannous donates blood. Photo from Stony Brook Medicine

Stony Brook University Hospital doctors and staff members joined a Marine veteran to get a head start on National Blood Donor Month, which runs through January.

“Today is a good reminder of how we can all join together in turning a catastrophic event into a remarkable get together with a lot of potential to save numerous lives.”

— Dr. Henry Tannous

At a Dec. 23 press conference at the hospital, Al Kirby, 52, announced a blood drive to show his gratitude to SBUH doctors and staff members. The Shirley resident’s life was saved Christmas Day 2018 at Stony Brook after 10 hours of surgery where 27 units of blood were needed. Kirby’s doctors, wife, children, friends and family members joined him for the announcement.

“Today is a good reminder of how we can all join together in turning a catastrophic event into a remarkable get together with a lot of potential to save numerous lives,” said Dr. Henry Tannous, co-director of the Stony Brook University Heart Institute and chief of the Division of Cardiothoracic Surgery.

According to SBUH officials, one blood donation can potentially save three lives.

“This crucial act of kindness will allow more families like the Kirbys to spend more holidays together,” Tannous said.

Kirby was loading up his car with gifts after a visit to his in-law’s house when he felt an intense stabbing pain in his chest, a rapid heartbeat and a burning sensation in his throat. His wife, Dawn Kirby, called 911 and asked the emergency responders to bring her husband to SBUH. His wife after the press conference said she credits the doctors and those who donated blood for saving her husband’s life and is grateful for his recovery.

“Every day is like Christmas,” she said.

Emergency department providers and the Heart Institute’s Cardiac Catheterization Lab’s team ruled out a coronary blockage and discovered Al Kirby had a severe aortic dissection. It took seven hours in the operating room for doctors to repair the rupture of his main aortic vessel. The procedure also prevented further dissection. The seven-hour operation was followed by another three hours to stop the internal bleeding.

“To me, the doctors are gods here and the staff are beyond angels, because of you I’m alive.”

— Al Kirby

Tannous said the medical team didn’t let their guard down and pushed on until they found a diagnosis. For the operation, he said medical staff members had to leave their families abruptly, and the cardiovascular operating room team worked tirelessly through the night.

“A 9 hour and 52 minutes surgery is surely a test of what’s humanly possible,” Tannous said.

The doctor said the blood bank was a “powerful ally” that had the operating room team’s backs. He added that if one link was missing in the system, the operation wouldn’t have been as successful as it was. Half of those who suffer from the same medical condition die within 24 hours.

Dr. Puja Parikh, interventional cardiologist and co-director of the Transcatheter Aortic Valve Replacement Program at SBU Heart Institute, said that since the surgery she has been working with Kirby on controlling his blood pressure and that he is doing well. Uncontrolled blood pressure and underlying aortic aneurysms are risk factors of the condition, even though it’s not known what caused the veteran’s medical emergency.

Kirby said the staff has increased the size of his family.

“To me, the doctors are gods here and the staff are beyond angels, because of you I’m alive, and I thank all of you for donating blood, which allowed someone like me … to be here speaking today,” Kirby said.

After the press conference, the veteran’s family and Stony Brook Medicine team members headed to the blood bank to donate where Tannous was the first to roll up his sleeves.

For more information on how to donate to the Stony Brook Blood Bank, call 631-444-3662 or visit www.stonybrookmedicine.edu/patientcare/bloodbank.

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Maintaining your mobility is crucial
Dr. David Dunaief

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). We need to reduce our risk factors to improve this scenario.

Some risk factors are obvious. Others are not. 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 ones include gout, atrial fibrillation and osteoarthritis. Lifestyle modifications, including a high-fiber diet and exercise, may help allay the risks.

Let’s look at the evidence.

Obesity

Obesity continually gets play in discussions of disease risk. But how substantial a risk factor is it?

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) (2). 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 a 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. An observational study found that activity levels had a surprisingly high impact on women’s heart disease risk (3). Of four key factors — weight, blood pressure, smoking and physical inactivity — age was the determinant as to which one had the most negative effect. 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. 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 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. (4) 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.

Fiber

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 (5).  

Those who consumed the most fiber, compared to the least, had a 25 percent reduction in post-heart attack mortality. Even more impressive is 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 cardiovascular events such as heart attacks (6).

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(1):15-22. (3) Br J Sports Med. 2014, May 8. (4) PLoS ONE. 2014, Mar 14, 2014 [https://doi.org/10.1371/journal.pone.0091286]. (5) BMJ. 2014;348:g2659. (6) N Engl J Med. 2000;343(1):16.

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, visit www.medicalcompassmd.com.    

After experiencing a stroke, Denise woke up to a shower of get well trinkets, flowers and balloons, but there was one item that stuck out to her the most − a handmade card that she could tell was crafted by a child. “The greeting card really made her day. It made her smile and brought her joy,” said her daughter, Nicole Wozny.

Wozny is an art educator at Park View Elementary School in Kings Park. Inspired by the greetings cards, the teacher decided to connect with the local hospital close to the school − St. Catherine of Siena Medical Center in Smithtown. She wanted to continue the same momentum by encouraging local students to participate in the art of healing by creating special holiday greeting cards to be distributed during key holidays in December.

“What an amazing feeling for my students to get the chance to enjoy the true meaning of the holidays by sharing their art,” said Wozny.

Many scholars and educators support art in schools as it has been demonstrated to improve self-esteem and confidence as well as cultivate empathy. While the holiday season is considered the most wonderful time of the year, it can be difficult for those healing and recovering in a hospital.

 “I thought how nice it would be, especially for patients who have no one visiting them or thinking of them,” said Wozny. “If every patient experiences a moment of joy from receiving a card − just as I know my mother did − our mission was accomplished.”

 The month-long Park View Greeting Project resulted in the creation of 400 cards, crafted by all the elementary students who were given creative range to inspire patients. 

Third-grade student council member Stella Roosa was thrilled to participate in the project coordinated by their art teacher. “I feel so happy to be able to do something for people − the cards are as special as they are,” said Stella. Another third-grade student council member, Owen Dorsey, added, “This was the best opportunity.” 

“At Park View Elementary we are committed to teaching students about service − so this project was aligned with our educational mission to teach the students to care for their community,” said Principal Kevin Storch. “This project cultivates service and kindness.” 

Park View Student Council students, Stella Roosa, Cassandra Chapman, Alexandra Faralan, Michael Reznick, Gabrielle Keaveny, Faith Hanley, Owen Dorsey, Ella Vicinanza, Samantha Katz, Dylan Schor, Lilah Goldman and Jack Krupp, along with Storch, Wozny and educators Traci Smith and Dana Farrell, delivered the cards on Dec. 13, just in time for the holiday season. 

 “We are very grateful to Mrs. Wozny and all the students at Park View Elementary School,” said St. Catherine of Siena’s President Jim O’Connor. “Their thoughtfulness and inspiring greetings will go a long way in lifting our patients’ spirits, bringing this special season alive through a heartfelt greeting card.”

Pictured with the students, from left, Park View staff member Carol Liguori; Park View Elementary School Principal Kevin Storch; art teacher Nicole Wozny; Park View teachers Dana Farrell and Traci Smith; St. Catherine of Siena’s President Jim O’Connor; St. Catherine of Siena’s Chief Medical Officer Mickel Khlat; and St. Catherine’s Community Outreach Coordinator John Perkins.

Photos courtesy of St. Catherine’s Medical Center

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Katherine Lewin with her newborn son Jonathan at St. Charles Hospital's new maternity wing. Photo by Kyle Barr

St. Charles Hospital’s nearly $4 million new maternity wing has one thing at the top of the mind, privacy.

St. Catherines officials cut the ribbon on the new maternity wing. Photo by Kyle Barr

At a ribbon cutting for the new renovated 16-room maternal/child pavilion Dec. 19, hospital officials boasted rooms with “hotel-like atmosphere,” that focus on letting families stay together with their newborn in relative quiet.

“Today the standard in the community is probably for privacy for mothers, because now their husbands stay with them, so you need to have more people in the room,” said Jim O’Connor, the president of St. Charles Hospital.

O’Connor said the new wing cost around $3.8 million, most of which came from the hospital’s capital budget, and took around 10 months to build. During that time patients were moved to the 3-West wing, in order to avoid the disturbance of construction for the doctors, nurses and patients.

The hospital’s foundation and auxiliary contributed about $500,000 to the construction, said Lisa Mulvey, executive director of the hospital’s foundation. Funds were raised through trustees and events such as their annual golf outing and spring luncheons. The end result, she said, was well worth it.

“It’s beautiful,” Mulvey said. “I couldn’t have pictured something more beautiful.”

Each room features new beds and more accommodations for person’s significant others with new sofa chairs and larger, walk-in showers. The rooms also include more modern isolettes for newborn children.

One of the new rooms at St. Catherine Hospital maternal unit. Photo by Kyle Barr

Dr. Jerry Ninia, the director of obstetrics and gynecology at the hospital, said the new wing’s technology helps in emergencies, but it’s always moreso the staff involved.

“It goes beyond the nice showers and the nice digs, so to speak,” he said. “It helps the staff, it’s always nice to work in a nice facility.”

The wing officially opened about three weeks ago, and patients are already making use of the facilities.

Ed Casper, an architect from Stantec engineering company that worked on the new wing, said just that morning he had become a grandfather, his grandson being born right there in the new wing.

“Our experience through the night last night was absolutely phenomenal,” he said.

One of the first children to be born in the new maternity ward was young Jonathan Lewin, less than a week old. His sparse, brown hair is already as long as thumbtacks. His mother, Katherine Lewin, 31, a nurse from Wading River, said her care there was “excellent, everyone here is great.”

She is excited to take her new son home, where she expects her 2 ½ year-old daughter is excited to be a sister.

“She asked if she could bring him home,” Lewin said.

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The Comsewogue School District has added its name to the list of districts that are standing up to New York State on a proposal that would mandate the HPV vaccine in state schools. 

The proposed amendment to Section 2164 of the public health law would require that all students born after 2009 receive the human papillomavirus vaccine as part of the state’s mandated school immunization program.

In a letter sent to Gov. Andrew Cuomo (D), Dec. 6, the district detailed its stance on the matter. 

“While the vaccination may be helpful in preventing certain forms of cancer, the choice as to whether to have children vaccinated should be made by parents in consultation with their physician,” John Swenning, board president, said in the letter. 

The HPV vaccine is designed to prevent cancer-causing infections, but several school districts including Shoreham-Wading River and Three Village have written letters similar to Comsewogue’s saying it is unnecessary.

In a letter signed by the school board and superintendent, SWR said they did not believe it was necessary for a vaccine for something not usually transmitted in schools.

“The HPV vaccination has historically been a parental decision, is not transmitted in schools, lacks the full support of the medical community and would require schools to enforce a widely unpopular mandate by excluding children,” the letter stated. “It should not be adopted.”

The Comsewogue School district went on to say the activities that cause this spread of HPV should not be occurring on school grounds, and HPV is not a public health risk in the school setting. They also said that if this bill passes, it will preclude children from being able to access a public school education.

In addition to the letter, Comsewogue district board held a workshop Dec. 5 to discussed the proposed mandate.

Superintendent Jennifer Quinn said the feeling she got from speaking with local officials is that the proposed mandate will not likely pass, but is still concerned about what it could potentially mean for students and parents in the district. 

“They told me that it is not happening,” she said. “I’m concerned that the other immunization changes happened so fast … that this might pass at the 11th hour, which could happen. It has been a little hard to predict lately.”

Quinn and other board members urged parents to reach out to local lawmakers. 

“It’s our kids, I don’t know if it’s the right thing to do but they’re telling you what they can put in their bodies,” Swenning said. 

Parents in attendance also brought up how the mandate could harm immunocompromised children, who can’t take certain vaccines and how the state may take away exemptions for the HPV vaccine. Current vaccine mandates exempt people who are immunocompromised.

Others were concerned the mandate would take away a parent’s prerogative and choice whether or not their child would get the vaccine. 

School officials also brought up the possibility of setting up a legislative committee session between elected officials and residents.

The main symptom of a heart attack is chest pain. Stock photo
As many as 35 percent of heart attacks may present without chest pain

By David Dunaief, M.D.

Dr. David Dunaief

Heart disease is the most common chronic disease in America. When we refer to heart disease, it is an umbrella term; heart attacks are one component. 

Fortunately, the incidence of heart attacks has decreased over the last several decades, as have deaths from heart attacks. However, there are still 790,000 heart attacks every year, and almost three-quarters of these are first heart attacks (1).

If you think someone is having a heart attack, call 911 as quickly as possible and have the patient chew an adult aspirin (325 mg) or four baby aspirins. While the Food & Drug Administration does not recommend aspirin for primary prevention of a heart attack, the use of aspirin here is for treatment of a potential heart attack, not prevention.

Heart attack symptoms

The main symptom is chest pain, which most people don’t have trouble recognizing. However, there are a number of other, more subtle, symptoms such as discomfort or pain in the jaw, neck, back, arms and epigastric, or upper abdominal areas. Others include nausea, shortness of breath, sweating, light-headedness and tachycardia (racing heart rate). One problem is that less than one-third of people know these other major symptoms (2). About 10 percent of patients present with atypical symptoms — without chest pain — according to one study (3).

It is not only difficult for the patient but also for the medical community, especially the emergency room, to determine who is having a heart attack. Fortunately, approximately 80 to 85 percent of chest pain sufferers are not having a heart attack. More likely, they have indigestion, reflux or other non-life-threatening ailments.

There has been a raging debate about whether men and women have different symptoms when it comes to heart attacks. Several studies speak to this topic.

Men vs. women

There is data showing that, although men have heart attacks more commonly, women are more likely to die from a heart attack (4). In a Swedish prospective (forward-looking) study, after having a heart attack, a significantly greater number of women died in hospital or near-term when compared to men. The women received reperfusion therapy, artery opening treatment that consisted of medications or invasive procedures, less often than the men.

However, recurrent heart attacks occurred at the same rate, regardless of sex. Both men and women had similar findings on an electrocardiogram; they both had what we call ST elevations. This was a study involving approximately 54,000 heart attack patients, with one-third of them being women.

One theory about why women are treated less aggressively when first presenting in the ER is that they have different and more subtle symptoms — even chest pain symptoms may be different. Women’s symptoms may include pain in the lower portion of the chest or upper portion of the abdomen and may have significantly less severe pain that could radiate or spread to the arms. But, is this true? Not according to several studies.

In one observational study, results showed that, though there were some subtle differences in chest pain, on the whole, when men and women presented with this main symptom, it was of a similar nature (5). There were 34 chest pain characteristic questions used to determine if a difference existed. These included location, quality or type of pain and duration. Of these, there was some small amount of divergence: The duration was shorter for a man (2 to 30 minutes), and pain subsided more for men than for women. The study included approximately 2,500 patients, all of whom had chest pain. The authors concluded that determination of heart attacks with chest pain symptoms should not factor in the sex of patients.

This trial involved an older population; patients were a median age of 70 for women and 59 for men, with more men having had a prior heart attack. The population difference was a conspicuous weakness of an otherwise solid study, since age and previous heart attack history are important factors.

In the GENESIS-PRAXY study, another observational study, but with a younger population, the median age of both men and women was 49. Results showed that chest pain remained the most prevalent presenting symptom in both men and women (6). However, of the patients who presented without distinct chest pain and with less specific EKG findings (non-ST elevations), significantly more were women than men. Those who did not have chest pain symptoms may have had some of the following symptoms: back discomfort; weakness; discomfort or pain in the throat, neck, right arm and/or shoulder; flushing; nausea; vomiting; and headache.

If the patients did not have chest pain, regardless of sex, the symptoms were diffuse and nonspecific. The researchers were looking at acute coronary syndrome, which encompasses heart attacks. In this case, independent risk factors for disease not related to chest pain included both tachycardia (rapid heart rate) and being female. The authors concluded that there need to be better ways to calibrate non-chest pain symptoms.

Some studies imply that as much as 35 percent of patients do not present with chest pain as their primary complaint (7).

Let’s summarize

So what have we learned about heart attack symptoms? The simplest lessons are that most patients have chest pain, and that both men and women have similar types of chest pain. However, this is where the simplicity stops and the complexity begins. The percentage of patients who present without chest pain seems to vary significantly depending on the study — ranging from less than 10 percent to 35 percent.

Non-chest pain heart attacks have a bevy of diffuse symptoms, including obscure pain, nausea, shortness of breath and light-headedness. This is seen in both men and women, although it occurs more often in women. When it comes to heart attacks, suspicion should be based on the same symptoms for both sexes. Therefore, know the symptoms, for it may be your life or a loved one’s that depends on it.

References:

(1) cdc.gov. (2) MMWR. 2008;57:175–179. (3) Chest. 2004;126:461-469. (4) Int J Cardiol. 2013;168:1041-1047. (5) JAMA Intern Med. 2014 Feb. 1;174:241-249. (6) JAMA Intern Med. 2013;173:1863-1871. (7) JAMA 2012;307:813-822.

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, visit www.medicalcompassmd.com.  

District Hires Environmental Firm to Test Middle School

Northport district officials have found an alternative location for its bus depot. Photo from Close Northport MS Facebook page

In response to a Nov. 20 TBR News Media article that uncovered that the Northport-East Northport school district was in violation of laws governing petroleum bulk storage, district officials announced at the Dec. 12 board meeting that they found a new bus depot and refueling location.

“We have found an alternate location and the resolution would allow the school board to enter negotiations to finalize that work with Cavay’s [Building & Lumber Supply] on Brightside Ave.,” Robert Banzer, superintendent of schools, said.

Over the last several weeks, the district addressed its violations with the Suffolk County Health Department and officials there said that the site was reinspected without violations found.

A separate resolution unanimously passed that would allow the district to utilize the fueling facilities operated by the Village of Northport for its bus fleet and maintenance.

“We are still seeking other possible methods of fueling, including [reaching out to] some of our other municipalities. We have reached out to them and they are considering it, “ Banzer said. “By January we should have this [relocation] in motion, if not sooner.”

Other highlights of the meeting include the board approving the subcommittee’s recommendations in hiring PW Grosser Consulting, a Bohemia-based environmental firm to begin framing a soil testing plan for the Northport Middle School. The firm would recommend soil testing parameters to the district beginning sometime in January.

The subcommittee members said that the firm could come do an initial walk-through of the building as early as later that week and would do other work throughout the winter break when students aren’t in school.

The announcements were made just days after students were again evacuated from several classrooms in the middle school after children were overcome by fumes.

A parent of a middle school student who spoke at the meeting said that children should be moved out of the school while testing is being done.

“We are very concerned, we need an answer ourselves on how this [testing] is going to happen,” he said. “The safe alternative is that they [the students] leave the school, and you do your testing.”

Subcommittee member Lauren Handler said as a group they haven’t discussed that as an official topic but agreed that the kids shouldn’t be in the building when they don’t know if its safe.

No vote was formally conducted on that issue.

State and county health officials have stated that the school board has jurisdiction over air quality at the school and not health officials.

The subcommittee plans to meet each Monday, beginning Jan. 6 or 13 of next year.

 

Studies have shown that eating fresh fruit and cinnamon may be beneficial to diabetics. Stock photo
Fresh fruit and cinnamon may reduce risk

By David Dunaief, M.D.

Dr. David Dunaief

What causes Type 2 diabetes? It would seem like an obvious answer: obesity, right? Well, obesity is a contributing factor but not necessarily the only factor. This is important because the prevalence of diabetes is at epidemic levels in the United States, and it continues to grow. The latest statistics show that about 12.2 percent of the U.S. population aged 18 or older has Type 2 diabetes, and about 9.4 percent when factoring all ages (1).

Not only may obesity play a role, but sugar by itself, sedentary lifestyle and visceral (abdominal) fat may also contribute to the pandemic. These factors may not be mutually exclusive, of course.

We need to differentiate among sugars, because form is important. Sugar and fruit are not the same with respect to their effects on diabetes, as the research will help clarify. Sugar, processed foods and sugary drinks, such as fruit juices and soda, have a similar effect, but fresh fruit does not.

Sugar’s impact

Sugar may be sweet, but it also may be a bitter pill to swallow when it comes to its effect on the prevalence of diabetes. In an epidemiological (population-based) study, the results show that sugar may increase the prevalence of Type 2 diabetes by 1.1 percent worldwide (2). This seems like a small percentage, however, we are talking about the overall prevalence, which is around 9.4 percent in the U.S., as we noted above.

Also, the amount of sugar needed to create this result is surprisingly low. It takes about 150 calories, or one 12-ounce can of soda per day, to potentially cause this rise in diabetes. This is looking at sugar on its own merit, irrespective of obesity, lack of physical activity or overconsumption of calories. The longer people were consuming sugary foods, the higher the incidence of diabetes. So the relationship was a dose-dependent curve. Interestingly, the opposite was true as well: As sugar was less available in some countries, the risk of diabetes diminished to almost the same extent that it increased in countries where it was overconsumed.

In fact, the study highlights that certain countries, such as France, Romania and the Philippines, are struggling with the diabetes pandemic, even though they don’t have significant obesity issues. The study evaluated demographics from 175 countries, looking at 10 years’ worth of data. This may give more bite to municipal efforts to limit the availability of sugary drinks. Even steps like these may not be enough, though. Before we can draw definitive conclusion from the study, however, there need to be prospective (forward-looking) studies.

Effect of fruit

The prevailing thought has been that fruit should only be consumed in very modest amounts in patients with — or at risk for — Type 2 diabetes. A new study challenges this theory. In a randomized controlled trial, newly diagnosed diabetes patients who were given either more than two pieces of fresh fruit or fewer than two pieces had the same improvement in glucose (sugar) levels (3). Yes, you read this correctly: There was a benefit, regardless of whether the participants ate more fruit or less fruit.

This was a small trial with 63 patients over a 12-week period. The average patient was 58 and obese, with a body mass index of 32 (less than 25 is normal). The researchers monitored hemoglobin A1C (HbA1C), which provides a three-month mean percentage of sugar levels.

It is very important to emphasize that fruit juice and dried fruit were avoided. Both groups also lost a significant amount of weight while eating fruit. The authors, therefore, recommended that fresh fruit not be restricted in diabetes patients.

What about cinnamon?

It turns out that cinnamon, a spice many people love, may help to prevent, improve and reduce sugars in diabetes. In a review article, the authors discuss the importance of cinnamon as an insulin sensitizer (making the body more responsive to insulin) in animal models that have Type 2 diabetes (4).

Cinnamon may work much the same way as some medications used to treat Type 2 diabetes, such as GLP-1 (glucagon-like peptide-1) agonists. The drugs that raise GLP-1 levels are also known as incretin mimetics and include injectable drugs such as Byetta (exenatide) and Victoza (liraglutide). In a study with healthy volunteers, cinnamon raised the level of GLP-1 (5). Also, in a randomized control trial with 100 participants, 1 gram of cassia cinnamon reduced sugars significantly more than medication alone (6). The data is far too preliminary to make any comparison with FDA-approved medications. However, it would not hurt, and may even be beneficial, to consume cinnamon on a regular basis.

Sedentary lifestyle

What impact does lying down or sitting have on diabetes? Here, the risks of a sedentary lifestyle may outweigh the benefits of even vigorous exercise. In fact, in a recent study, the authors emphasize that the two are not mutually exclusive in that people, especially those at high risk for the disease, should be active throughout the day as well as exercise (7).

So in other words, the couch is “the worst deep-fried food,” as I once heard it said, but sitting at your desk all day and lying down also have negative effects. This coincides with articles I’ve written on exercise and weight loss, where I noted that people who moderately exercise and also move around much of the day are likely to lose the greatest amount of weight.

As a medical community, it is imperative that we reduce the trend of increasing prevalence by educating the population, but the onus is also on the community at large to make lifestyle changes. So America, take an active role.

References:

(1) www.cdc.gov/diabetes. (2) PLoS One. 2013;8(2):e57873. (3) Nutr J. published online March 5, 2013. (4) Am J Lifestyle Med. 2013;7(1):23-26. (5) Am J Clin Nutr. 2007;85:1552–1556. (6) J Am Board Fam Med. 2009;22:507–512. (7) Diabetologia online March 1, 2013.

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, visit www.medicalcompassmd.com.      

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Speedy diagnosis and treatment improves outcomes

By David Dunaief, M.D.

Dr. David Dunaief

TIA (transient ischemic attack) is sometimes referred to as a “mini-stroke.” This is a disservice since it makes a TIA sound like something that should be taken lightly. Ischemia is reduced or blocked blood flow to the tissue, due to a clot or narrowing of the arteries. Symptoms may last less than five minutes. However, a TIA is a warning shot across the bow that needs to be taken very seriously on its own. It may portend life-threatening or debilitating complications that can be prevented with a combination of medications and lifestyle modifications.

Is TIA common?

It is diagnosed in anywhere from 200,000 to 500,000 Americans each year (1). The operative word is “diagnosed,” because it is considered to be significantly underdiagnosed. I have helped manage patients with symptoms as understated as the onset of double vision. Other symptoms may include facial or limb weakness on one side, slurred speech or problems comprehending others, dizziness or difficulty balancing or blindness in one or both eyes (2). TIA incidence increases with age (3).

What is a TIA?

It is a brief episode of neurological dysfunction caused by focal brain ischemia or retinal ischemia (low blood flow in the back of the eye) without evidence of acute infarction (tissue death) (4). In other words, TIA has a rapid onset with potential to cause temporary muscle weakness, creating difficulty in activities such as walking, speaking and swallowing, as well as dizziness and double vision.

Though they are temporary, TIAs have potential complications, from increased risk of stroke to heightened depressive risk to even death. Despite the seriousness of TIAs, patients or caregivers often delay receiving treatment.

Stroke risk

A TIA is a stroke that lasts only a few minutes.
Stock photo

After a TIA, stroke risk goes up dramatically. Even within the first 24 hours, stroke risk can be 5 percent (5). According to one study, the incidence of stroke is 11 percent after seven days, which means that almost one in 10 people will experience a stroke after a TIA (6). Even worse, over the long term, the probability that a patient will experience a stroke reaches approximately 30 percent, one in three, after five years (7).

The EXPRESS study, a population-based study that considered the effect of urgent treatment of TIA and minor stroke on recurrent stroke, evaluated 1,287 patients, comparing their initial treatment times after experiencing a TIA or minor stroke and their subsequent outcomes (8).

The Phase 1 cohort was assessed within a median of three days of symptoms and received a first prescription within 20 days. In Phase 2, median delays for assessment and first prescription were less than one day. All patients were followed for two years after treatment. Phase 2 patients had significantly improved outcomes over the Phase 1 patients. Ninety-day stroke risk was reduced from 10 to 2 percent, an 80 percent improvement.

The study’s authors advocate for the creation of TIA clinics that are equipped to diagnose and treat TIA patients to increase the likelihood of early evaluation and treatment and decrease the likelihood of a stroke within 90 days. The moral of the story is: Treat a TIA as a stroke should be treated, the faster the diagnosis and treatment, the lower the likelihood of sequalae, or complications.

Predicting the risk of stroke

Both DWI (diffusion-weighted imaging) and ABCD2 are potentially valuable predictors of stroke after TIA. The ABCD2 is a clinical tool used by physicians. ABCD2 stands for Age, Blood pressure, Clinical features and Diabetes, and it uses a scoring system from 0 to 7 to predict the risk of a stroke within the first two days of a TIA (9).

Heart attack

In one epidemiological study, the incidence of a heart attack after a TIA increased by 200 percent (10). These were patients without known heart disease. Interestingly, the risk of heart attacks was much higher in those over 60 years of age and continued for years after the event. Just because you may not have had a heart attack within three months after a TIA, this is an insidious effect; the average time frame for patients was five years from TIA to heart attack.

Mortality

TIAs decrease overall survival by 4 percent after one year, by 13 percent after five years and by 20 percent after nine years, especially in those over age 65 (11). The reason younger patients had a better survival rate, the authors surmise, is that their comorbidity (additional diseases) profile was more favorable.

Depression

In a cohort study that involved over 5,000 participants, TIA was associated with an almost 2.5-times increased risk of depressive disorder (12). Those who had multiple TIAs had a higher likelihood of depressive disorder. Unlike with stroke, in TIA it takes much longer to diagnose depression, about three years after the event.

What can you do?

Awareness and education are important. While 67 percent of stroke patients receive education about their condition, only 35 percent of TIA patients do (13). Many risk factors are potentially modifiable, with high blood pressure being at the top of the list, as well as high cholesterol, increasing age (over 55) and diabetes.

Secondary prevention (preventing recurrence) and prevention of complications are similar to those of stroke protocols. Medications may include aspirin, antiplatelets and anticoagulants. Lifestyle modifications include a Mediterranean and DASH diet combination. Patients should not start an aspirin regimen for chronic preventive use without the guidance of a physician.

If you or someone you know has TIA symptoms, the patient needs to see a neurologist and a primary care physician and/or a cardiologist immediately for assessment and treatment to reduce risk of stroke and other long-term effects.

References:

(1) Stroke. Apr 2005;36(4):720-723; Neurology. May 13 2003;60(9):1429-1434. (2) mayoclinic.org. (3) Stroke. Apr 2005;36(4):720-723. (4) N Engl J Med. Nov 21 2002;347(21):1713-1716. (5) Neurology. 2011 Sept 27; 77:1222. (6) Lancet Neurol. Dec 2007;6(12):1063-1072. (7) Albers et al., 1999. (8) Stroke. 2008;39:2400-2401. (9) Lancet. 2007;9558;398:283-292. (10) Stroke. 2011; 42:935-940. (11) Stroke. 2012 Jan;43(1):79-85. (12) Stroke. 2011 Jul;42(7):1857-1861. (13) JAMA. 2005 Mar 23;293(12):1435.

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, visit www.medicalcompassmd.com.    

Peter Scully, Suffolk County deputy county executive and water czar, responds to questions from  TBR News Media’s editorial staff:

1. You’ve been called Suffolk County’s water czar. Why does Suffolk County need a water czar?

The need for the county to have a high-level point person to advance the water quality agenda of County Executive Steve Bellone [D] is a result of two factors: The high priority that the county executive has placed on water quality issues, and the tremendous progress his administration has made over the past seven years in building a solid foundation to reverse decades of nitrogen pollution that has resulted primarily from the lack of sewers in Suffolk County and reliance on cesspools and septic systems that discharge untreated wastewater into the environment. The county executive succeeded in landing $390 million in post-Hurricane Sandy resiliency funding to eliminate 5,000 cesspools along river corridors on the South Shore by connecting parcels to sewers, and the county’s success in creating a grant program to make it affordable for homeowners to replace cesspools and septic systems with new nitrogen-reducing septic systems in areas where sewers are not a cost-effective solution, prompted the state to award Suffolk County $10 million to expand the county’s own Septic Improvement Program. These are the largest investments in water quality Suffolk has seen in 50 years, and the county executive saw the need to appoint a high-level quarterback to oversee the implementation of these programs.

 

2. Which groundwater contaminants are the highest priorities for Suffolk County? 

In 2014, the county executive declared nitrogen to be water quality public enemy No. 1. The nitrogen in groundwater is ultimately discharged into our bays, and about 70 percent of this nitrogen comes from on-site wastewater disposal (septic) systems. Excess nutrients have created crisis conditions, causing harmful algal blooms, contributing to fish kills and depleting dissolved oxygen necessary for health aquatic life. They have also made it impossible to restore our once nationally significant hard clam and bay scallop fisheries, have devastated submerged aquatic vegetation and weakened coastal resiliency through reduction of wetlands. Nitrogen also adversely impacts quality of drinking water, especially in areas with private wells, although public water supply wells consistently meet drinking water standards for nitrogen.

Other major contaminants of concern include volatile organic compounds, known as VOCs. For example, there is perchloroethlyene, historically from dry cleaners; and petroleum constituents — most recently MTBE, a gasoline additive — from fuel storage and transfer facilities.

Then there are pesticides. Active ingredients such as chlordane, aldicarb and dacthal have been banned, but some legacy contamination concerns exist, especially for private wells. Some currently registered pesticides are appearing in water supplies at low levels, including simazine/atrazine, imidacloprid and metalaxyl.

Emerging contaminants include PFAS, historically used in firefighting foams, water repellents, nonstick cookware; and 1,4-dioxane, an industrial solvent stabilizer also present at low levels in some consumer products. 

 

3. Are the chemicals coming from residential or industrial sites?

Contamination can emanate from a variety of sites, including commercial, industrial and residential properties. Many of the best-known cleanup sites are dealing with legacy impacts from past industrial activity. Examples include Grumman in Bethpage, Lawrence Aviation in Port Jefferson Station, Brookhaven National Laboratory in Upton and the Naval Weapons Industrial Reserve Plant in Calverton. There have been hundreds of Superfund sites on Long Island. Fortunately, most are legacy sites and new Superfund sites are relatively rare.

More recently, the use of firefighting foam has resulted in Superfund designations at the Suffolk County Firematics site in Yaphank, Francis S. Gabreski Air National Guard Base in Westhampton, and East Hampton Airport. The foam was used properly at the time of discharge, but it was not known that PFAS would leach and contaminate groundwater.

The county’s 2015 Comprehensive Water Resources Management Plan found that some chemicals, such as VOCs, continue to increase in frequency of detection and concentration. While some of this is attributable to legacy industrial plumes, experts believe that residential and small commercial sites are partially responsible for contamination. This is partly because any substances that are dumped into a toilet or drain will reach the environment, and because solvents move readily through our sandy aquifer. Septic waste is, of course a major of contamination. Residential properties can be also responsible for other pollution, such as nitrogen from fertilizers and pesticides.

4. Which industries currently generate the most groundwater pollution in Suffolk County? 

The county’s Department of Health Services Division of Environmental Quality staff advise that, historically, the major contributors to groundwater pollution in the county were dry cleaners, and fuel storage and transfer facilities. However, current dry cleaning practices have minimized any possible groundwater discharges, and modern fuel facilities are engineered to more stringent code requirements that have substantially eliminated catastrophic releases. Low-level discharges are still a concern, and are the subject of the county’s VOC action plan to increase inspections and optimize regulatory compliance.

There are thousands of commercial and industrial facilities, most of which have the potential to pollute — for example, with solvent cleaners. Best management practices and industrial compliance inspections are key to minimizing and eliminating further contamination.

 

5. The word “ban” is often a dirty word in politics, but do you see benefits to banning certain products, and/or practices, for the sake of protecting the county’s drinking water supply? (The bans on DDT, lead in gasoline and HFCS, for example, were very effective at addressing environmental and human health concerns.) 

Policymakers have not hesitated to ban the use of certain substances — DDT, lead in gasoline, chlordane, MTBE — in the face of evidence that the risks associated with the continued introduction of a chemical into the environment outweigh the benefits from a public health or environmental standpoint. Based on health concerns, I expect that there will be active discussion in the years ahead about the merits of restricting the use of products that introduce emerging contaminants like 1,4-dioxane and PFCs into the environment.

 

6. If people had more heightened awareness, could we slow or even eliminate specific contaminants? As consumers, can people do more to protect groundwater? 

There is no question that heightened awareness about ways in which everyday human activities impact the environment leads people to change their behaviors in ways that can reduce the release of contaminants into the environment. A good example is the county’s Septic Improvement Program, which provides grants and low interest loans for homeowners who choose to voluntarily replace their cesspools or septic systems with new nitrogen-reducing technology. More than 1,000 homeowners have applied for grants under the program, which set a record in October with more 100 applications received.

If a home is not connected to sewers, a homeowner can replace their cesspool or septic system with an innovative/alternative on-site wastewater treatment system. Suffolk County, New York State and several East End towns are offering grants which can make it possible for homeowners to make this positive change with no significant out-of-pocket expense. Consumers can choose to not flush bleaches or toxic/hazardous materials down the drain or into their toilets. Consumers can also take care to deliver any potentially toxic or hazardous household chemicals to approved Stop Throwing Out Pollutants program sites. Homeowners can choose not to use fertilizers or pesticides, or to opt for an organic, slow-release fertilizer at lowest label setting rates.

 

7. Can you offer examples of products to avoid or practices to adopt that would better protect the drinking water supply? 

Consumers can choose to not flush bleaches or household hazardous materials down the drain or into their toilets. Consumers can also take care to deliver any potentially toxic or hazardous household chemicals to approved STOP program sites. Homeowners can choose not to use fertilizers or pesticides, or to opt for an organic, slow release fertilizer at lowest label setting rates.

 

8. Aside from banning products or chemicals, and raising awareness, how do you address the issue?

Promoting the use of less impactful alternatives to products which have been shown to have a significant and/or unanticipated impact on public health or the environment, on a voluntary basis, is a less contentious approach than banning a substance or placing restrictions on its use through a legislative or rulemaking process. Such an approach should only be taken with the understanding that its success, value and significance will depend in large part on public awareness and education.

 

9. What about product labeling, similar to the U.S. Office of the Surgeon General warnings about cigarettes, or carcinogens in California, etc.? Can the county require products sold to include a groundwater contamination warning?

The question of whether the county Legislature has authority to implement labeling requirements could be better addressed by an attorney.

 

10. People, including some elected officials and people running for public office, sometimes say that sewage treatment plants remove all contaminants from wastewater. Can you set the record straight? What chemicals, including radioactive chemicals, are and are not removed from wastewater via sewage treatment?

Tertiary wastewater treatment plants are designed primarily to remove nitrogen, in addition to biodegradable organic matter. However, wastewater treatment is also effective at removing many volatile organic compounds. Some substances, such as 1,4-dioxane, are resistant to treatment and require advanced processes for removal. Evidence shows that the use of horizontal leaching structures instead of conventional drainage rings may facilitate removal of many pharmaceuticals and personal care products, known as PPCPs. Advanced treatment technologies, such as membrane bioreactors, are also being tested for efficacy of removal of PPCPs.

Staff advise that the mere presence of chemicals in wastewater in trace amounts does not necessarily indicate the existence of a public health risk. All wastewater treatment must treat chemicals to stringent federal and state standards. In some cases, such as for emerging contaminants, specific standards do not exist. In those cases, the unspecified organic contaminant requirement of 50 parts per billion is commonly applied.

 

11. Can you provide an example of a place where residential and industrial groundwater contamination concerns were reversed or adequately addressed?

There are numerous examples, mostly under the jurisdiction of U.S. Environmental Protection Agency or NYS Department of Environmental Conservation, in which groundwater concerns have been addressed through treatment to remove contaminants. Because health and safety are always the most important issues, the first priority is typically to make sure that people who live near an impacted site have a safe supply of drinking water. In areas served by public water suppliers — Suffolk County Water Authority or a local water district — this is not usually an issue, since public water suppliers are highly regulated and are required to test water supply wells regularly. In areas where people are not connected to a public water system, and rely instead on private wells, the Suffolk County Department of Health Services will work with the water supplier to identify properties that are not connected to a public water system and then contact homeowners to urge them to have their water tested at no charge to make sure that it is safe for consumption. 

Over the past several years, Suffolk County, New York State and the Suffolk County Water Authority have worked together to connect hundreds of homes that had relied on private wells to the public water system, to make sure people have access to safe drinking water.

 

12. Are you hopeful about addressing the issues? 

I am hopeful and optimistic about the success of efforts to reverse the ongoing degradation of water quality that has resulted from reliance on cesspools and septic systems. For the first time in Long Island’s history, environmentalists, business leaders, scientists, organized labor and the building trades all agree that the long-term threat that has resulted from the lack of sewers to both the environment and economy is so great that a long-term plan to address the need for active wastewater treatment is not an option, but a necessity. Experience shows that public awareness can be a significant factor in driving public policy.